Patients may not respond or show only partial response to initial empirical treatment including the use of oral contraceptives [14, 37]. As the lining of submucous and intramural cysts expresses steroid hormone receptors, cyst size may increase during the menstrual cycle and regress at the time of menstruation [2, 11].

Surgical excision is necessary in cases that do not respond to medical treatment. Nabeshima et al. reported laparoscopic total resection of a cystic adenomyoma using transtrocar ultrasonic guidance after a previous unsuccessful resection by laparotomy [16]. In a series of nine cases Takeuchi et al. observed that laparoscopic excision resulted in a statistically and clinically significant reduction of symptoms [12]. Bedaiwy et al. favoured the laparoscopic approach as it allows sufficient access [24].

Other surgical approaches have been proposed include ultrasound guided radiofrequency needle ablation [21], the use of single-incision with monopolar cautery [17] or the use of robotic surgery [39].

Giana et al. and Kumar described the accidental hysteroscopic drainage of a submucous adenomyotic cyst [27, 45]. This approach was used in one reported case [44].