Current and Future Medical Treatment of Adenomyosis

The impact of reproductive health needs on women's employment: a qualitative insight into managing endometriosis and work

BACKGROUND

Reproductive health conditions present various challenges for women in all aspects of their lives, including in the workplace. This study explores the workplace experiences of employed women with reproductive healthcare needs arising predominantly from endometriosis, as well as adenomyosis and infertility.

METHODS

Semi-structured interviews were conducted with 12 women with one or more of these conditions who were employed while experiencing symptoms of their condition or seeking treatment (such as in-vitro fertilization or laparoscopic surgery).

RESULTS

Interviewees reported significant physical and psychological hardship because of their reproductive health conditions, namely pain associated with endometriosis. The impact of reproductive health needs and treatment on women's ability to work included: difficulty managing symptoms, additional pressure to perform, exhaustion of 'sick leave', and working less and negative impact on career progression. In terms of how workplaces can improve the wellbeing of women with endometriosis and other reproductive health needs, women would benefit from: flexibility and working from home, access to paid reproductive health leave, and improved workplace education, trust and understanding.

CONCLUSIONS

Women's own accounts of how endometriosis and their reproductive health impacts their working lives, and what employers can do to support them, provides a platform to better understand women's needs. These findings can inform public-policy solutions and workplace policies to better meet the needs of women with endometriosis and improve their workforce participation.

The use of dienogest in treatment of symptomatic adenomyosis: A systematic review and meta-analysis

Adenomyosis is a gynaecological problem that impacts women's quality of life by causing dysmenorrhea, chronic pelvic pain, and menorrhagia. The search continues for the best medical treatment for symptomatic adenomyosis. This systematic review and meta-analysis investigated the role of dienogest, an oral progestin, in reducing pain and bleeding associated with adenomyosis. Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, Scopus, and Web of Science were searched in January 2024. The primary outcome was pain scores for dysmenorrhea, whereas secondary outcomes were chronic pelvic pain (CPP), uterine volume (UV), and menorrhagia. One comparison was performed comparing outcomes in symptomatic adenomyosis before and after treatment with dienogest. Pooled analysis of included studies reported a statistically significant reduction of dysmenorrhea pain score after dienogest treatment (mean difference -5.86 cm on a 10-cm visual analogue scale, 95 % CI -7.20 to -4.53, I2 = 97 %). Regarding chronic pelvic pain, a meta-analysis of included studies showed a significant decline in pain after treatment (standardized mean difference -2.37, 95 % CI -2.89 to -1.86, I2 = 60 %). However, uterine volume did not differ significantly after treatment (mean difference -4.65 cm3, 95 % CI -43.22 to 33.91). Menorrhagia was improved significantly after treatment (Peto odds ratio 0.07, 95 % CI 0.03 to 0.18). In conclusion, dienogest seems to be effective in controlling painful symptoms and uterine bleeding in women with adenomyosis at short and long-term therapy.

Percutaneous cryoablation of symptomatic uterine adenomyomas: Initial experience

OBJECTIVE

To assess the efficacy and safety of percutaneous image-guided cryoablation of adenomyomas MATERIAL AND METHODS: Five symptomatic women who wanted to preserve their uterus and fertility underwent a single session of percutaneous image-guided cryoablation of adenomyoma. Three to six 17-gauge cryoprobes were introduced percutaneously into the adenomyoma under ultrasound and laparoscopy guidance. Clinical efficacy was defined as the diminution of the Visual Analogue Scale of pain (VAS), the decrease in uterine bleeding and the improvement of quality of life assessed by the endometriosis health profile 5 (EHP-5) 12 months after treatment. Technical efficacy was defined by the reduction in volume of each treated adenomyoma on MRI. Complications were classified using the Clavien-Dindo classification system. Hysterosonography was performed at least 3 months after the procedure.

RESULTS

Compared to the baseline, all symptom scores had decreased after 12 months: median VAS 8/10 (range, 5-10) to 4/10 (range, 0-7); median dyspareunia score 7/10 (range, 0-10) to 2/10 (range, 0-8); median bleeding score 335 (range, 102-920) to 76 (range, 0-88); median EHP-5 score 60/100 (range, 50-75) to 50/100 (range, 32-55). The median volume of adenomyosis decreased from 57 cm3 (range, 8-87) to 9 cm3 (range, 2-45) at 12 months. No postoperative complications occurred. Two patients had incomplete intrauterine adhesions that were easily removed hysteroscopically.

