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Zhang B, Shi J, Gu Z, Wu Y, Li X, Zhang C, Yan H, Li Q, Lyu S, Dai Y, Leng J. The role of different LNG-IUS therapies in the management of adenomyosis: a systematic review and meta-analysis. Reprod Biol Endocrinol 2025; 23:23. [PMID: 39948612 PMCID: PMC11823221 DOI: 10.1186/s12958-025-01349-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Accepted: 01/24/2025] [Indexed: 02/17/2025] Open
Abstract
OBJECTIVE To summarize evidence on the efficacy and safety of the levonorgestrel-releasing intrauterine system (LNG-IUS) in managing adenomyosis (AM), both as a monotherapy and in combination with other therapies. METHODS We searched Medical Literature Analysis and Retrieval System On-Line: Medline, The Cochrane Library, Embase, SinoMed, China National Knowledge Infrastructure, and Wanfang from the inception to Aug 12, 2024 for articles using the LNG-IUS both alone and combined with other therapies in patients with AM. The primary outcome included dysmenorrhea, menstrual bleeding, uterine volume, endometrial thickness and quality of life. The secondary outcome was the assessment of adverse events. Data synthesis was conducted using random-effects model with significant heterogeneity (I2 > 50%), otherwise using fixed-effects model. RESULTS The final analysis included 28 studies. Compared with etonogestrel, LNG-IUS was more effective in reducing uterine volume and associated with a lower risk of weight gain, but showed no significant difference in reducing dysmenorrhea and endometrial thickness. Comparing LNG-IUS with mifepristone, there was no significant difference in terms of quality of life. The combination of LNG-IUS with Gonadotropin-releasing hormone agonists (GnRH-a) was more effective than LNG-IUS alone, providing benefits in reducing dysmenorrhea (mean deviation, MD: -1.14), menstrual bleeding (MD: -11.94), uterine volume (MD: -30.39), endometrial thickness (MD: -0.89), and adverse events. The combination of LNG-IUS with surgical excision was more effective than surgical excision alone, providing benefits in reducing dysmenorrhea (MD: -1.49), menstrual bleeding (MD: -5.13) at 12 months, reducing uterine volume at 6 (MD: -9.23), 12 (MD: -16.53) and 24 (MD: -27.17) months. The combination of LNG-IUS with focused ultrasound ablation (FUA) was more effective than FUA alone, providing benefits in reducing dysmenorrhea (MD: -0.62), menstrual bleeding (MD: 0.17). CONCLUSIONS This study found no clear evidence to recommend single-drug therapy for improving pain and quality of life in AM management within 12 months. Combining LNG-IUS with GnRH-a is effective in alleviating pain, controlling heavy bleeding, reducing lesion volume, reducing the probability of expulsion and irregular bleeding. Postoperative LNG-IUS helps reduce long-term pain and bleeding. In combined FUA, LNG-IUS is effective for managing short-term pain and bleeding. TRIAL REGISTRATION PROSPERO registration number: CRD42024578824.
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Affiliation(s)
- Biyun Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Jinghua Shi
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Zhiyue Gu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Yushi Wu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Xiaoyan Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Chenyu Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Hailan Yan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Qiutong Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Shiqing Lyu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Yi Dai
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Jinhua Leng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China.
- , Shuaifuyuan No. 1, Dongcheng District, Beijing, China.
