doi:10.1111/jog.14571 J. Obstet. Gynaecol. Res.

2020

Laparoscopic adenomyomectomy combined

with levonorgestrel-releasing intrauterine system
in the treatment of adenomyosis: Feasibility
and effectiveness

Feng Sun1,2,3*, Ye Zhang1,2,3*, Min You1,2,3, YePing Yang1,2,3, YingYing Yu1,2,3 and
Hong Xu1,2,3
1
Department of Gynecology and Obstetrics, International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong
University School of Medicine, Shanghai, China
2
Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
3
Shanghai Municipal Key Clinical Specialty, Shanghai, China

Abstract
Aim: To evaluate the clinical efficacy and safety of laparoscopic adenomyomectomy combined with
intraoperative replacement of levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of
symptomatic adenomyosis.
Methods: This is a case-series study in a university medical center. A total of 52 patients with symptom-
atic adenomyosis were treated by laparoscopic adenomyomectomy combined with intraoperative
replacement of LNG-IUS from January 2015 to July 2018. Visual analog scale, menstrual flow and uterine
volume were compared before and after the surgery (3, 12 and 24 months). Meanwhile, LNG-IUS-
induced adverse reactions (e.g. irregular vaginal bleeding, amenorrhea, expulsion, and perforation) were
also recorded.
Results: All operations were successfully completed via laparoscopy without conversion to laparotomy.
No severe complications were noted during the surgical procedure or follow-up period. The mean postop-
erative visual analog scale and menstrual flow scores and the volume of the uterus were significantly
decreased (all P < 0.001) at 3, 12, and 24 months postoperatively, compared with preoperative scores. The
clinical effective rates among the patients with dysmenorrhea were 98%, 96% and 96% at 3, 12 and
24 months after the operation, respectively. And the clinical effectiveness rate of menorrhagia was 97.6%,
95.2% and 95.2% at 3, 12 and 24 months after treatment, respectively. Among all related adverse reactions,
amenorrhea was the most common (n = 12, 23.1%). There was one case of LNG-IUS perforation (1.9%) and
two cases of expulsion (3.8%).
Conclusion: Laparoscopic adenomyomectomy combined with intraoperative replacement of LNG-IUS is a
novel and effective conservative surgical procedure for symptomatic adenomyosis treatment.
Key words: adenomyosis, conservative surgery, laparoscopic adenomyomectomy, levonorgestrel-releasing
intrauterine system.

Received: June 19 2020.

Accepted: November 2 2020.
Correspondence: Dr Hong Xu, Department of Gynecology & Obstetrics, International Peace Maternity & Child Health Hospital, Shanghai
Jiao Tong University School of Medicine, No.910 HengShan Road, XuHui District, ShangHai, China. Email: xuhong1168@126.com
*These two authors contributed equally to this work and should be considered co-first authors.

