1
|
Etrusco A, Barra F, Chiantera V, Ferrero S, Bogliolo S, Evangelisti G, Oral E, Pastore M, Izzotti A, Venezia R, Ceccaroni M, Laganà AS. Current Medical Therapy for Adenomyosis: From Bench to Bedside. Drugs 2023; 83:1595-1611. [PMID: 37837497 PMCID: PMC10693526 DOI: 10.1007/s40265-023-01957-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 10/16/2023]
Abstract
Adenomyosis, characterized by the growth of endometrial tissue within the uterine wall, poses significant challenges in treatment. The literature primarily focuses on managing abnormal uterine bleeding (AUB) and dysmenorrhea, the main symptoms of adenomyosis. Nonsteroidal anti-inflammatory drugs (NSAIDs) and tranexamic acid provide limited support for mild symptoms or symptom re-exacerbation during hormone therapy. The levonorgestrel-releasing intrauterine system (LNG-IUS) is commonly employed in adenomyosis management, showing promise in symptom improvement and reducing uterine size, despite the lack of standardized guidelines. Dienogest (DNG) also exhibits potential benefits, but limited evidence hinders treatment recommendations. Danazol, while effective, is limited by androgenic side effects. Combined oral contraceptives (COCs) may be less effective than progestins but can be considered for contraception in young patients. Gonadotropin-releasing hormone (GnRH) agonists effectively manage symptoms but induce menopausal symptoms with prolonged use. GnRH antagonists are a recent option requiring further investigation. Aromatase inhibitors (AIs) show promise in alleviating AUB and pelvic pain, but their safety necessitates exploration and limited use within trials for refractory patients. This review highlights the complexity of diagnosing adenomyosis, its coexistence with endometriosis and uterine leiomyomas, and its impact on fertility and quality of life, complicating treatment decisions. It emphasizes the need for research on guidelines for medical management, fertility outcomes, long-term effects of therapies, and exploration of new investigational targets. Future research should optimize therapeutic strategies, expand our understanding of adenomyosis and its management, and establish evidence-based guidelines to improve patient outcomes and quality of life.
Collapse
Affiliation(s)
- Andrea Etrusco
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Palermo, Italy
| | - Fabio Barra
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"-ASL4, Metropolitan Area of Genoa, Genoa, Italy.
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Gynecologic Oncology, National Cancer Institute-IRCCS-Fondazione "G. Pascale", Naples, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Stefano Bogliolo
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"-ASL4, Metropolitan Area of Genoa, Genoa, Italy
| | - Giulio Evangelisti
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Engin Oral
- Department of Obstetrics and Gynecology, Bezmialem Vakif University, Istanbul, Turkey
| | - Mariana Pastore
- Hospital Pharmacy, Santa Maria della Misericordia University Hospital, University of Udine, Udine, Italy
| | - Alberto Izzotti
- Unit of Mutagenesis and Cancer Prevention, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
| | - Renato Venezia
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Palermo, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore-Don Calabria" Hospital, Negrar di Valpolicella, Verona, Italy
| | - Antonio Simone Laganà
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Palermo, Italy
| |
Collapse
|
2
|
Moldassarina RS. Modern view on the diagnostics and treatment of adenomyosis. Arch Gynecol Obstet 2023; 308:171-181. [PMID: 37060397 DOI: 10.1007/s00404-023-06982-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 02/14/2023] [Indexed: 04/16/2023]
Abstract
Adenomyosis is identified by the enlargement of the uterus secondary to such areas of the endometrium as the endometrial glands and stroma located deep in the myometrium, which causes its hyperplasia and hypertrophy. The most common signs of the development of adenomyosis in a patient are copious menstrual bleeding and dysmenorrhea. However, it should be borne in mind that in some patients, the disease may be asymptomatic. Despite the wide abundance of imaging and other diagnostic methods for diagnosing adenomyosis, there are currently no standard verified diagnostic criteria for pathologists. In addition, women with adenomyosis often have other concomitant gynaecological diseases, such as endometriosis or leiomyomas, which makes it difficult to diagnose and choose the optimal treatment for patients. Therefore, the purpose of this study was to highlight up-to-date and relevant information for the practitioner about the epidemiology, clinical manifestations, diagnostics and treatment options for adenomyosis. Sources from four databases (PubMed, Web of Science, Elsevier and Google Scholar) were used to search for data. As a result of a literature review, it was established that the "gold" standard for the diagnostics of adenomyosis is histological research methods, in particular, biopsy performed during hysteroscopy or laparoscopy, whereas imaging methods (transvaginal sonography, magnetic resonance imaging) are more often used for differential diagnostics of adenomyosis with other diseases. In addition, magnetic resonance imaging allows for a better differential diagnostics between adenomyosis and myomatosis and helps to recognise the disease at an early stage. Regarding treatment, there is currently no particular therapy and algorithms for the treatment of adenomyosis, which is primarily due to the lack of precise criteria for the diagnostics of the disease. However, the most effective therapeutic methods at the present stage are the use of aromatase inhibitors and gonadotropin-releasing hormone antagonists, whilst minimally invasive techniques, in particular, endometrial ablation and uterine artery embolisation, are becoming increasingly popular amongst surgical techniques.
