Novel conservative medical therapy for uterine adenomyosis with a danazol-loaded intrauterine device

Current Medical Therapy for Adenomyosis: From Bench to Bedside

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.

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.

The Role of Platelets in the Pathogenesis and Pathophysiology of Adenomyosis

Widely viewed as an enigmatic disease, adenomyosis is a common gynecological disease with bewildering pathogenesis and pathophysiology. One defining hallmark of adenomyotic lesions is cyclic bleeding as in eutopic endometrium, yet bleeding is a quintessential trademark of tissue injury, which is invariably followed by tissue repair. Consequently, adenomyotic lesions resemble wounds. Following each bleeding episode, adenomyotic lesions undergo tissue repair, and, as such, platelets are the first responder that heralds the subsequent tissue repair. This repeated tissue injury and repair (ReTIAR) would elicit several key molecular events crucial for lesional progression, eventually leading to lesional fibrosis. Platelets interact with adenomyotic cells and actively participate in these events, promoting the lesional progression and fibrogenesis. Lesional fibrosis may also be propagated into their neighboring endometrial-myometrial interface and then to eutopic endometrium, impairing endometrial repair and causing heavy menstrual bleeding. Moreover, lesional progression may result in hyperinnervation and an enlarged uterus. In this review, the role of platelets in the pathogenesis, progression, and pathophysiology is reviewed, along with the therapeutic implication. In addition, I shall demonstrate how the notion of ReTIAR provides a much needed framework to tether to and piece together many seemingly unrelated findings and how it helps to make useful predictions.

Conservative surgical and drug therapies for adenomyosis Medicine

Adenomyosis is a benign invasion/infiltration of endometrial glands and stroma in the uterine myometrium. The optimal choice of adenomyosis treatment remains a subject of discussion. For patients with adenomyosis without fertility requirements, hysterectomy can be performed by laparotomy or laparoscopic surgery to eliminate symptoms. However, this is an inadequate option for women who want to preserve fertility or avoid more extensive surgery. To summarize the medicine and conservative surgery treatment for adenomyosis. An extensive literature search was performed using PubMed, Web of Science, Embase, Ovid Medline, Cochrane Central Register of Controlled Trials, Google Scholar and China National Knowledge Infrastructure (CNKI) without language restriction. The search terms were as follows: adenomyomas, adenomyosis, conservative therapy; combined therapy; medicine; surgery. The search included all titles and abstracts assessing conservative treatment for adenomyosis including medical and surgical therapy. All published papers were analyzed if considered relevant. Increasing current conservative treatments will not only improve the quality of life of the patients but also preserve fertility. Therefore, conservative treatment is extremely important for patients with fertility requirements or a strong desire to retain the uterus. Conservative treatment for adenomyosis may become a future trend in the field of gynecology.

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.

Expression of Lewis (b) blood group antigen interferes with oral dienogest therapy among women with adenomyosis

Adenomyosis is frequently observed in premenopausal women, and oral dienogest is the recommended treatment to target the underlying pathology and improve the symptoms. This retrospective study investigated the association of Lewis (b) antigen expression with outcomes of dienogest therapy among women with adenomyosis. Records from a total of 342 adenomyosis patients were analysed, who were prescribed with oral dienogest for a maximum of 16 weeks. Expression levels of Lewis (b) antigen were measured to categorize all patients into either Le (b)- and Le(b)+ groups. Treatment outcomes, in terms of uterine volume, menstrual flow, pain symptoms and quality of life, were compared between the two groups. While oral dienogest therapy showed considerable clinical efficacy in both groups of patients, the extent of improvements in treatment outcomes was significantly more pronounced in Le (b)- group than Le (b)+ group, with respect to treatment time, uterine symptoms, menstrual flow, pain symptoms and quality of life. No difference in adverse effects was observed between the two groups. Expression of Lewis (b) blood group antigen interferes with oral dialogist therapy among women with adenomyosis.

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.