© 2020 Japan Society of Obstetrics and Gynecology 1

F. Sun et al.
Introduction
Adenomyosis is a common benign gynecological dis-
ease characterized by ectopic endometrial glands and
stroma within the myometrium.1 Hysterectomy has
been the main mode of treatment for adenomyosis.2
Recently, with the decrease of onset age and the
increasing desire to preserve the uterus even among
older women, several available medical and surgical
options are used for treating adenomyosis. Medical
treatment includes gonadotropin-releasing hormone
agonists (GnRH-a), levonorgestrel-releasing intrauter-
ine device (LNG-IUS), oral contraceptive combined
pills, progestogens and danazol.3,4 Unfortunately, the
effect of these medical treatments is often transient and
accompanied by side effects.5 Conservative surgeries
have emerged as a popular treatment while preserving
fertility. However complete excision can be difficult
because adenomyosis generally lacks a cleavage plane
and residual small lesions may continue to relapse.
According to a systematic review by Younes et al.,6
depending on the duration of follow-up, recurrence
rates after excision can be as high as 50%.
LNG-IUS is a T-shaped intrauterine device with a
filament tail, which constantly releases progesterone
to the uterus within the 5 years of validity. Besides
efficient contraception,7 its noncontraceptive benefits
from adenomyosis have been extensively studied in
recent years.8 Multiple studies demonstrated that dys-
menorrhea score, menstrual flow, uterine volume and
serum CA125 levels are significantly improved in
patients with adenomyosis after LNG-IUS implanta-
tion.9 However, for patients with severe adenomyosis
having a large uterus, such treatment is limited.10
However, to date, laparoscopic adenomyomectomy
combined with intraoperative replacement of LNG-IUS
has not been reported. The simultaneous replacement of
LNG-IUS in laparoscopic conservative surgery not only
reduces postoperative recurrence rate but also avoids
the pain of placing LNG-IUS in patients after surgery.
The aim of this study was to determine the long-term
clinical efficacy of laparoscopic adenomyomectomy
combined with intraoperative replacement of LNG-IUS
in the treatment of symptomatic adenomyosis.
Methods
Participants
Patients with symptomatic adenomyosis who were
willing to preserve their uterus were included in this
2 © 2020 Japan Society of Obstetrics and Gynecology
Figure 1 Preoperative (a) and postoperative (b) enhanced
magnetic resonance imaging.
study from May 2015 to January 2018. The inclusion
criteria for the present study were age 18–45 years,
premenopausal status with regular frequency of men-
struation, diagnosis of adenomyosis by magnetic reso-
nance imaging (MRI), severe dysmenorrhea and/or
menorrhagia. The exclusion criteria were submucous
myoma, ovarian cyst, pregnancy, current breast can-
cer or history of breast cancer, pathologic discoveries
of malignancy (e.g. endometrial cancer), any contrain-
dication to the placement of LNG-IUS, previous sur-
gery for adenomyosis, postmenopausal status or the
patient declined to participate.
The features of adenomyosis on MRI scans (Fig. 1a)
include low signal intensity widening of the junc-
tional zone on T2-weighted images, which corre-
sponds to smooth muscle hyperplasia, as well as
scattered foci of increased signal intensity throughout
the myometrium corresponding to ectopic endome-
trial tissue, cysts or hemorrhagic foci.11 The diagnosis
was confirmed by postoperative pathology.
The study was approved by the Institutional
Review Board of the International Peace Maternity
and Child Health Hospital of China Welfare Institute.
All participants provided consent before enrollment.
Data collection
We collected the patients’ information, including
sociodemographic characteristics, type of adenomyosis,
final postoperative pathological diagnosis, intraoperative
and postoperative parameters and length of hospital
stays. Menstrual blood loss was assessed using the
Mansfield–Voda–Jorgensen (MVJ) menstrual bleeding
scale ranging from 1 (spotting) to 6 (gushing). An MVJ
score equal to or > 5 is considered menorrhagia.12 A
visual analog scale (VAS) was used to evaluate the
degree of menstrual pain (0, no pain; 1–3, mild pain; 4–6,
moderate pain; 7–10, severe pain).13 The uterine volume
was measured using transvaginal ultrasonography by
 Laparoscopic surgery & LNG-IUS in AM