CONCLUSION

Cryoablation may be a promising alternative treatment for symptomatic adenomyoma in women who want to preserve their uterus.

Low-dose letrozole - an effective option for women with symptomatic adenomyosis awaiting IVF: a pilot randomized controlled trial

RESEARCH QUESTION

Can low-dose letrozole reduce dysmenorrhoea, menorrhagia and sonographic features in symptomatic women with adenomyosis awaiting IVF?

DESIGN

This was a longitudinal randomized prospective pilot study to explore the effectiveness of low-dose letrozole and compare it with a gonadotropin releasing hormone (GnRH) agonist in reducing dysmenorrhoea, menorrhagia and sonographic features in symptomatic women with adenomyosis awaiting IVF. The women were treated for 3 months, either with the GnRH agonist goserelin 3.6 mg/month (n = 77) or the aromatase inhibitor letrozole 2.5 mg three times weekly (n = 79). Dysmenorrhoea and menorrhagia were evaluated at randomization and followed up monthly using a visual analogue score (VAS) and pictorial blood loss assessment chart (PBAC), respectively. A quantitative scoring method was used to assess the improvement of sonographic features after 3 months of treatment.

RESULTS

Both groups reported a marked improvement in symptoms after 3 months of treatment. In both the letrozole and GnRH agonist groups, VAS and PBAC scores decreased significantly over the 3 months (letrozole: P = 0.0001 and P = 0.0001 for VAS and PBAC, respectively; GnRH agonist: P = 0.0001 and P = 0.0001 for VAS and PBAC, respectively). Participants on letrozole had regular menstruation cycles, while most of the women who received the GnRH agonist were amenorrhoeic, with only four women reporting mild bleeding. Haemoglobin concentrations also improved after both treatments (letrozole P = 0.0001, GnRH agonist P = 0.0001). A quantitative assessment of sonographic features showed significant improvements following both treatments (diffuse adenomyosis of the myometrium: letrozole P = 0.015, GnRH agonist P = 0.039; diffuse adenomyosis of the junctional zone: letrozole P = 0.025, GnRH agonist P = 0.001). Women with adenomyoma also responded well to both therapies (letrozole P = 0.049, GnRH agonist P = 0.024), whereas the letrozole group responded comparatively better in focal adenomyosis when the outer myometrium was involved (letrozole P < 0.001, GnRH agonist P = 0.26). No noticeable side effects were observed in women receiving letrozole therapy. Additionally, letrozole therapy was found to be more cost-effective than GnRH agonist treatment.

CONCLUSIONS

Low-dose letrozole treatment is a low-cost alternative to a GnRH agonist, with comparable effects in improving the symptoms and sonographic features of adenomyosis in women awaiting IVF.

Management of uterine adenomyosis: current trends and uterine artery embolization as a potential alternative to hysterectomy

Adenomyosis is a challenging clinical condition that is commonly being diagnosed in women of reproductive age. To date, many aspects of the disease have not been fully understood, making management increasingly difficult. Over time, minimally invasive diagnostic and treatment methods have developed as more women desire uterine preservation for future fertility or to avoid major surgery. Several uterine-sparing treatment options are now available, including medication, hysteroscopic resection or ablation, conservative surgical methods, and high-intensity focused ultrasound each with its own risks and benefits. Uterine artery embolization is an established treatment option for uterine fibroids and has recently gained ground as a safe and cost-effective method for treatment of uterine adenomyosis with promising results. In this review, we discuss current trends in the management of uterine adenomyosis with a special focus on uterine artery embolization as an alternative to hysterectomy.