Collapse
Affiliation(s)
- Rymgul S Moldassarina
- Department of Obstetrics and Gynecology, Pavlodar Branch of the Semey Medical University, 72/1 Toraigyrov Str., 140002, Pavlodar, Republic of Kazakhstan.
| |
Collapse
|
3
|
Lv M, Yu J, Huang Y, Ma J, Xiang J, Wang Y, Li L, Zhang Z, Liao H. Androgen Signaling in Uterine Diseases: New Insights and New Targets. Biomolecules 2022; 12:1624. [PMID: 36358974 PMCID: PMC9687413 DOI: 10.3390/biom12111624] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 12/06/2023] Open
Abstract
Common uterine diseases include endometriosis, uterine fibroids, endometrial polyps, endometrial hyperplasia, endometrial cancer, and endometrial dysfunction causing infertility. Patients with uterine diseases often suffer from abdominal pain, menorrhagia, infertility and other symptoms, which seriously impair their health and disturb their lives. Androgens play important roles in the normal physiological functions of the uterus and pathological progress of uterine diseases. Androgens in women are synthesized in the ovaries and adrenal glands. The action of androgens in the uterus is mainly mediated by its ligand androgen receptor (AR) that regulates transcription of the target genes. However, much less is known about the signaling pathways through which androgen functions in uterine diseases, and contradictory findings have been reported. This review summarizes and discusses the progress of research on androgens and the involvement of AR in uterine diseases. Future studies should focus on developing new therapeutic strategies that precisely target specific AR and their related signaling pathways in uterine diseases.
Collapse
Affiliation(s)
- Mu Lv
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Juanjuan Yu
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Yan Huang
- Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai 200032, China
| | - Jie Ma
- Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Jun Xiang
- Department of Urology, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China
| | - Yanqiu Wang
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China
| | - Linxia Li
- Department of Obstetrics and Gynecology, Seventh People’s Hospital of Shanghai University of Traditional Chinese Medicine, 358 Datong Road, Shanghai 200137, China
| | - Zhenbo Zhang
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China
- Shanghai Key Laboratory for Assisted Reproduction and Reproductive Genetics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200135, China
| | - Hong Liao
- Department of Clinical Laboratory Medicine, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai 200040, China
| |
Collapse
|
4
|
Al-Badr AA. Danazol. PROFILES OF DRUG SUBSTANCES, EXCIPIENTS, AND RELATED METHODOLOGY 2022; 47:149-326. [PMID: 35396014 DOI: 10.1016/bs.podrm.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A comprehensive profile of danazol describing the nomenclatures, formulae, elemental composition, appearance, uses and applications is presented. The profile contains the method which was utilized for the preparation of the drug substance and its respective scheme is outlined. The physical characteristics of the drug including the solubility, X-ray powder diffraction pattern, differential scanning calorimetry, thermal behavior and spectroscopic studies are described. The methods which were used for the analysis of the drug substance in bulk drug and/or in pharmaceutical formulations including the compendial, spectrophotometric, electrochemical and the chromatographic methods are reported. The stability, toxicity, pharmacokinetics, bioavailability, drug evaluation and monitoring, comparisons, pharmacology, in addition to several compiled reviews on the drug substance which were involved. Finally, two hundred and seventy-nine references are listed at the end of this profile.
Collapse
Affiliation(s)
- Abdullah A Al-Badr
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, Riyadh, Kingdom of Saudi Arabia
| |
Collapse
|
5
|
Kossaï M, Penault-Llorca F. Role of Hormones in Common Benign Uterine Lesions: Endometrial Polyps, Leiomyomas, and Adenomyosis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1242:37-58. [PMID: 32406027 DOI: 10.1007/978-3-030-38474-6_3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Leiomyoma, adenomyosis, and endometrial polyps are benign uterine disorders which seem to develop in the context of hormonal imbalances, due to steroid hormones, estrogen and progesterone, in association with various factors ranging from genetic factors to modifiable lifestyle factors. A growing body of evidence suggests that those hormones and their receptors are key modulators in the genesis and the growth of those pathologic entities. Further studies are required to understand their involvement in the pathogenesis of those lesions and their link to other factors such as extracellular matrix components, growth factors, chemokines, cytokines, and tissue repair mechanisms.