Treatment options and reproductive outcome for adenomyosis-associated infertility

PURPOSE

Adenomyosis is a benign gynecological disease mostly diagnosed in the forth and fifth decades. The recent improvement of the diagnostic tools and a better understanding of the pathology allowed clinicians to postulate a possible relationship between adenomyosis and infertility and to diagnose it in younger asymptomatic women during infertility work-up. Purpose of this article is to review the different theories regarding the possible correlation between adenomyosis and infertility and to discuss the treatment options and the final reproductive outcome after the treatment.

MATERIALS AND METHODS

We search Pubmed for articles published in the English language with the use of the following MeSH search terms: "adenomyosis" combined with "treatment" and "fertility outcome" with the restriction to the human species. A manual search of review articles and cross-references completed the search. All selected articles were assessed for study design, patients characteristic, diagnosis of adenomyosis, type of treatment, post-treatment rates of conception, full-term pregnancy and completeness of information of the data sets.

RESULTS

Limited data are available concerning the efficacy of the different treatment options of adenomyosis on fertility outcome and the only ones published are retrospective evaluations or small case series.

CONCLUSIONS

Adenomyosis represents a common gynecological disorder with a negative impact on fertility. However, it remains challenging to establish if adenomyosis is the only cause of the infertility or not, because patients, in both case and control groups, may be affected by concomitant endometriosis. Further studies are required to determine the reason of implantation failure in women with adenomyosis and the impact of adenomyosis on infertile women with or without endometriosis.

The Investigation and Management of Adenomyosis in Women Who Wish to Improve or Preserve Fertility

The management of adenomyosis remains a great challenge to practicing gynaecologists. Until recently, hysterectomy has been the only definitive treatment in women who have completed child bearing. A number of nonsurgical and minimally invasive, fertility-sparing surgical treatment options have recently been developed. This review focuses on three aspects of management, namely, (1) newly introduced nonsurgical treatments; (2) management strategies of reproductive failures associated with adenomyosis; and (3) surgical approaches to the management of cystic adenomyoma.

Progestins for the Treatment of Endometriosis: An Update

Endometriosis is a gynecological condition that affects approximately 10% of women of reproductive age, including 25–40% of infertile women. Dysmenorrhea, dyspareunia and chronic pelvic pain are the most common symptoms. Currently available medical therapies for endometriosis do not cure the disease, but are directed at symptom relief, typically utilizing the hormone responsiveness of endometriotic tissue to induce lesion atrophy. Unfortunately, pain relapse after treatment suspension is a common event. Treatment with pharmacological therapies for endometriosis should be conceived in terms of years, thus agents that must be withdrawn after a few months due to poor tolerability or severe metabolic side effects do not greatly benefit women with symptomatic endometriosis. The characteristics of progestins render this class an ideal pharmacological choice for administration over extended periods. The present paper will review the rationale for using progestins and their mechanism of action in endometriosis. Thereafter, the results obtained by various progestins in the treatment of endometriosis will be evaluated (danazol, gestrinone, norethisterone acetate, desogestrel, cyproterone acetate, megestrol acetate, medroxyprogesterone acetate, and levonorgestrel). A progestin called dienogest, recently introduced for the treatment of endometriosis, will be given special focus, describing its mechanism of action and clinical results.

Myomas and Adenomyosis: Impact on Reproductive Outcome

Among uterine structural abnormalities, myomas and adenomyosis represent two distinct, though frequently coexistent entities, with a remarkable prevalence in women of reproductive age. Various mechanisms have been proposed to explain the impact of each of them on reproductive outcome. In respect to myomas, current evidence implies that submucosal ones have an adverse effect on conception and early pregnancy. A similar effect yet is not quite clear and has been suggested for intramural myomas. Still, it seems reasonable that intramural myomas greater than 4 cm in diameter may negatively impair reproductive outcome. On the contrary, subserosal myomas do not seem to have a significant impact, if any, on reproduction. The presence of submucosal and/or large intramural myomas has also been linked to adverse pregnancy outcomes. In particular increased risk for miscarriage, fetal malpresentation, placenta previa, preterm birth, placenta abruption, postpartum hemorrhage, and cesarean section has been reported. With regard to adenomyosis, besides the tentative coexistence of adenomyosis and infertility, to date a causal relationship among these conditions has not been fully confirmed. Preterm birth and preterm premature rupture of membranes, uterine rupture, postpartum hemorrhage due to uterine atony, and ectopic pregnancy have all been reported in association with adenomyosis. Further research on the impact of adenomyosis on reproductive outcome is welcome.