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Shi J, Gu Z, Wu Y, Li X, Zhang J, Zhang C, Yan H, Dai Y, Leng J. Long-term efficacy and safety of levonorgestrel releasing intrauterine system in the treatment of adenomyosis: evidence mapping. Arch Gynecol Obstet 2024; 310:55-67. [PMID: 38836931 DOI: 10.1007/s00404-024-07546-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 05/02/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE To summarize evidence on levonorgestrel releasing intrauterine system (LNG-IUS) in the treatment of adenomyosis (AM) and to identify potential research gaps. METHODS Search was conducted in MEDLINE, The Cochrane Library, EMBASE, CBM, CNKI, and Wanfang. We included studies investigating patients with AM treated with LNG-IUS combined with conservative therapy. RESULTS Thirty-nine studies compared LNG-IUS with other conservative therapeutic drugs. The most common comparison was GnRH-a + LNG-IUS vs. LNG-IUS alone, followed by LNG-IUS vs. mifepristone, expected treatment, and GnRH-a. GnRH-a + LNG-IUS was more beneficial in reducing the intensity of dysmenorrhea than LNG-IUS alone at the 6-month follow-up in patients with an enlarged uterus and moderate to severe dysmenorrhea. Large and well-designed studies are needed to confirm the efficacy of LNG-IUS and GnRH-a on reducing uterine volume at 6-month follow-up. Thirty-two studies investigated LNG-IUS as the postoperative management. The most common comparison was surgical excision + LNG-IUS vs. surgical excision. Results showed VAS scores were lower in the surgical excision + LNG-IUS group than in the surgical excision group at the 1-year follow-up. Evidence on endometrial thickness, quality of life, adverse events and beneficial effect at 3 and 5 years are needed. CONCLUSIONS Combined GnRH-a and LNG-IUS treatment was more efficacious than LNG-IUS alone for patients with an enlarged uterus and moderate to severe dysmenorrhea. Moreover, LNG-IUS seemed to show potential long-term benefits in postoperative therapy, warranting further meta-analysis for confirmation.
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Affiliation(s)
- Jinghua Shi
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Zhiyue Gu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Yushi Wu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Xiaoyan Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Jing Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Chenyu Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Hailan Yan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Yi Dai
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Jinhua Leng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Dongcheng District, Beijing 100730, China.
- National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China.
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Jiang J, Pan Y, Yu J, Zhang Y, Yang Y, Xu H, Sun F. Laparoscopic adenomyomectomy combined with levonorgestrel-releasing intrauterine system is effective for long-term management of adenomyosis. BMC Womens Health 2024; 24:28. [PMID: 38191409 PMCID: PMC10775492 DOI: 10.1186/s12905-023-02795-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/20/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUD Laparoscopic adenomyomectomy combined with intraoperative placement of levonorgestrel-releasing intrauterine device (LNG-IUS) is a novel conservative surgical procedure for adenomyosis. Our study aimed to compare the efficacy of surgery with or without intraoperative placement of LNG-IUS treatment in adenomyosis. METHODS We retrospectively reviewed the medical records of adenomyosis patients who received laparoscopic adenomyomectomy from January 2014 to April 2020, finally including 70 patients undergoing surgery-LNG-IUS as group A and 69 patients undegoing surgery only as group B. Risk factors for three-year relapse were analyzed using Cox's multivariate proportional hazard analysis. RESULTS Visual analog scale and Mansfield-Voda-Jorgensen Menstrual Bleeding Scale scores of group A at 3, 6, 12, 24, and 36 months were significantly lower than those of group B at the corresponding points (P < .001 for both scales). Individuals in both groups showed statistically significant symptom relief. The recurrence rate in group A was significantly lower than that in group B at 36 months after the surgery (2.94% vs. 32.84%, P < .001). A cox proportional hazard model showed that relapse was significantly associated with coexisting ovarian endometriosis (adjusted hazard ratio [aHR], 2.94; 95% confidence interval [CI], 1.33-7.02, P = .015). Patients who received surgery-LNG-IUS had a lower risk of recurrence than those with surgery-alone (aHR, 0.07; 95% CI, 0.016-0.31, P < .001). CONCLUSIONS Conservative surgery with intraoperative placement of LNG-IUS is effective and well-accepted for long-term therapy with a lower recurrence rate for adenomyosis. Coexistent ovarian endometriosis is a major factor for adenomyosis relapse.
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Affiliation(s)
- Jilan Jiang
- 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
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
- Shanghai Municipal Key Clinical Speciality, Shanghai, China
| | - Yilian Pan
- 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
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
- Shanghai Municipal Key Clinical Speciality, Shanghai, China
| | - Jin Yu
- 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
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
- Shanghai Municipal Key Clinical Speciality, Shanghai, China
| | - Ye Zhang
- 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
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
- Shanghai Municipal Key Clinical Speciality, Shanghai, China
| | - Yeping Yang
- 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
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China
- Shanghai Municipal Key Clinical Speciality, Shanghai, China
| | - 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.
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.
- Shanghai Municipal Key Clinical Speciality, Shanghai, China.
| | - Feng Sun
- 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.
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.
- Shanghai Municipal Key Clinical Speciality, Shanghai, China.
