Progression of adenomyosis magnetic resonance imaging features under ulipristal acetate for symptomatic fibroids

The Present and the Future of Medical Therapies for Adenomyosis: A Narrative Review

Uterine Adenomyosis is a benign condition characterized by the presence of endometrium-like epithelial and stromal tissue in the myometrium. Several medical treatments have been proposed, but still, no guidelines directing the management of adenomyosis are available. While a hysterectomy is typically regarded as the definitive treatment for adenomyosis, the scarcity of high-quality data leaves patients desiring fertility with limited conservative options. Based on the available data, the levonorgestrel-IUD appears to offer the most favorable outcomes. Other treatments, including GnRH antagonists, dienogest, prolactin, and oxytocin modulators, show promise; however, further data are required to establish their efficacy definitively. Furthermore, there are many emerging therapies that have been developed that seem worthy of consideration in the near future. The aim of this narrative review was to explore the current medical treatments available for adenomyosis and to provide a glimpse of future therapies under assessment. For this scope, we performed a literature search on PubMed and Medline from incept to September 2022 using the keywords: "medical treatment", "non-steroidal anti-inflammatory", "progesterone intrauterine device", "dienogest", "combined oral contraceptives", "gonadotropin releasing hormone agonist", "gonadotropin releasing hormone antagonist", "danazol", "aromatase inhibitors", "ulipristal acetate", "anti-platelet therapy", "dopamine", "oxytocin antagonists", "STAT3", "KRAS", "MAPK", "micro-RNA", "mifepristone", "valproic acid", "levo-tetrahydropalamatine", and "andrographolide". The search was limited to articles in English, with subsequent screening of abstracts. Abstracts were screened to select relevant studies.

Contemporary approaches in the management of uterine leiomyomas

BACKGROUND

Leiomyomas (fibroids), the most common benign solid tumours in females, originate from the myometrium and are associated with poor quality of life for patients. The current management of uterine leiomyomas mainly includes surgical interventions such as hysterectomy and myomectomy, either by laparoscopy or laparotomy, which have several complications and are not ideal for preserving fertility. Therefore, there is a need to develop or repurpose medical treatments that do not require surgical intervention.

OBJECTIVE

Many drugs are used to treat the symptoms associated with uterine fibroids. The main objective of this systematic review is to give an up-to-date account of potential pharmacological agents (non-surgical methods) for the management of uterine leiomyomas.

SEARCH STRATEGY

PubMed was searched for scientific and clinical literature using the keyword 'uterine fibroids' along with the drug names described in each section. For example, 'uterine fibroids' and 'ulipristal acetate' were the keywords used to search for literature on ulipristal acetate (UPA).

RESULTS

Various preclinical and clinical studies have shown that some drugs and herbal formulations exhibit activity in the management of uterine leiomyomas. Recent studies found that drugs such as UPA, elagolix, EC313, asoprisnol, nutritional supplements and herbal preparations were helpful in treating the symptoms associated with uterine leiomyomas.

CONCLUSION

Many drugs show efficacy in patients with symptomatic uterine fibroids. UPA is one of the most studied and prescribed medicines for uterine fibroids; however, its usage has been restricted due to a few recent incidences of hepatic toxicity. Herbal drugs and natural supplements have also shown promising effects on uterine fibroids. The synergistic effects of nutritional and herbal supplements have been reported in certain cases, and should be studied in detail. Further research is warranted to identify the mode of action of the drugs, and to determine the precise conditions that would explain the causes of toxicity in some patients.

Ulipristal Acetate in Adenomyosis

Adenomyosis is defined as the invasion of the basal endometrium (stroma and glands) into the underlying myometrium. It may lead to abnormal uterine bleeding (AUB), pelvic pain, and infertility. The definitive treatment is hysterectomy. Some conservative measures have been used in patients willing to procreate. Ulipristal acetate is a selective progesterone receptor modulator used to treat AUB caused by leiomyomas. This is a systematic review on the use of ulipristal to treat adenomyosis. Eight eligible articles were retrieved from PubMed, SCOPUS, and Cochrane Library. Only one randomized clinical trial was published until date concerning this matter. It seems that ulipristal acetate induces partial or complete remission of AUB caused by adenomyosis, but the evidence concerning its effect on pelvic pain and the radiologic findings of the disease is conflicting. Nevertheless, given the paucity of data, it is still preliminary to draw any conclusion about the subject.

Conservative Management of Uterine Adenomyosis: Medical vs. Surgical Approach

Uterine adenomyosis is a commonly encountered estrogen-dependent disease in reproductive-age women, causing heavy menstrual bleeding, intense pelvic pain, and infertility. Although adenomyosis was previously considered a disease of multiparous women, it is becoming increasingly evident that it also affects younger nulliparous women and may compromise their fertility potential. It is clear that hysterectomy, the standard approach to definitively manage the disease, is not an option for patients wishing to preserve their fertility, so there is an urgent need to develop novel conservative strategies. We searched the current literature for available methods for conservative management of adenomyosis, including both pharmacological and surgical approaches. There is no existing drug that can cure adenomyosis at present, but some off-label treatment options may be used to tackle disease symptoms and improve fertility outcomes. Adenomyosis in patients wishing to conceive can be 'treated' by conservative surgery, though these procedures require highly experienced surgeons and pose a considerable risk of uterine rupture during subsequent pregnancies. While currently available options for conservative management of adenomyosis do have some capacity for alleviating symptoms and enhancing patient fertility perspectives, more effective new options are needed, with gonadotropin-releasing hormone antagonists showing encouraging results in preliminary studies.

Current and Prospective Treatment of Adenomyosis

(1) Background: Adenomyosis is a poorly understood entity which makes it difficult to standardize treatment. In this paper we review and compare the currently approved medical and surgical treatments of adenomyosis and present the evidence behind them. (2) Methods: A PubMed search was conducted to identify papers related to the different treatments of adenomyosis. The search was limited to the English language. Articles were divided into medical and surgical treatments. (3) Results: Several treatment options have been studied and were found to be effective in the treatment of adenomyosis. (4) Conclusions: Further randomized controlled trials are needed to compare treatment modalities and establish a uniform treatment algorithm for adenomyosis.