Medical Management of Endometriosis

Endometriosis is a chronic medical condition that affects around 6% to 10% of reproductive age women. Pelvic pain, dysmenorrhea, and infertility are the most common presenting symptoms. The disease is characterized by estrogen-dependent growth of the endometrial glands and stroma outside the endometrial cavity. The diagnosis requires a high degree of suspicion and can be only confirmed on histopathology. Treatment includes medical and surgical options. Both hormonal and nonhormonal medical options are available and are tried at first with a goal to control pain and stop the growth of the endometriotic lesions. Nonsteroidal anti-inflammatory drugs, oral contraceptive pills, gonadotropin-releasing hormone (GnRH) agonists, aromatase inhibitors are some of the commonly used medications. With more research on the molecular and biochemical aspects of endometriosis, newer targets of therapy are being developed like selective progesterone receptor modulators, antiangiogenic factors and immunomodulators. In women who do not respond to medical therapy or have severe symptoms, surgical excision of the endometrial lesions and adhesions is often helpful and offers confirmatory diagnosis by histopathology.

The Impact of Adenomyosis on Women's Fertility

Until recently, adenomyosis has been associated with multiparity, not impaired fertility. Currently, adenomyosis is diagnosed with increasing frequency in infertile patients since women delay their first pregnancy until their late 30s or early 40s. Although an association between adenomyosis and infertility has not been fully established, based on the available information, recent studies suggested that adenomyosis has a negative impact on female fertility. Several uncontrolled studies with limited data also suggested that treatment of adenomyosis may improve fertility. This article discusses (i) the hypothesis and epidemiology of adenomyosis, (ii) diagnostic techniques, (iii) clinical evidence of correlation between adenomyosis and infertility, (iv) proposed mechanism of infertility in women with adenomyosis, (v) different treatment strategies and reproductive outcomes, and (vi) assisted reproductive technology outcome in women with adenomyosis.

Adenomyosis: what is new?

Adenomyosis is described as the benign invasion of endometrium into the myometrium, with endometrial glands and stroma surrounded by the hypertrophic and hyperplastic myometrium. It may affect 20% of female population and most widely seen among perimenopausal and multiparous women. Its etiopathogenesis, diagnosis, clinical findings and current various treatment options will be discussed in this article.

[Treatment of adenomyosis (excluding pregnancy project)]

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.

An unexpected diagnosis of adenomyosis in the subfertile woman

A 38-year-old nulliparous female presented to an assisted conception clinic with subfertility and a long-standing history of dysmenorrhoea. Transvaginal ultrasound revealed two lesions in the body of the uterus, which were presumed to be fibroids. A decision was made to remove these lesions prior to attempting in vitro fertilisation (IVF). However, on laparotomy, deeply penetrating adenomyosis was discovered, resulting in an unexpected hysterectomy and significant blood loss. Based on our experience, we highlight the importance of suspecting a diagnosis of adenomyosis preoperatively and the methods by which this diagnosis can be made, in order to avoid potential unforeseen outcomes as described in this case. We discuss conservative management options for this condition, particularly in women wishing to preserve fertility.