the following formula: volume = 0.5233 × D1 × D2 × D3, cul-de-sac of Douglas. The material for frozen sections
where D1 is the longitudinal dimension, D2 is the was taken during the operation.
anteroposterior dimension and D3 is the transverse The patients were changed to the lithotomy posi-
dimension.10 Hemoglobin level < 120 g/L was defined tion, and we measured the depth of the uterine cavity
as anemia.14 with the probe. If the depth is less than 10 cm, we
All laparoscopic operations were performed under inserted an LNG-IUS (Bayer, Shanghai, China) con-
routine general anesthesia. The operative procedures taining 52 mg of levonorgestrel immediately after
were as follows. Adenomyosis can be subclassified as completion of the operation (Fig. 1b).
focal or diffuse. The former can usually be almost The scores of dysmenorrhea and menstrual volume
completely resected. The raised portion of the focal before and after treatment were compared to deter-
adenomyosis was dissected using a monopolar inci- mine whether the symptoms were alleviated using
sion. Adenomyosis tissue was then excised from the the following criteria16: (i) obvious relief: the differ-
edges of the defect to access the healthy myometrium ence is over two points; (ii) partial relief: the differ-
via a monopolar incision, or with scissors until soft ence is one point; (iii) complete relief: symptoms are
tissue was reached. In the latter case, an incision was completely relieved and (iv) aggravation: postopera-
made in the midline of the serosal surface of the fun- tive scores increase. Clinical relief included obvious
dus by using scissors (or monopolar) and continued relief, partial relief and complete relief. Postoperative
along the sagittal direction until the uterine cavity amenorrhea was defined as the absence of menstrual
was reached. The incision was further continued bleeding for at least 12 months after surgery.
along the posterior and anterior walls of the uterus to
the level of the internal os of the cervix. Afterward, Clinical follow-up
adenomyomatous tissues were grasped with forceps,
All patients were followed up at 3, 12 and 24 months
identified and excised from the surrounding
after surgery. Follow-up visits included assessments
myometrium as completely as possible. Then the
of changes in dysmenorrhea, menorrhagia. The vol-
endometrial lining was approximated with figure-of-
ume of the uterus was also measured at follow-up
eight sutures of 2–0 Vicryl. And the myometrium and
using vaginal ultrasound.
serosa of the bisected uterus were sutured with 1–0
Vicryl by using the double-flap method.15 At the end
of the surgery, the drainage catheter was left in the Table 2 Surgical findings
Variables Number
(%)/range
Table 1 Baseline characteristics of all enrolled partici-
pants (n = 52) Types of adenomyosis
Diffuse 11
Variables Range Focal 41
Age (years) 40.0 ± 4.4 (29–51) Lesion location
Parity, n (%) Anterior wall (%) 8
0 6 (11.5) Posterior wall (%) 38
≥1 46 (88.5) Fundus uterus (%) 6
Symptoms Preoperative uterine volume (cm3)† 186.0 ± 76.4
Dysmenorrhea alone 9 Combined with DIE, n (%) 13 (25)
Menorrhagia alone 1 Operation time (min)† 182.6 ± 49.0 (90–335)
Both 41 Blood loss (mL)† 195 ± 171 (50–1000)
Anemia, n (%) 33 (64.5) Intraoperative blood 1
Medication treatment failure transfusion (n)
GnRH agonist 8 Weight of specimen (g)† 90.1 ± 32.3
Oral contraceptive 1 Uterine cavity entered, 35 (67.3)
LNG-IUS only 5 n (%)
GnRH agonist + LNG-IUS 1 Uterine cavity depth 7.8 ± 1.0 (5.5–9.5)
Previous abdominal surgery after the operation(cm)†
Cesarean section 21 Hospital stay (days)† 8.4 ± 2.3 (6–17)
Myoectomy 2 Postoperative Intestinal
Appendectomy 2 complications (n) obstruction (2)
Adnexal surgery 8 Conversion to laparotomy (n) 0

GnRH, gonadotropin-releasing hormone; LNG-IUS, levonor- †Data were presented as mean ± standard deviation (range).
gestrel-releasing intrauterine system. DIE, deep infiltrating endometriosis.