Collapse
Affiliation(s)
- Myriam Kossaï
- Department of Pathology and Molecular Pathology, Centre Jean Perrin, Clermont-Ferrand, France. .,UMR INSERM 1240, Universite Clermont Auvergne, Clermont-Ferrand, France.
| | - Frédérique Penault-Llorca
- Department of Pathology and Molecular Pathology, Centre Jean Perrin, Clermont-Ferrand, France. .,UMR INSERM 1240, Universite Clermont Auvergne, Clermont-Ferrand, France.
| |
Collapse
|
6
|
Di Guardo F, Shah M, Cerana MC, Biondi A, Karaman E, Török P, Yela DA, Giampaolino P, Marín-Buck A, Laganà AS. Management of women affected by endometriosis: Are we stepping forward? JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2019. [DOI: 10.1177/2284026519841520] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Endometriosis is an estrogen-dependent chronic disease defined by the presence of endometrial-like tissue, glands and stroma in ectopic areas. Among all the pathogenic theories proposed to explain the origin of the disease, a pivotal role for immune, hormonal, and epigenetic disbalances have been hypothesized. Endometriosis affects up to 10%–15% of women in reproductive age and represents one of the most common gynecological causes of severe pelvic pain. The main symptoms reported by patients are dysmenorrhea and deep dyspareunia. Although the histological confirmation has been commonly considered mandatory, to date the possibility offered by the improvement in imagining techniques allows to make a proper diagnosis of the disease in most of the cases. Medical therapy represents only a symptomatic treatment and not the definitive solution. The aim of the hormonal therapy is to abolish the menstrual flow using progestin, oral contraceptives, and gonadotropin-releasing hormone agonists to reduce pelvic pain. Surgical treatment consisting of laparoscopy has the goal of abolishing pain and may be conservative or radical in nature depending on the patients’ desire of spontaneous conception in the future. Radical surgery seems to be associated with a higher percentage of pain relief as well as higher recurrence rates. Due to the worldwide acceptance and the ongoing evolution of minimally invasive surgery to treat both benign and malignant diseases, future investigations may be conducted to consider this approach to save the function of all the organs involved by the disease and to reduce post-operative discomfort and psychological impact.
Collapse
Affiliation(s)
- Federica Di Guardo
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Mohsin Shah
- Department of Physiology, Institute of Basic Medical Sciences, Khyber Medical University, Peshawar, Pakistan
| | - Maria Cecilia Cerana
- Department of Internal Medicine, The University of Connecticut, Farmington, CT, USA
| | - Antonio Biondi
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Erbil Karaman
- Department of Obstetrics and Gynecology, Faculty of Medicine, Van Yüzüncü Yıl University, Van, Turkey
| | - Péter Török
- Department of Obstetrics and Gynecology, University of Debrecen Clinical Center, Debrecen, Hungary
| | - Daniela A. Yela
- Department of Obstetrics and Gynecology, Universidade Estadual de Campinas, Campinas, Brazil
| | | | - Alejandro Marín-Buck
- Department of Surgery, Universidad Cardenal Herrera-CEU, CEU Universities, Valencia, Spain
- Department of Gynecology, Hospital Provincial de Castellón, Castellón, Spain
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| |
Collapse
|
7
|
Vannuccini S, Luisi S, Tosti C, Sorbi F, Petraglia F. Role of medical therapy in the management of uterine adenomyosis. Fertil Steril 2018; 109:398-405. [PMID: 29566852 DOI: 10.1016/j.fertnstert.2018.01.013] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/08/2018] [Accepted: 01/09/2018] [Indexed: 12/19/2022]
Abstract
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.
Collapse
Affiliation(s)
- Silvia Vannuccini
- Department of Health Sciences, University of Florence, Obstetrics and Gynecology, Careggi University Hospital, Florence, Italy
| | - Stefano Luisi
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Claudia Tosti
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Flavia Sorbi
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Obstetrics and Gynecology, Careggi University Hospital, Florence, Italy
| | - Felice Petraglia
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Obstetrics and Gynecology, Careggi University Hospital, Florence, Italy.
| |
Collapse
|
8
|
Sriprasert I, Pakrashi T, Kimble T, Archer DF. Heavy menstrual bleeding diagnosis and medical management. Contracept Reprod Med 2017; 2:20. [PMID: 29201425 PMCID: PMC5683444 DOI: 10.1186/s40834-017-0047-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/07/2017] [Indexed: 11/10/2022] Open
Abstract
Heavy menstrual bleeding (HMB) is a common gynecological problem that has a significant impact on a woman’s quality of life and the activities of daily living. Due to the difficulty in accurately describing menstrual bleeding abnormalities using older terminology, the PALM-COEIN classification system of the Federation Internationale de Gynecologie et d’Obstetrique was proposed to describe and identify the etiology of abnormal endometrial bleeding. As there is no single pathway that is associated with HMB, there are several therapeutic interventions involving different molecular pathways to reduce HMB. This article will highlight the current evidence as it relates to the etiology of HMB as well as medical modalities of treatment.