Efficacy of dienogest in the treatment of symptomatic adenomyosis: a pilot study

Adenomyosis is a common disorder in premenopausal women that causes dysmenorrhea, pelvic pain and menorrhagia. Considering that adenomyosis is an estrogen-dependent disease, the medical treatment is based on this hormone. Effective and well-tolerated medical treatments for symptomatic adenomyosis are needed. Dienogest, an oral progestin, has been extensively investigated in the treatment of endometriosis. In this report, we present the results on the efficacy and safety of dienogest in the treatment of symptomatic adenomyosis. Seventeen patients with symptomatic adenomyosis were included in this study, of which 15 continued dienogest for up to 24 weeks. Dienogest significantly reduced adenomyosis-associated pelvic pain as well as serum CA-125 and CA19-9 levels. It also demonstrated a modest suppression of estradiol (>50 pg/ mL), which is consistent with the findings of other reports. During treatment, five patients experienced worsening anemia because of metrorrhagia, which is the most frequent adverse effect associated with dienogest. This report suggests that dienogest is an effective and well-tolerated therapy for symptomatic adenomyosis.

An overview of the current status of clinical trials on endometriosis: issues and concerns

OBJECTIVE

To examine and compare differences, if any, between industry- and nonindustry-sponsored clinical trials on endometriosis and to evaluate the effect of prior published positive preclinical results, or lack thereof, on trial status.

DESIGN

Cross-sectional study of clinical trials on endometriosis that evaluate drugs/biologicals registered at ClinicalTrials.gov as of July 3, 2013.

SETTING

University-affiliated hospital.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Trial status, size, phase, and duration; use of comparator groups; drug classes, number of arms, targeting conditions; and presence or absence of prior positive preclinical results before the launch of the trial.

RESULT(S)

Eighty trials were identified. The trials sponsored by industry and non-industry have distinct features, differing in trial status, phase, comparator, drug classes, number of arms, trial size, and duration. The phase II/III trials are predominantly industry supported, but these trials frequently use placebo as the comparator. Trials launched without prior published preclinical results do not seem to fare well, although the presence of such studies is no guarantee for success.

CONCLUSION(S)

Questions as to whether the drug on trial is truly superior to the best available drug or of its cost-benefit profile are overlooked in most cases. There seems to be a deluge of "me-too" drugs with equivocal superiority over existing drugs and cost-benefit profiles. Because clinical trials are time-consuming, no blockbuster drug for endometriosis seems to be on the horizon yet.

Infertility and adenomyosis

Classically, the diagnosis of adenomyosis has only been possible on a hysterectomy specimen, usually in women in their late fourth and fifth decades, and, therefore, evaluating any relationship with infertility was simply not possible. As a consequence, to this day, no epidemiologic data exists linking adenomyosis to a state of subfertility. Today, new imaging techniques have enabled a noninvasive diagnosis at a much earlier time and a number of single-case or small series reports have appeared showing that medical, surgical, or combined treatment can restore fertility in women with adenomyosis, an indirect proof of an association. At the functional level, several anomalies found in the so-called junctional zone, or inner myometrium, in adenomyosis patients have been shown to be associated with poor reproductive performance, mainly through perturbed uterine peristalsis. Additional evidence for an association comes from experimental data: in baboons, adenomyosis is associated with lifelong primary infertility, as well as to endometriosis. Finally, indirect proof comes from studies of the eutopic and ectopic endometrium in women with adenomyosis proving the existence of an altered endometrial function and receptivity. In conclusion, sufficient indirect proof exists linking adenomyosis to infertility to warrant systematic clinical studies.

Adenomyosis and infertility

Today an accurate diagnosis of adenomyosis can be made thanks to progress in imaging techniques: sonography and magnetic resonance imaging (MRI). This has made it possible to clinically correlate the presence of adenomyosis to infertility. At the same time, a series of pathogenetic hypotheses have been presented to explain this correlation. First, the identification of the myometrial junctional zone (JZ) and of its disruption and thickening has been linked to poor reproductive performance mainly through perturbed uterine peristalsis, a phenomenon that originates exclusively from the JZ in the nonpregnant uterus. In addition, a number of biochemical and functional alterations in both eutopic and heterotopic endometrium in women with adenomyosis have now been found to lead to lower receptivity, indicated by the presence of 'implantation marker' defects. In these patients there is also an altered decidualization and abnormal concentrations of intrauterine free radicals. All these abnormalities in the endometrial environment seem to contribute to subfertility. Several attempts have been made to restore fertility in adenomyosis patients, the oldest being gonadotrophin-releasing hormone agonists coupled to conservative surgery. Also, uterine artery embolization and MRI-assisted high-intensity focused ultrasound ablation have been tried with some degree of success.