© 2020 Japan Society of Obstetrics and Gynecology 3

F. Sun et al.
Follow-up was performed regularly and LNG-IUS-
induced adverse reactions (e.g. irregular vaginal
bleeding, amenorrhea, expulsion and perforation)
were recorded.
Statistical analysis
Continuous variables with Gaussian distribution were
expressed as mean ± SD. Categorical variables were
expressed as number/category. Parametric and non-
parametric continuous variables were compared with
the Student’s t-test or the Wilcoxon rank sum test, as
appropriate. The chi-squared test was used for com-
parison of categorical variables. Significance was
assumed when P was less than 0.05 (SPSS 16.0.0, SPSS,
Inc. Chicago, IL, USA).
Results
1. The baseline characteristics of all participants are
shown in Table 1.
Figure 2 Comparison of preoperative visual analog scale (VAS) score (a), menstrual flow (MVJ) score (b) and uterine vol-
ume (c) at 3-, 12-, and 24-month post-treatment.（*P<.001)
4 © 2020 Japan Society of Obstetrics and Gynecology
We included a total of 52 women with adenomyosis
in this study. Patient ages ranged from 29 to 51 years,
averaging 40.0 ± 4.4 years. Forty-six cases had given
birth. Six cases were nulligravid. Thirty-three cases
were combined with anemia. Fifteen patients had
medication treatment failure. Among the patients,
50 suffered from dysmenorrhea and 42 suffered from
menorrhagia. A total of 24 cases had a history of
abdominal operations (e.g. endometriosis, uterine
fibroids, ovarian cysts and cesarean section).
Table 2 presents the results of the surgery.
Eleven patients (21%) had diffused adenomyosis
and 41 patients (79%) had focal adenomyosis. Most of
them are posterior adenomyosis (n = 38, 73%). All
operations were successfully completed via laparos-
copy without conversion to laparotomy. The mean
operation time was 182.6 ± 49.0 min and the mean
blood loss was 195 ± 171 (50–1000) mL. One case
underwent intraoperative blood transfusion. The
 Laparoscopic surgery & LNG-IUS in AM

Table 3 Evaluation of treatment efficacy in 50 patients with dysmenorrhea

Time points Complete relief, Obvious relief, Partial relief, No response, Clinical
n (%) n (%) n (%) n (%) effectiveness (%)†
3 months 32 (64) 13 (26) 4 (8) 1 (2) 98
12 months 35 (70) 10 (20) 3 (6) 2 (4) 96
24 months 36 (72) 10 (20) 2 (4) 2 (4) 96
†The clinical effectiveness was calculated by adding complete/obvious/partial relief rate of certain time point up.

Table 4 Evaluation of treatment efficacy in 42 patients with menorrhagia after treatment

Time points Complete relief, Obvious relief, Partial relief, No response, Clinical
n (%) n (%) n (%) n (%) effectiveness (%)†
3 months 2 (4.8) 36 (85.7) 3 (7.1) 1 (2.4) 97.6
12 months 9 (21.4) 30 (71.4) 2 (4.8) 2 (4.8) 95.2
24 months 12 (28.6) 27 (64.3) 1 (2.4) 2 (4.8) 95.2
†The clinical effectiveness was calculated by adding complete/obvious/partial relief rate of certain time point up.

median weight of the resected tissue was Improvement of dysmenorrhea.

90.1 ± 32.3 g. Postoperative intestinal obstruction
occurred in two patients and improved after conser- For 50 women who suffered from dysmenorrhea
vative treatment. During the operation, uterine cavity before treatment, the mean VAS score significantly
was entered in 35 (67.3%) patients. The uterine cavity decreased after the operation (P < 0.001). The clinical
depth after the operation was 7.8 ± 1.0 cm, and LNG- effective rates among the patients with dysmenorrhea
IUS were inserted in all patients. Thirteen cases (25%) were 98%, 96% and 96% at 3, 12 and 24 months after
were combined with deep infiltrating endometri- the operation, respectively (Table 3).
osis (DIE).
Improvement of menstrual volume.
According to VAS standards for dysmenorrhea,
patients with dysmenorrhea (n = 50) were scored
Of the 42 women with menorrhagia, the clinical
before treatment and 3 , 12 and 24 months after treat-
effectiveness rate of menorrhagia was 97.6%, 95.2%
ment, respectively. Compared with the preoperative
and 95.2% at 3, 12 and 24 months after treatment,
values (8.3 ± 1.9), the VAS score decreased signifi-
respectively, suggesting that there was a significant
cantly at 3, 12 and 24 months (0.7 ± 1.1, 0.4 ± 1.1,
improvement in menorrhagia (Table 4).
0.2 ± 0.4), respectively (P < 0.001) (Fig. 2a).