Collapse
Affiliation(s)
- Intira Sriprasert
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Tarita Pakrashi
- Department of Obstetrics and Gynecology, Jones Institute for Reproductive Medicine/Eastern Virginia Medical School, Norfolk, VA USA
| | - Thomas Kimble
- CONRAD Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA USA
| | - David F Archer
- CONRAD Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA USA
| |
Collapse
|
9
|
Long-Term Vaginal Danazol Treatment in Fertile Age Women with Adenomyosis. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2017. [DOI: 10.5301/je.5000270] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The aim of the study was to evaluate the clinical efficacy of long-term vaginal danazol treatment in fertile age women with adenomyosis on pain symptoms and abnormal uterine bleeding (AUB). Methods A retrospective study on 66 young women with dysmenorrhea and/or dyspareunia, AUB and 2D-ultrasound diagnosis of adenomyosis was conducted at University Hospital of Siena (Italy). Women included were treated with a daily low-dose vaginal danazol (200 mg) for 6 months, followed by 2 different schedules: group A) continuous treatment for further 18 months (n = 30); group B) cyclic intermittent treatment with 3 months’ therapy followed by 3 months’ interval for further 18 months (n = 36). A visual analog scale (VAS) for pain symptoms, a pictorial blood-loss assessment chart (PBAC) for uterine bleeding, 2D-ultrasound signs of adenomyosis and quality-of-life measures were assessed at baseline and after both vaginal progestin regimens. Results The pain symptoms, PBAC score and uterine volume were significantly reduced (p<0.0001) after 6 months, and the reduction persisted in both group of patients until the end. Mental and physical index score values increased (p<0.0001) in both groups at the end of treatment, with significantly higher mental index scores in intermittent than in continuous treatment (p<0.0001), associated with some drop-out (10%). Conclusions A long-term treatment with vaginal danazol is effective to control pain and AUB in women with adenomyosis. The 6 months’ treatment followed by a cyclic 3 months’ treatment for further 18 months has the best compliance in symptomatic patients with adenomyosis.
Collapse
|
10
|
Tosti C, Biscione A, Morgante G, Bifulco G, Luisi S, Petraglia F. Hormonal therapy for endometriosis: from molecular research to bedside. Eur J Obstet Gynecol Reprod Biol 2017; 209:61-66. [DOI: 10.1016/j.ejogrb.2016.05.032] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/08/2016] [Accepted: 05/18/2016] [Indexed: 12/31/2022]
|
11
|
Current and Future Medical Treatment of Adenomyosis. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2016. [DOI: 10.5301/je.5000261] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Adenomyosis is a benign gynecological disorder associated with abnormal uterine bleeding, dysmenorrhea, dyspareunia and infertility, requiring a life-long management plan through medical or surgical treatment. The choice depends on woman's age, reproductive status and clinical symptoms. However, until now no drug labelled for adenomyosis is available; thus, the present review will focus on medical treatments currently used for adenomyosis and those in development. Adenomyosis may be considered a sex steroid hormone-related disorder associated with an intense inflammatory process. The use of gonadotropin-releasing hormone agonists (GnRH-a) for treating adenomyosis is described blocking the hypothalamic-pituitary-gonadal axis; however, it has long been associated with frequent and intolerable hypoestrogenic side effects. An antiproliferative effect of progestins suggests their use for treating adenomyosis, reducing bleeding and pain. Continuous oral norethisterone acetate or medroxyprogesterone acetate may help to inducing regression of adenomyosis, relief pain and reduce bleeding. The use of vaginal danazol has therapeutic effect on adenomyosis combining progestogenic and anti-inflammatory activity. The intrauterine device releasing levonorgestrel (Lng-IUD) is widely assessed in menorrhagia, and has been shown to be extremely effective in resolving pain and bleeding symptoms associated with adenomyosis. Recent data show a therapeutic effect of dienogest on adenomyosis symptoms. New drugs are under development for the treatment of adenomyosis, such as aromatase inhibitors (AIs) and selective estrogen receptor modulators (SERMs), that produce a hypoestrogenic environment reducing pain, but are correlated with some adverse effects and a recurrence of symptoms after discontinuation of treatment. Selective progesterone receptor modulators (SPRMs) may reduce adenomyosis-associated pelvic pain, by inhibiting endometrial proliferation and suppressing adenomyotic lesion growth, as shown in animal models; however, the long-term effect with SPRMs needs further determination.