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Choudhury S, Jena SK, Mitra S, Padhy BM, Mohakud S. Comparison of efficacy between levonorgestrel intrauterine system and dienogest in adenomyosis: a randomized clinical trial. Ther Adv Reprod Health 2024; 18:26334941241227401. [PMID: 38283750 PMCID: PMC10812097 DOI: 10.1177/26334941241227401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 12/20/2023] [Indexed: 01/30/2024] Open
Abstract
Background Medical management of adenomyosis is an emerging perspective in modern gynecology. Though levonorgestrel intrauterine system (LNG-IUS) and dienogest (DNG) effectively relieve symptoms in adenomyosis, neither has been approved for the same indication. Our study aims to compare the efficacy and safety of these progestins in treating adenomyosis. Objective To study the efficacy and safety of LNG-IUS versus DNG in patients with symptomatic adenomyosis. Design Open-labeled, parallel, single-centered, randomized clinical trial. Methods Patients with adenomyosis-associated pain with or without abnormal uterine bleeding were randomly allocated to either LNG-IUS group or DNG group. The primary outcome was a reduction in painful symptoms after 12 weeks of treatment measured by visual analog scale (VAS) score. Changes in menstrual blood loss (MBL), improvement in quality of life (QoL), and adverse drug reactions were also analyzed. Results The VAS score significantly decreased from baseline in both groups. The baseline and post-treatment VAS scores in the LNG-IUS group were 6.41 ± 1.07 and 3.41 ± 1.04 (p = <0.001) and in the DNG group, were 6.41 ± 0.95 and 3.12 ± 1.40 (p = <0.001), respectively. A significantly greater proportion of patients in the LNG-IUS group experienced lighter MBL as compared to the DNG group [27/30 (90%) in the LNG-IUS group versus 17/22 (77.2%) in the DNG group (p = 0.006)]. Both the groups had improvement in QOL scores calculated by the World Heath Organisation QOL scale (WHOQOL BREF) questionnaire; however, it was more pronounced in the DNG group [(28.76 ± 30.47 in the LNG-IUS group versus 48.26 ± 44.91 in the DNG group (p = 0.04)]. Both the agents were safe as there were no reported major adverse drug reactions. Conclusion DNG can be an effective and safe alternative to LNG-IUS for the medical management of adenomyosis. Trial registration The trial was prospectively registered at the clinical trial registry - India (CTRI) vide CTRI number CTRI/2020/05/025186.
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Affiliation(s)
- Satish Choudhury
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, MIG 08, Housing Board Colony, Athgarh, Cuttack, Bhubaneswar, Odisha 754029, India
| | - Saubhagya Kumar Jena
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Subarna Mitra
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Biswa Mohan Padhy
- Department of Pharmacology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Sudipta Mohakud
- Department of Radiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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MacGregor B, Munro MG, Lumsden MA. Therapeutic options for the management of abnormal uterine bleeding. Int J Gynaecol Obstet 2023; 162 Suppl 2:43-57. [PMID: 37538018 DOI: 10.1002/ijgo.14947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Just as the investigation of abnormal uterine bleeding (AUB) is approached systematically using the two FIGO systems for AUB in the reproductive years, treatment options can be considered similarly. Therapeutic options fall into two categories-medical and surgical-and while medical management is typically regarded as first-line therapy, there are several exceptions defined by the presenting cause or causes, mainly when infertility is a concurrent issue. In the early 1990s, up to 60% of women underwent a hysterectomy for the symptom of heavy menstrual bleeding (HMB), but this figure has decreased. The number of women undergoing a hysterectomy for benign disorders continues to decline, along with an increase in hysterectomies performed using minimally invasive techniques. Discussions about therapeutic options are tailored to the individual patient, and we include the risks and benefits of each option, including no management, to enable the patient to make an informed choice. The different types of treatment options and the factors affecting decision-making are considered in this article.