Incidence of adverse reactions (Table 5).

The MVJ score of patients who suffered menorrha-
gia (n = 42) before operation was 5.8 ± 0.4. The score
was reduced to 1.5 ± 0.8, 1.0 ± 0.8 and 0.7 ± 0.5 at 3-,
Table 5 Side effects reported during the 2-year period
12- and 24-month postoperative (P < 0.001), respec- on levonorgestrel-releasing intrauterine system
tively, indicating significant improvement in hyper-
Side effect 24 months (n, %)
menorrhea (Fig. 2b).
Uterine volume at various follow-up time points after Irregular bleeding 5 (9.6)
Expulsions† 2 (3.8)
the operation was decreased significantly compared
Perforation 1 (1.9)
with preoperative values (185.9 ± 76.39 cm3) with uter- Amenorrhea 12 (23.1)
ine volume (75.9 ± 27.9, 67.3 ± 24.5 and 67.8 ± 48.7 at Weight gain 2 (3.8)
3, 12 and 24 months, respectively) (P < 0.001). How- Soreness of waist 7 (13.5)
ever, no significant differences were found between 3-, †Expulsion was defined as unintentional loss of the device
12- and 24-month post-treatment (Fig. 2c). from the uterus.

© 2020 Japan Society of Obstetrics and Gynecology 5

F. Sun et al.
Adverse reactions found during follow-up included
amenorrhea (12 cases, 23.1%), irregular uterine bleed-
ing (five cases, 9.6%), weight gain >2 kg (two cases,
3.8%), soreness of waist (seven cases, 13.5%), LNG-
IUS perforation from incision of the uterine fundus
(one case, 1.9%) and expulsions (two cases, 3.8%).
Irregular uterine bleeding was assessed on a daily
basis as it is the most frequently reported adverse
effect within the first 6 months after LNG-IUS
placement.
Discussion
The traditional hysterectomy remains the main thera-
peutic strategy in the long term. However, consider-
ing the relevant technical progress of conservative
surgical techniques in recent years and the expansion
of lesion removal, the short-term efficacy of conserva-
tive surgical techniques is significant in improving
adenomyosis-related dysmenorrhea and abnormal
uterine bleeding.17
Adenomyotic lesions are often unclear and diffusely
distributed, so it is difficult to remove them
completely.18 Therefore, it is plausible that residual
small lesions may continue to grow and relapse.19
Hence, adjuvant application of GnRH-a after
adenomyomectomy in the treatment of adenomyosis
can effectively reduce dysmenorrhea and menorrhagia.
It is reported that of those who received 6 courses of
GnRH-a after laparoscopic adenomyomectomy, 11.5%
experienced relapse compared with 39.1% experienced
relapse in the surgical-only treatment group,20 but with
a high recurrence rate after drug discontinuation.21 Zhu
et al.22 reported that significant differences of the recur-
rence rate were found between patients with
adenomyosis who were only treated with GnRH-a
postoperatively and patients who were treated with
GnRH-a plus LNG-IUS after surgery (33.3% vs 5.1%).
The benefits of the LNG-IUS, particularly the effects
on dysmenorrhea and menorrhagia, have been proven
to be effective against adenomyosis.8 However, the rate
of treatment failure after LNG-IUD insertion for the