Collapse
|
12
|
Menstrual management and reproductive concerns in adolescent and young adult women with underlying hematologic or oncologic disease. Curr Opin Pediatr 2016; 28:421-7. [PMID: 27138999 DOI: 10.1097/mop.0000000000000359] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Heavy menstrual bleeding is common among adolescent and young adult women, and can affect health-related quality of life. The cause of heavy menstrual bleeding is not uncommonly because of an underlying hematologic or oncologic disease process, which substantially influences the way patients are counseled and treated. RECENT FINDINGS Options for menstrual management are more numerous today than ever before and range from minimizing monthly blood loss to suppressing the cycle altogether. However, an underlying bleeding disorder or malignancy can introduce many nuances and limits in individual patient care, which this review highlights. Additionally, because survival rates for adolescent and young adult cancers are improving, more of these patients are planning for lives after their disease, which may include starting or adding to a family. Options for fertility preservation during cancer therapy regimens are solidifying and both primary practitioners and subspecialists should be aware of the possibilities. SUMMARY Patients with underlying hematologic or oncologic disease require management of menstrual bleeding, but also deserve a comprehensive evaluation and counseling regarding their individualized contraceptive needs and fertility preservation options during their reproductive years. This review employs the latest evidence from current literature to help guide clinicians caring for this unique demographic.
Collapse
|
13
|
Bradley LD, Gueye NA. The medical management of abnormal uterine bleeding in reproductive-aged women. Am J Obstet Gynecol 2016; 214:31-44. [PMID: 26254516 DOI: 10.1016/j.ajog.2015.07.044] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 06/28/2015] [Accepted: 07/30/2015] [Indexed: 10/23/2022]
Abstract
In the treatment of women with abnormal uterine bleeding, once a thorough history, physical examination, and indicated imaging studies are performed and all significant structural causes are excluded, medical management is the first-line approach. Determining the acuity of the bleeding, the patient's medical history, assessing risk factors, and establishing a diagnosis will individualize their medical regimen. In acute abnormal uterine bleeding with a normal uterus, parenteral estrogen, a multidose combined oral contraceptive regimen, a multidose progestin-only regimen, and tranexamic acid are all viable options, given the appropriate clinical scenario. Heavy menstrual bleeding can be treated with a levonorgestrel-releasing intrauterine system, combined oral contraceptives, continuous oral progestins, and tranexamic acid with high efficacy. Nonsteroidal antiinflammatory drugs may be utilized with hormonal methods and tranexamic acid to decrease menstrual bleeding. Gonadotropin-releasing hormone agonists are indicated in patients with leiomyoma and abnormal uterine bleeding in preparation for surgical interventions. In women with inherited bleeding disorders all hormonal methods as well as tranexamic acid can be used to treat abnormal uterine bleeding. Women on anticoagulation therapy should consider using progestin-only methods as well as a gonadotropin-releasing hormone agonist to treat their heavy menstrual bleeding. Given these myriad options for medical treatment of abnormal uterine bleeding, many patients may avoid surgical intervention.
Collapse
|
14
|
Vaginally Administered Danazol: An Overlooked Option in the Treatment of Rectovaginal Endometriosis? JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2015; 37:1098-103. [DOI: 10.1016/s1701-2163(16)30075-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
15
|
Sayyah-Melli M, Bidadi S, Taghavi S, Ouladsahebmadarek E, Jafari-Shobeiri M, Ghojazadeh M, Rahmani V. Comparative study of vaginal danazol vs diphereline (a synthetic GnRH agonist) in the control of bleeding during hysteroscopic myomectomy in women with abnormal uterine bleeding: a randomized controlled clinical trial. Eur J Obstet Gynecol Reprod Biol 2015; 196:48-51. [PMID: 26675055 DOI: 10.1016/j.ejogrb.2015.10.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 10/20/2015] [Accepted: 10/28/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the usefulness of vaginal danazol and diphereline in the management of intra-operative bleeding during hysteroscopy. DESIGN Randomized controlled clinical trial. SETTING University hospital. PATIENTS One hundred and ninety participants of reproductive age were enrolled for operative hysteroscopy. Thirty women were excluded from the study. INTERVENTIONS One hundred and sixty participants with submucous myomas were allocated at random to receive either vaginal danazol (200mg BID, 30 days before surgery) or intramuscular diphereline (twice with a 28-day interval). MAIN OUTCOME MEASURES Severity of intra-operative bleeding, clarity of the visual field, volume of media, operative time, success rate for completion of operation and postoperative complications. RESULTS Overall, 145 patients completed the study. In the danazol group, 78.1% of patients experienced no intra-operative uterine bleeding, and 21.9% experienced mild bleeding. In the diphereline group, 19.4% of patients experienced no intra-operative uterine bleeding, but mild, moderate and severe bleeding was observed in 31.9%, 45.8% and 2.8% of patients, respectively. The difference between the groups was significant (p<0.001). A clear visual field was reported more frequently in the danazol group compared with the diphereline group (98.6% vs 29.2%, p<0.001). The mean operative time was 10.9 min and 10.6 min in the danazol and diphereline groups, respectively (p=0.79). The mean volume of infused media was 2.0L in both groups (p=0.99). The success rate was 100% for both groups with no intra-operative complications. CONCLUSION Both vaginal danazol and diphereline were effective in controlling uterine bleeding during operative hysteroscopy. However, vaginal danazol provided a clearer visual field.
