Pharmacological Treatment for Symptomatic Adenomyosis: A Systematic Review

Abstract

Objective To assess the efficacy of non-surgical treatment for adenomyosis. Data Sources A search was performed by two authors in the Pubmed, Scopus, and Scielo databases and in the grey literature from inception to March 2018, with no language restriction. Selection of Studies We have included prospective randomized studies for treating symptomatic women with adenomyosis (abnormal uterine bleeding and/or pelvic pain) diagnosed by ultrasound or magnetic resonance imaging. Data Collection Studies were primarily selected by title and abstract. The articles that were eligible for inclusion were evaluated in their entirety, and their data was extracted for further processing and analysis. Data Synthesis From 567 retrieved records only 5 remained for analysis. The intervention groups were: levonorgestrel intrauterine system (LNG-IUS)(n = 2), dienogest (n = 2), and letrozole (n = 1). Levonorgestrel intrauterine system was effective to control bleeding when compared to hysterectomy or combined oral contraceptives (COCs). One study assessed chronic pelvic pain and reported that LNG-IUS was superior to COC to reduce symptoms. Regarding dienogest, it was efficient to reduce pelvic pain when compared to placebo or goserelin, but less effective to control bleeding than gonadotropin-releasing hormone (GnRH) analog. Letrozole was as efficient as GnRH analog to relieve dysmenorrhea and dyspareunia, but not for chronic pelvic pain. Reduction of uterine volume was seen with aromatase inhibitors, GnRH analog, and LGN-IUD. Conclusion Levonorgestrel intrauterine system and dienogest have significantly improved the control of bleeding and pelvic pain, respectively, in women with adenomyosis. However, there is insufficient data from the retrieved studies to endorse each medication for this disease. Further randomized control tests (RCTs) are needed to address pharmacological treatment of adenomyosis.

Proposal for developing treatment algorithms of women with symptomatic adenomyosis: A single‐center experience

“…DNG is an oral progesterone receptor agonist and can offer an effective therapeutic option for continuous longterm treatment of adenomyosis. 3,6,[9][10][11][12][13] DNG has become a useful drug in the treatment of adenomyosis, but there are no specific treatment guidelines and best practice recommendations for management of adenomyosis. 6 Many gynecologists have accumulated rich experience in DNG treatment of endometriosis 33 and may find it effective to use DNG in patients with adenomyosis who coexist with OMA (Table S2).…”

“…There are multiple treatment strategies for women with symptomatic adenomyosis. 3 Treatment options used worldwide include conservative medical treatment and curative surgical treatment. [4][5][6][7][8] If the patient desires conservative treatment, a nonsteroidal antiinflammatory drug or low-dose oral estrogenprogestin is proposed.…”

“…5,6,[9][10][11][12] DNG is prescribed as a long-term treatment for many women with pain associated with adenomyosis. 3,[9][10][11][12][13] Occasionally, we encounter cases of discontinuing DNG treatment due to abnormal bleeding. 9,[14][15][16][17][18][19] Therefore, women with hemoglobin levels below 8.0 g/dL, a maximum diameter of the uterine body greater than 10 cm in diameter, and a maximum thickness of the myometrium greater than 4 cm in diameter were excluded from previous clinical study in Japan.…”

Diagnosis and treatment of adenomyosis

“…The levonorgestrel intrauterine system is the most-studied treatment, with the largest randomized controlled trial (n = 86) showing comparable improvement in hemoglobin and quality of life compared with hysterectomy at 6 months. 5 Other treatments include tranexamic acid, nonsteroidal anti-inflammatory drugs, combined hormonal contraceptives and other progestins (norethindrone acetate, medroxyprogesterone, dienogest). If initial treatment fails after 3-6 months, referral to a gynecologist is suggested, to consider other medical (i.e., gonadotropin-releasing hormone agonists), interventional or surgical options.…”

“…If initial treatment fails after 3-6 months, referral to a gynecologist is suggested, to consider other medical (i.e., gonadotropin-releasing hormone agonists), interventional or surgical options. 1,3,5 PRACTICE | FIVE THINGS TO KNOW ABOUT ...…”