patients with adenomyosis was related to the uterine
volume. Specifically, the treatment failure rate of large-
volume uterus (150 mL) with LNG-IUD was signifi-
cantly higher than that of small volume uterus due to
high risk of prolapse or expulsion.23,24 Among the
52 patients in our study, preoperative uterine volume
was 186.0 ± 76.4 cm3, with six (11.5%) patients treated
with LNG-IUS before surgery and failed. In our study,
6 © 2020 Japan Society of Obstetrics and Gynecology
we applied laparoscopic adenomyomectomy combined
with intraoperative replacement of LNG-IUS in the
treatment of adenomyosis. The uterine size after
adenomyomectomy is more suitable for the placement
of LNG-IUS. Postoperative VAS score and menstrual
volume (MVJ score) significantly decreased, and uterine
volume was gradually reduced to the normal level.
LNG-IUS, as adjuvant therapy after adenomyomectomy
in our study, was found to significantly inhibit the
development of residual small adenomyotic lesions with
expulsion rate (3.8%) lower than that in only LNG-IUS
treatment (16%).25
Despite adverse reactions, such as amenorrhea and
irregular bleeding in some patients, the latter was
well-tolerated, and patients were willing to continue
implanting the intrauterine device.
As we all know, there is a strong association
between adenomyosis and endometriosis.26 Recently,
Chapron et al.27 reported that focal adenomyosis
located in the outer myometrium was observed more
frequently in women with endometriosis. In our study,
13 were combined with deep infiltrating endometriosis
(uterosacral ligaments, rectovaginal endometriosis).
With the development of minimally invasive tech-
niques, laparoscopic surgery for the treatment of DIE
is considered a valid alternative that is able to deliver
all the advantages of minimally invasive therapy also
in case of advanced diseases.28 Laparoscopic excision
for patients with adenomyosis or concurrent DIE can
improve the postoperative efficacy.
Here, two patients received another surgery due to
unsatisfactory outcome. A 43-year-old patient was
diagnosed with focal adenomyoma of the posterior
wall with severe dysmenorrhea. She underwent
laparoscopic adenomyomectomy combined with
intraoperative replacement of LNG-IUS in 2015, but the
postoperative dysmenorrhea was not significantly
relieved, and the postoperative abdominal pain became
persistent 6 months after surgery. Computerized
tomography indicated that the LNG-IUS was displaced
into the myometrium. The patient refused to keep the
uterus and insisted on a total hysterectomy because of
the severe pain. Therefore, we performed a hysterec-
tomy 1 year after the conservative surgery. Laparos-
copy showed LNG-IUS perforation from incision of the
uterine fundus. Similar case has also been reported in
laparotomy adenomyomectomy combined with LNG-
IUS.29 This might have been caused by the loose suture
of the serosal layer. Meticulous suture without leaving
any dead space should be performed for reconstructing
the uterine wall to avoid LNG-IUS perforation from the