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Affiliation(s)
| | - Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
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Shi JH, Zhu SY, Li XY, Dai Y, Leng JH. The role of levonorgestrel-releasing intrauterine system for recurrence prevention after conservative surgery among patients with coexistent ovarian endometrioma and diffuse adenomyosis: A retrospective case control study with long-term follow up. J Gynecol Obstet Hum Reprod 2023; 52:102572. [PMID: 36914113 DOI: 10.1016/j.jogoh.2023.102572] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/27/2023] [Accepted: 03/08/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND When ovarian endometrioma coexist with adenomyosis, the risk of postoperative recurrence increased. How is the effect of levonorgestrel-releasing intrauterine system (LNG-IUS) on symptomatic recurrence for those patients was unknown. METHODS This study retrospectively analyzed 119 women with coexistent endometrioma and diffuse adenomyosis who received laparoscopic excision of pelvic endometriosis from January 2009 to April 2013. Women were categorized into two groups: intervention group with LNG-IUS and control group with expectant observation after surgery. Data were compared in terms of preoperative history, laboratory and intraoperative findings, and clinical outcomes during follow-up, including pain regression, changes in uterine volume and recurrence. RESULTS During a median 79 months (range, 6-107) of follow-up, patients with LNG-IUS experienced a significantly lower symptomatic recurrence of either ovarian endometrioma or dysmenorrhea (11.1% vs. 31.1%, p = 0.013), compared with women under expectant observation by Kaplan-Meier survival analysis (χ2 = 5.448, p = 0.020) and Cox univariate assessment (hazard ratio of 0.336, 95% confidence interval 0.128-0.885, p = 0.027). Patients treated with LNG-IUS demonstrated a more prominent reduction in uterine volume (-14.1 ± 20.9 vs. 8.7 ± 48.8, p = 0.003) and higher percentage of complete pain remission (95.6% vs. 86.5%). For multivariate analysis, use of LNG-IUS (aHR 0.159, 95%CI 0.033-0.760, p = 0.021) and severity of dysmenorrhea (aHR 4.238, 95%CI 1.191-15.082, p = 0.026) were two independent factors associated with overall recurrence. CONCLUSION Postoperative insertion of LNG-IUS may prevent recurrence in symptomatic women with comorbidity of ovarian endometrioma and diffuse adenomyosis.
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Affiliation(s)
- Jing-Hua Shi
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Shi-Yang Zhu
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China, Key Laboratory of Obstetrics and Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Xiao-Yan Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China.
| | - Yi Dai
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Jin-Hua Leng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
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Liu L, Tian H, Lin D, Zhao L, Wang H, Hao Y. Risk of Recurrence and Reintervention After Uterine-Sparing Interventions for Symptomatic Adenomyosis: A Systematic Review and Meta-Analysis. Obstet Gynecol 2023; 141:711-723. [PMID: 36897132 PMCID: PMC10026977 DOI: 10.1097/aog.0000000000005080] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/17/2022] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To evaluate the risk of recurrence and reintervention after uterine-sparing treatment options for symptomatic adenomyosis, including adenomyomectomy, uterine artery embolization (UAE), and image-guided thermal ablation. DATA SOURCES We searched electronic databases such as Web of Science, MEDLINE, Cochrane Library, EMBASE, ClinicalTrials.gov, and Google Scholar from January 2000 to January 2022. The search was conducted using the following search terms: "adenomyosis," "recurrence," "reintervention," "relapse," and "recur." METHODS OF STUDY SELECTION All studies that described the risk of recurrence or reintervention after uterine-sparing interventions for symptomatic adenomyosis were reviewed and screened according to the eligibility criteria. Recurrence was defined as the reappearance of symptoms (painful menses or heavy menstrual bleeding) after significant or complete remission, or the reappearance of adenomyotic lesions confirmed by ultrasonography or magnetic resonance imaging. TABULATION, INTEGRATION, AND RESULTS The outcome measures were presented as the frequency with percentage and pooled with 95% CI. A total of 42 studies (single-arm retrospective and prospective studies) that represented 5,877 patients were included. The recurrence rates after adenomyomectomy, UAE, and image-guided thermal ablation were 12.6% (95% CI 8.9-16.4%), 29.5% (95% CI 17.4-41.5%), and 10.0% (95% CI 5.6-14.4%), respectively. The reintervention rates were 2.6% (95% CI 0.9-4.3%), 12.8% (95% CI 7.2-18.4%), and 8.2% (95% CI 4.6-11.9%) after adenomyomectomy, UAE, and image-guided thermal ablation, respectively. Subgroup analysis and sensitivity analysis were performed, and the heterogeneity was reduced in several analyses. CONCLUSION Uterine-sparing techniques were successful in treating adenomyosis with low reintervention rates. Uterine artery embolization had higher recurrence and reintervention rates than other techniques; however, patients treated with UAE had larger uteri and larger adenomyosis, indicating that selection bias may influence these results. More randomized controlled trials with a larger population are needed in the future. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021261289.