Recent advances in understanding and managing adenomyosis

Adenomyosis is a benign uterine disorder in which endometrial glands and stroma are pathologically demonstrated in the uterine myometrium and it is considered a specific entity in the PALM-COEIN FIGO (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified - International Federation of Gynecology and Obstetrics) classification of causes of abnormal uterine bleeding (AUB). Although it has always been considered the classic condition of multiparous women over 40 years old who have pain and heavy menstrual bleeding, diagnosed at hysterectomy, the epidemiological scenario has completely changed. Adenomyosis is increasingly identified in young women with pain, AUB, infertility, or no symptoms by using imaging techniques such as transvaginal ultrasound and magnetic resonance. However, there is no agreement on the definition and classification of adenomyotic lesions from both the histopathology and the imaging point of view, and the diagnosis remains difficult and unclear. A uniform and shared reporting system needs to be implemented in order to improve our understanding on imaging features, their relationship with pathogenic theories, and their importance in terms of clinical symptoms and response to treatment. In fact, adenomyosis pathogenesis remains elusive and not a single theory can explain all of the different phenotypes of the disease. Furthermore, adenomyosis often coexists with other gynecological conditions, such as endometriosis and uterine fibroids, increasing the heterogeneity of available data. Treatment requires a lifelong management plan as the disease has a negative impact on quality of life in terms of menstrual symptoms, fertility, and pregnancy outcome and has a high risk of miscarriage and obstetric complications.

Does presence of adenomyosis affect reproductive outcome in IVF cycles? A retrospective analysis of 973 patients

RESEARCH QUESTION

Reports on the effect of adenomyosis on assisted reproductive technology (ART) outcomes are conflicting. Does presence of adenomyosis affect reproductive outcome in IVF cycles in women pretreated with gonadotrophin releasing hormone (GnRH) agonist?

DESIGN

In this retrospective cohort study, 973 women were divided into four groups: only endometriosis (n = 355); endometriosis and adenomyosis (n = 88); adenomyosis alone (n = 64); and tubal factor infertility as controls (n = 466). The pregnancy outcome parameters (clinical pregnancy, miscarriage rate, live birth rate) were compared between these groups.

RESULTS

The clinical pregnancy rate was 36.62% in women with endometriosis alone, 22.72% in women with endometriosis and adenomyosis, 23.44% in women who only had adenomyosis and 34.55% in controls. Miscarriage rates were as follows: 14.62%, 35%, 40% and 13.04%, respectively. Live birth rates were 27.47% in controls; 26.48% in women with only endometriosis; 11.36% in women with endometriosis and adenomyosis; and 12.5% in women with only adenomyosis. Live birth was observed to be less in adenomyosis groups compared with controls and women with only endometriosis. No significant difference was observed in clinical pregnancy, miscarriage or live birth rate between controls and women with only endometriosis. Live birth rate was significantly different between controls and women with adenomyosis only (P = 0.01) and women with endometriosis and adenomyosis (P = 0.002).

CONCLUSION

Presence of adenomyosis seems to have adverse effects on IVF outcomes in clinical pregnancy rate, live birth rate and miscarriage rate. Screening for adenomyosis might be considered before ART so that the couple has better awareness of the prognosis.

Role of medical therapy in the management of uterine adenomyosis

Adenomyosis is a benign uterine condition affecting women at various ages with different symptoms. The management of these patients is still controversial. Few clinical studies focusing on medical or surgical treatment for adenomyosis have been performed. No drug is currently labelled for adenomyosis and there are no specific guidelines to follow for the best management. Anyhow, medical treatments are effective in improving symptoms (pain, abnormal uterine bleeding and infertility). The rationale for using medical treatment is based on the pathogenetic mechanisms of adenomyosis: sex steroid hormones aberrations, impaired apoptosis, and increased inflammation. Several nonhormonal (i.e., nonsteroidal anti-inflammatory drugs) and hormonal treatments (i.e., progestins, oral contraceptives, gonadotropin-releasing hormone analogues) are currently used off-label to control pain symptoms and abnormal uterine bleeding in adenomyosis. Gonadotropin-releasing hormone analogues are indicated before fertility treatments to improve the chances of pregnancy in infertile women with adenomyosis. An antiproliferative and anti-inflammatory effect of progestins, such as dienogest, danazol and norethindrone acetate, suggests their use in medical management of adenomyosis mainly to control pain symptoms. On the other hand, the intrauterine device releasing levonorgestrel resulted is extremely effective in resolving abnormal uterine bleeding and reducing uterine volume in a long-term management plan. Based on new findings on pathogenetic mechanisms, new drugs are under development for the treatment of adenomyosis, such as selective progesterone receptor modulators, aromatase inhibitors, valproic acid, and anti-platelets therapy.