Collapse
Affiliation(s)
- M Sayyah-Melli
- Women's Reproductive Health Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - S Bidadi
- Women's Reproductive Health Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
| | - S Taghavi
- Women's Reproductive Health Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
| | - E Ouladsahebmadarek
- Women's Reproductive Health Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
| | - M Jafari-Shobeiri
- Women's Reproductive Health Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
| | - M Ghojazadeh
- Women's Reproductive Health Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
| | - V Rahmani
- Women's Reproductive Health Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
16
|
Pelage L, Fenomanana S, Brun JL, Levaillant JM, Fernandez H. [Treatment of adenomyosis (excluding pregnancy project)]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2015; 43:404-11. [PMID: 25899118 DOI: 10.1016/j.gyobfe.2015.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 03/18/2015] [Indexed: 12/27/2022]
Abstract
In this review we aimed to update the possibilities of adenomyosis treatment in women excluding those with a desire for pregnancy. Adenomyosis is defined as the presence of endometrial tissue within the myometrium and frequently underestimated. Over the last decades, its pathophysiology has been better known. The diagnosis is essentially based on clinical symptoms like menorrhagia and dysmenorrhea. Transvaginal ultrasound and magnetic resonance imaging are the main tools of the radiologic diagnosis. However, the definitive diagnosis is histological. The most effective treatment remains hysterectomy; however it is expensive, radical and at risk of morbidity compared with medical or surgical conservative management. The literature has reported several series of patients undergoing various treatments, thus allowing different therapeutic options. The levonorgestrel-releasing intrauterine device showed its efficacy alone or in combination with hysteroscopic treatment. Oral progestins, GnRH agonists are useful at short term or in preoperative condition. Some conservative treatments like focused ultrasound therapies or uterus-sparing operative treatment stay under evaluation and seems to be effective. Embolization has been the subject of several studies and must be outlined. Furthermore, several molecules, such as modulators of progesterone receptors and the aromatase inhibitors have been recently studied and are perhaps future treatments.
Collapse
Affiliation(s)
- L Pelage
- Service de gynécologie-obstétrique, hôpital Kremlin-Bicêtre, AP-HP, 78, avenue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France.
| | - S Fenomanana
- Pôle obstétrique gynécologie reproduction, centre Aliénor-d'Aquitaine, hôpital Pellegrin, 33076 Bordeaux, France
| | - J-L Brun
- Pôle obstétrique gynécologie reproduction, centre Aliénor-d'Aquitaine, hôpital Pellegrin, 33076 Bordeaux, France
| | - J-M Levaillant
- Service de gynécologie-obstétrique, hôpital Kremlin-Bicêtre, AP-HP, 78, avenue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France
| | - H Fernandez
- Service de gynécologie-obstétrique, hôpital Kremlin-Bicêtre, AP-HP, 78, avenue du Général-Leclerc, 94275 Le Kremlin-Bicêtre, France; CESP-Inserm U1018, « reproduction et développement de l'enfant », 82, rue du Général-Leclerc, 94276 Le Kremlin-Bicêtre cedex, France; Université Paris-Sud, 63, rue Gabriel-Péri, 94276 Le Kremlin-Bicêtre cedex, France
| |
Collapse
|
17
|
Diaphragmatic Endometriosis: Review of the Literature and First Case of Robot-Assisted Laparoscopic Treatment. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2014. [DOI: 10.5301/je.5000179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Thoracic endometriosis is a rare disorder affecting women in reproductive age. The etiopathogenesis of this disease is not well understood. The symptoms appear, but not necessarily, during periods in person affected by the condition. Methods A 35-year-old woman came to our clinic, the Infertility and Assisted Reproduction Center of the University of Pisa, for infertility treatment. She described a clinical history of abdominal pain with irradiation up to the right shoulder, depending on her breathing or position, during menstruation. She also reported that she did not experience these symptoms while taking an oral contraceptive. Pelvic ultrasound examination and thorax X-ray were normal. The patient also underwent thoracic and abdominal pelvis magnetic resonance imaging (MRI). Thoracic MRI revealed a nodule on the right hemidiaphragm. It was decided to perform surgical removal of the nodule. Robotic-assisted surgery was used because of its multiple advantages in comparison with laparoscopic surgery, such as a 3-dimensional view, a decrease in surgeon fatigue and tremors, and an increase of wrist motion with improved dexterity and greater surgical precision. The surgery was performed in May 2012. The patient was put on the left lateral bedside. Pneumoperitoneum with CO2 was established with an intra-abdominal pressure of 12 mm Hg using a Veress needle. Robotic trocars of 8-mm diameter were introduced at the diaphragmatic level and connected to the robot arms. Her pelvic and abdominal organs appeared healthy. The right hemidiaphragm presented adherence with the liver due to endometriosis disease. We removed the adhesion, and we performed the excision of the diaphragmatic endometriotic nodule. The nodule was extracted through an endobag. Operative time lasted 2 hours. Conclusions The postoperative evolution was satisfactory, and the patient left the hospital on the third postoperative day. No complications occurred. We showed that this approach is feasible and safe, without conversion to laparotomy.