uterine incision. Another case was a 43-year-old patient
with menorrhagia. Her hemoglobin concentration was
as low as 59.2 g/L before the first surgery, and the uter-
ine volume was 397.70 cm3. Magnetic resonance imag-
ing showed diffuse lesions involving the whole uterus.
The amount of menstrual bleeding had significantly
decreased within 6 months after the operation, but
increased at 9 months to more than the preoperative
amount with LNG-IUS expulsion. The MRI evaluation
showed that the majority of adenomyosis lesions were
located in the inner muscular layer. Therefore, she
underwent hysteroscopic excision of myometrial
adenomyotic lesions combined with intraoperative
replacement of LNG-IUS, as reported previously.30 The
most obvious advantage of hysteroscopic resection of
adenomyotic lesions is that it is especially appropriate
for adenomyosis in which adenomyotic lesions are
located in the inner muscular layer. Until now, the
patient was very satisfied with the MVJ score of two.
Our study is the first to evaluate the efficacy,
side effects and acceptability of the laparoscopic
adenomyomectomy combined with intraoperative
replacement of LNG-IUS. But there were still several
limitations. First, this was a retrospective case-series
study. Second, the follow-up period of this study
was only 24 months. A large-scale randomized
case–control study including comparisons with other
conservative treatment methods after surgery and
long-term follow-up data is required to confirm our
results.
In summary, for patients strongly desiring to retain
the uterus with severe adenomyosis that the large
uterine volume is not suitable for preoperative place-
ment of LNG-IUS, or concurrent deep endometriosis,
the laparoscopic adenomyomectomy combined with
intraoperative replacement of LNG-IUS can remove
adenomyotic lesions to the maximum extent possible,
significantly improve symptoms and markedly
decrease the uterine volume suitable for LNG-IUS. In
addition, the new technique inhibits the development
of residual lesions in the long term while effectively
reducing recurrence. Therefore, it may be considered
a useful method for an effective surgical approach for
the treatment of symptomatic adenomyosis with large
uterus.
Acknowledgments
This work was supported by Medicine and
Engineering Interdisciplinary Research Fund of
© 2020 Japan Society of Obstetrics and Gynecology
Laparoscopic surgery & LNG-IUS in AM
Shanghai Jiao Tong University (YG2019QNB06),
Foundation for innovative Research Groups of the
National Natural Science Foundation of China
(grant 81701402).
Disclosure
None declared.
References
1. Harada T, Khine YM, Kaponis A, Nikellis T, Decavalas G,
Taniguchi F. The impact of adenomyosis on women’s fertil-
ity. Obstet Gynecol Surv 2016; 71: 557–568.
2. Grimbizis GF, Mikos T, Tarlatzis B. Uterus-sparing opera-
tive treatment for adenomyosis. Fertil Steril 2014; 101:
472–487.
3. Cucinella G, Granese R, Calagna G et al. Oral contraceptives
in the prevention of endometrioma recurrence: Does the dif-
ferent progestins used make a difference? Arch Gynecol
Obstet 2013; 288: 821–827.
4. Bragheto AM, Caserta N, Bahamondes L, Petta CA.
Effectiveness of the levonorgestrel-releasing intrauterine sys-
tem in the treatment of adenomyosis diagnosed and moni-
tored by magnetic resonance imaging. Contraception 2007;
76: 195–199.
5. Al Jama FE. Management of adenomyosis in subfertile
women and pregnancy outcome. Oman Med J 2011; 26:
178–181.
6. Younes G, Tulandi T. Conservative surgery for adenomyosis
and results: A systematic review. J Minim Invasive Gynecol
2018; 25: 265–276.
7. Bednarek PH, Jensen JT. Safety, efficacy and patient accept-
ability of the contraceptive and non-contraceptive uses of
the LNG-IUS. Int J Womens Health 2010; 1: 45–58.
8. Cho S, Nam A, Kim H et al. Clinical effects of the
levonorgestrel-releasing intrauterine device in patients
with adenomyosis. Am J Obstet Gynecol 2008; 198: 373
e1–373 e7.
9. Lockhat FB, Emembolu JO, Konje JC. The efficacy, side-
effects and continuation rates in women with symptomatic
