The efficacy of ultrasonic ablation combined with medication in the treatment of adenomyosis: a systematic review and network meta-analysis

Background Adenomyosis occurs when tissue from the inner lining of the endometrium grows into the muscle wall of the myometrium. Previous studies have suggested that High-Intensity Focused Ultrasound (HIFU) combined with medications may improve treatment outcomes for adenomyosis; however, the comparative efficacy of different medication combinations remains unclear. This network meta-analysis aimed to compare and rank the efficacy of various medications combined with HIFU in patients with adenomyosis. Methods Randomized controlled trials reporting on HIFU combined with medications for adenomyosis were retrieved from 8 databases from their inception to 23 June 2025. The literature meeting the inclusion criteria was evaluated for quality and risk of bias using the Cochrane 5.1 manual and RoB2. Subsequently, a Bayesian network meta-analysis was conducted using R software. Results A total of six interventions (HIFU + GnRH-a, HIFU + testosterone propionate, HIFU + percutaneous ethanol injection, HIFU + microbubble contrast agent, HIFU + oxytocin, and HIFU + microbubble contrast agent + oxytocin) were included to evaluate their efficacy on intraoperative indicators of adenomyosis compared with HIFU alone. A total of 8,700 records were retrieved, with 16 studies ultimately included, involving 1,685 patients with adenomyosis. Compared with HIFU alone, HIFU combined with ethanol ablation demonstrated the highest efficacy in non-perfused volume ratios (NPVR) (Mean Difference (MD) = 27, 95% Confidence Interval (CI): 2.7 to 52), sonication energy (MD = −230%, 95% CI: −290 to −180), and treatment duration (MD = −44%, 95% CI: −80 to −7.8); Additionally, HIFU combined with Gonadotropin-releasing hormone agonist (GnRH-a) showed superiority in energy efficiency factor (MD = −31%, 95% CI: −90 to −13). Conclusion The efficacy of HIFU combined with medications in the treatment of adenomyosis is superior to that of HIFU alone. Different medications offer distinct advantages in enhancing the therapeutic effect of HIFU. Systematic Review Registration clinicaltrials.gov , identifier CRD420251143604.