Collapse
|
18
|
Abu Hashim H. Medical treatment of idiopathic heavy menstrual bleeding. What is new? An evidence based approach. Arch Gynecol Obstet 2012; 287:251-60. [PMID: 23117248 DOI: 10.1007/s00404-012-2605-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 10/18/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) is an important health problem affecting up to 30 % of reproductive age women, interfering with their quality of life. Medical therapy, with the avoidance of unnecessary surgery, is an attractive option. PURPOSE To provide a comprehensive review of the current medical treatments available for idiopathic HMB and to focus on the newly introduced modalities. Furthermore, to provide a practical algorithm based on the best available evidence. METHODS A PubMed search was conducted looking for the different trials, reviews and various guidelines relating to medical treatment of idiopathic HMB. RESULTS The most effective medical treatment for idiopathic HMB is the levonorgestrel-releasing intrauterine system. It provides a reliable long-term effect. Importantly, there is a growing scientific evidence for new modalities entailing; modified-release formulation of tranexamic acid, the new four-phasic estradiol valerate/dienogest contraceptive pills and combined contraceptive vaginal ring. Also, vaginal danazol has been tried. CONCLUSION Maintenance of status quo, i.e., keeping first-line treatment of idiopathic HMB as medical treatment is an essential issue. Modified-release formulation of tranexamic acid, the new four-phasic contraceptive pills and contraceptive vaginal ring are recently added to the medical armamentarium for treatment of idiopathic HMB increasing its efficacy.
Collapse
Affiliation(s)
- Hatem Abu Hashim
- Department of Obstetrics and Gynecology, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| |
Collapse
|
19
|
Florio P, Filippeschi M, Imperatore A, Mereu L, Franchini M, Calzolari S, Mencaglia L, Litta P. The practicability and surgeons' subjective experiences with vaginal danazol before an operative hysteroscopy. Steroids 2012; 77:528-33. [PMID: 22342469 DOI: 10.1016/j.steroids.2012.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 01/21/2012] [Accepted: 01/23/2012] [Indexed: 11/28/2022]
Abstract
This randomized, double blind, placebo-controlled study compared the usefulness of danazol 400mg vaginally versus 600mg orally in women as a preoperative preparation for hysteroscopic surgery. Ninety-one fertile women were randomly allocated to Group A (46 patients received 400mg of danazol placed into the posterior vaginal fornix and three oral tablets of commercially available folic acid as a placebo), and Group B [45 women treated with 600mg of danazol orally (200mg three times daily) and two vaginal tablets of Lactobacillus rhamnosus as a placebo]. The patients underwent an operative hysteroscopy, transvaginal sonography, blood tests, and a histological assay. A visual analog scale (VAS) score to compute the degree of the surgeon's satisfaction was used. The outcome measures were as follows: an evaluation of the changes in the endometrial thickness, the prevalence of endometrial atrophy, changes in the blood tests, any collateral effects, the degree of difficulty and view, the duration of the surgical procedure, any complications during the operative hysteroscopy and associated side effects, and the surgeon's satisfaction with the endometrial preparation. The vaginal administration route was associated with a more pronounced effect on the endometrial thickness. Significantly more patients receiving vaginal danazol (45/46) had a hypotrophic endometrium than those receiving oral danazol (37/45, P<0.01). In addition, the patients receiving danazol vaginally had a shorter operating time, lower infusion volume, fewer side effects, and a higher surgeon satisfaction. Vaginal danazol adequately prepares the endometrium for an operative hysteroscopy by thinning the endometrium effectively with few side effects and little impact on the metabolic parameters.
Collapse
Affiliation(s)
- Pasquale Florio
- Department of Pediatrics, Obstetrics and Reproductive Medicine, Section of Obstetrics and Gynecology, University of Siena, Siena, Italy.