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Affiliation(s)
- Lu Liu
- Department of Ultrasound Medicine, South China Hospital, Medical School, Shenzhen University, Shenzhen, China
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Harada T, Taniguchi F, Guo S, Choi YM, Biberoglu KO, Tsai SS, Alborzi S, Al‐Jefout M, Chalermchokcharoenkit A, Sison‐Aguilar AG, Fong Y, Senanayake H, Popov A, Hestiantoro A, Kaufman Y. The Asian Society of Endometriosis and Adenomyosis guidelines for managing adenomyosis. Reprod Med Biol 2023; 22:e12535. [PMID: 37701076 PMCID: PMC10493363 DOI: 10.1002/rmb2.12535] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 08/03/2023] [Indexed: 09/14/2023] Open
Abstract
This is the first guidelines for adenomyosis from the Asian Society of Endometriosis and Adenomyosis.
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Affiliation(s)
| | | | - Sun‐Wei Guo
- OB/GYN HospitalFudan UniversityShanghaiChina
| | | | | | | | | | - Moamar Al‐Jefout
- United Arab Emirates University, College of Medicine and Health SciencesAbu DhabiUAE
| | | | | | - Yoke‐Fai Fong
- National University of SingaporeSingapore CitySingapore
| | | | - Alexander Popov
- Moscow Regional Scientific Research Institute of Obstetrics and GynecologyMoscowRussia
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Jain V, Chodankar RR, Maybin JA, Critchley HOD. Uterine bleeding: how understanding endometrial physiology underpins menstrual health. Nat Rev Endocrinol 2022; 18:290-308. [PMID: 35136207 PMCID: PMC9098793 DOI: 10.1038/s41574-021-00629-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 12/16/2022]
Abstract
Menstruation is a physiological process that is typically uncomplicated. However, up to one third of women globally will be affected by abnormal uterine bleeding (AUB) at some point in their reproductive years. Menstruation (that is, endometrial shedding) is a fine balance between proliferation, decidualization, inflammation, hypoxia, apoptosis, haemostasis, vasoconstriction and, finally, repair and regeneration. An imbalance in any one of these processes can lead to the abnormal endometrial phenotype of AUB. Poor menstrual health has a negative impact on a person's physical, mental, social, emotional and financial well-being. On a global scale, iron deficiency and iron deficiency anaemia are closely linked with AUB, and are often under-reported and under-recognized. The International Federation of Gynecology and Obstetrics have produced standardized terminology and a classification system for the causes of AUB. This standardization will facilitate future research endeavours, diagnosis and clinical management. In a field where no new medications have been developed for over 20 years, emerging technologies are paving the way for a deeper understanding of the biology of the endometrium in health and disease, as well as opening up novel diagnostic and management avenues.
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Affiliation(s)
- Varsha Jain
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Rohan R Chodankar
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
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Elbasueny B, Geerts M, Allaire C, Yong PJ, Bedaiwy MA. Medical Treatment of Adenomyosis. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022. [DOI: 10.1007/s13669-022-00325-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Tellum T, Omtvedt M, Naftalin J, Hirsch M, Jurkovic D. A systematic review of outcome reporting and outcome measures in studies investigating uterine-sparing treatment for adenomyosis. Hum Reprod Open 2021; 2021:hoab030. [PMID: 34466664 PMCID: PMC8398753 DOI: 10.1093/hropen/hoab030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/08/2021] [Indexed: 01/03/2023] Open
Abstract
STUDY QUESTION Which outcomes and outcome measures are reported in interventional trials evaluating the treatment of adenomyosis? SUMMARY ANSWER We identified 38 studies, reporting on 203 outcomes using 133 outcome measures. WHAT IS KNOWN ALREADY Heterogeneity in outcome evaluation and reporting has been demonstrated for several gynaecological conditions and in fertility studies. In adenomyosis, previous systematic reviews have failed to perform a quantitative analysis for central outcomes, due to variations in outcome reporting and measuring. STUDY DESIGN, SIZE, DURATION A systematic search of Embase, Medline and Cochrane Register of Controlled Trials (CENTRAL) was performed with a timeframe from 1950 until February 2021, following the preferred reporting items for systematic reviews and meta-analysis (PRISMA). PARTICIPANTS/MATERIALS, SETTING, METHODS