endometriosis undergoing treatment with an intra-uterine
administered progestogen (levonorgestrel): A 3 year follow-
up. Hum Reprod 2005; 20: 789–793.
10. Park DS, Kim ML, Song T et al. Clinical experiences of the
levonorgestrel-releasing intrauterine system in patients with
large symptomatic adenomyosis. Taiwan J Obstet Gynecol
2015; 54: 412–415.
11. Shwayder J, Sakhel K. Imaging for uterine myomas and
adenomyosis. J Minim Invasive Gynecol 2014; 21:
362–376.
12. Mansfield PK, Voda A, Allison G. Validating a pencil-and-
paper measure of perimenopausal menstrual blood loss.
Womens Health Issues 2004; 14: 242–247.
13. Gerlinger C, Schumacher U, Wentzeck R et al. How can we
measure endometriosis-associated pelvic pain? J Endometr
2012; 4: 109–116.
7
F. Sun et al.
14. Stoltzfus RJ. Rethinking anaemia surveillance. Lancet 1997;
349: 1764–1766.
15. Huang X, Huang Q, Chen S, Zhang J, Lin K, Zhang X. Efficacy of
laparoscopic adenomyomectomy using double-flap method for
diffuse uterine adenomyosis. BMC Womens Health 2015; 15: 24.
16. Shui L, Mao S, Wu Q et al. High-intensity focused ultra-
sound (HIFU) for adenomyosis: Two-year follow-up results.
Ultrason Sonochem 2015; 27: 677–681.
17. Chong GO, Lee YH, Hong DG, Cho YL, Lee YS. Long-term
efficacy of laparoscopic or robotic adenomyomectomy with
or without medical treatment for severely symptomatic
adenomyosis. Gynecol Obstet Invest 2016; 81: 346–352.
18. Di Spiezio Sardo A, Calagna G, Santangelo F et al. The role
of hysteroscopy in the diagnosis and treatment of
Adenomyosis. Biomed Res Int 2017; 2017: 2518396.
19. Maheshwari A, Gurunath S, Fatima F, Bhattacharya S.
Adenomyosis and subfertility: A systematic review of preva-
lence, diagnosis, treatment and fertility outcome. Hum
Reprod Update 2012; 18: 374–392.
20. Yu W, Liu G, Liu C, Zhang Z. Recurrence-associated factors
of laparoscopic adenomyomectomy for severely symptom-
atic adenomyoma. Oncol Lett 2018; 16: 3430–3438.
21. Wang PH, Liu WM, Fuh JL, Cheng MH, Chao HT. Compari-
son of surgery alone and combined surgical-medical treat-
ment in the management of symptomatic uterine
adenomyoma. Fertil Steril 2009; 92: 876–885.
22. Zhu L, Chen S, Che X, Xu P, Huang X, Zhang X. Compari-
sons of the efficacy and recurrence of adenomyomectomy
for severe uterine diffuse adenomyosis via laparotomy ver-
sus laparoscopy: A long-term result in a single institution.
J Pain Res 2019; 12: 1917–1924.
8 © 2020 Japan Society of Obstetrics and Gynecology
23. Zhang P, Song K, Li L, Yukuwa K, Kong B. Efficacy of com-
bined levonorgestrel-releasing intrauterine system with
gonadotropin-releasing hormone analog for the treatment of
adenomyosis. Med Princ Pract 2013; 22: 480–483.
24. Lee KH, Kim JK, Lee MA et al. Relationship between uterine
volume and discontinuation of treatment with levonorgestrel-
releasing intrauterine devices in patients with adenomyosis.
Arch Gynecol Obstet 2016; 294: 561–566.
25. Sheng J, Zhang WY, Zhang JP, Lu D. The LNG-IUS study
on adenomyosis: A 3-year follow-up study on the efficacy
and side effects of the use of levonorgestrel intrauterine sys-
tem for the treatment of dysmenorrhea associated with
adenomyosis. Contraception 2009; 79: 189–193.
26. Devlieger R, D’Hooghe T, Timmerman D. Uterine
adenomyosis in the infertility clinic. Hum Reprod Update
2003; 9: 139–147.
27. Chapron C, Tosti C, Marcellin L et al. Relationship between
the magnetic resonance imaging appearance of adenomyosis
and endometriosis phenotypes. Hum Reprod 2017; 32:
1393–1401.
28. Rausei S, Sambucci D, Spampatti S et al. Laparoscopic treat-
ment of deep infiltrating endometriosis: Results of the com-
bined laparoscopic gynecologic and colorectal surgery. Surg
Endosc 2015; 29: 2904–2909.
29. Gao Y, Shan S, Zhao X, Jiang J, Li D, Shi B. Clinical efficacy
of adenomyomectomy using "H" type incision combined
with Mirena in the treatment of adenomyosis. Medicine
(Baltimore) 2019; 98: e14579.
30. Xia W, Zhang D, Zhu Q et al. Hysteroscopic excision of
symptomatic myometrial adenomyosis: Feasibility and effec-
tiveness. BJOG 2017; 124: 1615–1620.