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Bates JS, Buie LW, Woodis CB. Management of menorrhagia associated with chemotherapy-induced thrombocytopenia in women with hematologic malignancy. Pharmacotherapy 2012; 31:1092-110. [PMID: 22026397 DOI: 10.1592/phco.31.11.1092] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abnormal uterine bleeding in women with a blood dyscrasia, such as leukemia, or who experience thrombocytopenia secondary to myelosuppressive chemotherapy is a clinical condition associated with significant morbidity. Consequently, effective management is necessary to prevent adverse outcomes. Prevention of menorrhagia, defined as heavy regular menstrual cycles with more than 80 ml of blood loss/cycle or a cycle duration longer than 7 days, in this patient population is the goal of therapy. Gonadotropin-releasing hormone analogs (e.g., leuprolide) are promising therapies that have been shown to decrease vaginal bleeding during periods of thrombocytopenia and to have minimal adverse effects other than those associated with gonadal inhibition. In patients who experience menorrhagia despite preventive therapies, or in patients who have thrombocytopenia and menorrhagia at diagnosis, treatment is indicated. For these women, treatment options may include platelet transfusions, antifibrinolytic therapy (e.g., tranexamic acid), continuous high-dose oral contraceptives, cyclic progestins, or other therapies for more refractory patients such as danazol, desmopressin, and recombinant factor VIIa. Hormonal therapies are often the mainstay of therapy in women with menorrhagia secondary to thrombocytopenia, but data for these agents are sparse. The most robust data for the treatment of menorrhagia are for tranexamic acid. Most women receiving tranexamic acid in randomized trials experienced meaningful reductions in menstrual bleeding, and this translated into improved quality of life; however, these trials were not performed in patients with cancer. Further clinical trials are warranted to evaluate both preventive and therapeutic agents for menorrhagia in premenopausal women with cancer who are receiving myelosuppressive chemotherapy.
Collapse
Affiliation(s)
- Jill S Bates
- North Carolina Cancer Hospital, University of North Carolina Hospitals and Clinics, Chapel Hill, North Carolina, USA
| | | | | |
Collapse
|
21
|
Abstract
Pharmacological therapies for the treatment of abnormal uterine bleeding are effective and generally well tolerated. This review presents an evidence-based approach to medical therapy. Selection depends on the etiology and amount of bleeding, need for contraception or preservation of fertility, perimenopause status, and medication efficacy and adverse effects.Available nonhormonal agents include nonsteroidal anti-inflammatory agents, which reduce bleeding by 25% to 35% and improve dysmenorrhea through reduced prostaglandin levels; tranexamic acid, which inhibits plasminogen activator with a 40% to 60% reduction in menstrual blood loss; and intranasal desmopressin, which is an antifibrinolytic for women with an underlying bleeding disorder (eg, von Willebrand disease).Hormonal regimens cause the inhibition of endometrial growth. Cyclic progestogen therapy for 21 days results in a significant reduction in menstrual blood loss. Limited data suggest that oral contraceptives reduce menstrual blood loss by 40% to 50% with decreased breast tenderness and dysmenorrhea and a reduction in risk of uterine and ovarian cancer. The progestin-releasing intrauterine devices are effective up to 97% by 6 months and provide relief of dysmenorrhea and contraception. Long-acting progestogen injections produce amenorrhea and provide contraception but are associated with irregular spotting and reversible bone loss. Danazol leads to endometrial atrophy with a reduced menstrual loss; androgenic adverse effects may be lessened with lower doses or vaginal use. Gonadotrophin agonists lead to ovarian suppression and are used to shrink fibroids or the endometrium preoperatively but are limited by hypoestrogenic adverse events. Emergency use of parenteral conjugated estrogens has a 70% chance of stopping abnormal bleeding but an increased risk of thrombosis.
Collapse
|
22
|
Future developments in the medical treatment of abnormal uterine bleeding: what can we expect? Menopause 2011; 18:462-6. [PMID: 21701433 DOI: 10.1097/gme.0b013e3182127b53] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
New therapies for abnormal uterine bleeding have been slow to reach the marketplace for a variety of reasons. These reasons include the availability of cost-effective therapies already available and the extraordinarily difficult and expensive regulatory barriers emphasizing long-term safety. Common comorbidities like bleeding diatheses, adenomyosis, and leiomyomata further complicate clinical development, necessitating large study samples and making it more expensive. Even the accurate measurement of menstrual blood loss adds an additional hindrance to novel drug development. These obstacles and the currently available therapies will be reviewed in the context of developing new methods for approaching this complicated and prevalent clinical problem.
Collapse
|
23
|
Ferrero S, Tramalloni D, Venturini PL, Remorgida V. Vaginal danazol for women with rectovaginal endometriosis and pain symptoms persisting after insertion of a levonorgestrel-releasing intrauterine device. Int J Gynaecol Obstet 2011; 113:116-9. [DOI: 10.1016/j.ijgo.2010.11.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 11/07/2010] [Accepted: 01/19/2011] [Indexed: 10/18/2022]
|