Studies reporting on any uterus-sparing intervention to treat adenomyosis, both prospective and retrospective, were eligible for inclusion. Inclusion criteria were a clear definition of diagnostic criteria for adenomyosis and the modality used to make the diagnosis, a clear description of the intervention, a follow-up time of ≥6 months, a study population of n ≥ 20, a follow-up rate of at least 80%, and English language. The population included premenopausal women with adenomyosis. Risk of bias was assessed using the Evidence Project risk of bias tool. MAIN RESULTS AND THE ROLE OF CHANCE We included 38 studies (6 randomized controlled trials and 32 cohort studies), including 5175 participants with adenomyosis. The studies described 10 interventions and reported on 203 outcomes, including 43 classified as harms, in 29 predefined domains. Dysmenorrhoea (reported in 82%), heavy menstrual bleeding (HMB) (in 79%) and uterine volume (in 71%) were the most common outcomes. Fourteen different outcome measures were used for dysmenorrhoea and 17 for HMB. Quality of life was reported in 9 (24%) studies, patient satisfaction with treatment in 1 (3%). A clear primary outcome was stated in only 18%. LIMITATIONS, REASONS FOR CAUTION This review includes studies with a high risk of bias. WIDER IMPLICATIONS OF THE FINDINGS Shortcomings in the definition and choice of outcomes and outcome measures limit the value of the conducted research. The development and implementation of a core outcome set (COS) for interventional studies in adenomyosis could improve research quality. This review suggests a lack of patient-centred research in adenomyosis and people with adenomyosis should be involved in the development and implementation of the COS. STUDY FUNDING/COMPETING INTERESTS No funds specifically for this work were received. T.T. receives fees from General Electrics for lectures on ultrasound independently of this project. TRIAL REGISTRATION NUMBER This review is registered with the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42020177466) and the Core Outcome Measures in Effectiveness Trials (COMET) initiative (registration number 1649).
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Affiliation(s)
- T Tellum
- Department of Gynecology, Oslo University Hospital, Oslo, Norway
| | - M Omtvedt
- Department of Gynecology, Oslo University Hospital, Oslo, Norway
| | - J Naftalin
- Institute for Women's Health, University College Hospital, London, UK
| | - M Hirsch
- Department of Gynaecology, Oxford University Hospitals, Oxford, UK
| | - D Jurkovic
- Institute for Women's Health, University College Hospital, London, UK
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Hai N, Hou Q, Guo R. Ultrasound-guided transvaginal radiofrequency ablation combined with levonorgestrel-releasing intrauterine system for symptomatic uterine adenomyosis treatment. Int J Hyperthermia 2021; 38:65-69. [PMID: 33472465 DOI: 10.1080/02656736.2021.1874063] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To evaluate the clinical outcomes of transvaginal ultrasound-guided radiofrequency ablation (RFA) combined with a levonorgestrel-releasing intrauterine system (LNG-IUS) for the treatment of symptomatic uterine adenomyosis. METHODS Patients with symptomatic uterine adenomyosis treated with ultrasound-guided RFA in combined with an LNG-IUS from January 2013 to January 2016 and followed up for 3 years after treatment were selected. Assessment endpoints included the uterine volume reduction rate, dysmenorrheal score, symptom severity score and adverse events. RESULTS Among the 72 patients, 64 completed the 3-year follow-up evaluations after treatment. No LNG-IUS expulsion was reported. Dysmenorrhea and symptom severity scores statistically significantly declined after the combined treatment of RFA and LNG-IUS was administered. The uterine volume significantly decreased, and the average reduction rate was 55%. CONCLUSION Ultrasound-guided RFA combined with an LNG-IUS might be a simple, safe and effective alternative for the treatment of symptomatic adenomyosis.
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Affiliation(s)
- Ning Hai
- Department of Ultrasound, Beijing Chaoyang Hospital Capital Medical University, Beijing, China.,Department of Gynecology, The PLA Rocket Force General Hospital, Beijing, China
| | - Qingxiang Hou
- Department of Gynecology, The PLA Rocket Force General Hospital, Beijing, China
| | - Ruijun Guo
- Department of Ultrasound, Beijing Chaoyang Hospital Capital Medical University, Beijing, China
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