Adenomyosis: from the sign to the diagnosis. Imaging, diagnostic pitfalls and differential diagnosis: a pictorial review

Adenomyosis is a pathological gynaecological condition characterised by benign invasion of the endometrium into the myometrium. It is often misdiagnosed, or is not easily recognised, although it is responsible for disabling symptoms such as menorrhagia, abnormal uterine bleeding, dysmenorrhoea and infertility in premenopausal women. The aim of this pictorial review is to analyse the features of adenomyosis by illustrating the most usual and typical imaging patterns, along with the unusual appearances, seen in a vast array of gynaecological imaging modalities. The different findings of focal and diffuse adenomyosis along with the diagnostic limitations of ultrasound, hysterosalpingography and magnetic resonance imaging are described, as are the pitfalls and differential diagnosis with other pathological conditions that are often misdiagnosed as adenomyosis. The role of the different imaging modalities in planning appropriate treatment and their usefulness in monitoring therapy are also discussed.

Future developments in the medical treatment of abnormal uterine bleeding: what can we expect?

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.

Evaluation of the efficacy of a danazol-loaded intrauterine contraceptive device on adenomyosis in an ICR mouse model

BACKGROUND

Danazol, a synthetic steroid with antigonadotrophic properties, has been widely used for the treatment of endometriosis and adenomyosis. However, the local application of danazol to the uterus to treat adenomyosis is controversial. The objective of this study is to develop an effective treatment for adenomyosis using danazol via intrauterine contraceptive device (IUCD) delivery.

METHODS

An adenomyosis animal model was established using Institute for Cancer Research, Swiss-derived (ICR) mice, grafted with a single pituitary gland (n = 30). Four months after grafting, IUCDs with three different quantities of danazol were prepared and used to treat the ICR mice with adenomyosis. After 2 months of treatment with a danazol-loaded IUCD, the number of adenomyosis nodules and the hematoxylin-eosin staining scores were measured and compared with mice given daily oral danazol and controls (no adenomyosis).

RESULTS

As the danazol dose increased, the nodule number decreased reaching significance at a dose of 2.0 mg per 20 g body weight (P = 0.002). When compared with oral administration, the plasma danazol concentrations with IUCD delivery were low and stable.

CONCLUSIONS

These results suggest that an IUCD loaded with an appropriate dose of danazol may be an effective treatment for adenomyosis and that human trials are warranted.

Hormonal treatments for adenomyosis

Like endometriosis and uterine myomas, adenomyosis presents the typical characteristics of oestrogen-dependent diseases. The medical treatment of adenomyosis is based on the hormonal dependency of the disease and its strongly debated similarities with endometriosis. Infact, despite the evident differences between the two conditions, the therapies that treat endometriosis effectively have also been successful for the treatment of adenomyosis. Although the two diseases have distinct epidemiological features, they have the same 'target tissue' for hormonal therapy, namely ectopic endometrium. Recognized approaches are systemic hormonal treatments, which are generally used for endometriosis and are capable of suppressing the oestrogenic induction of the disease, and local hormonal treatment that targets the ectopic endometrium directly. Gonadotropin-releasing hormone agonists, danazol and intrauterine levonorgestrel- or danazol-releasing devices have been used in the treatment of adenomyosis. Despite the solid rational basis for its hormonal treatment, few studies have been performed on medical therapy for adenomyosis.

Concomitant treatment of severe uterine adenomyosis in a premenopausal woman with an aromatase inhibitor and a gonadotropin-releasing hormone agonist

OBJECTIVE

To assess the effect of aromatase inhibitors with GnRH agonist for a severe symptomatic adenomyosis that is refractory to GnRH agonist and danazol with GnRH agonist.

DESIGN

Case report.

SETTING

Clinical practice in university hospital.

PATIENT(S)

A 34-year-old woman with a complaint of severe dysmenorrheal, symptomatic anemia, and a desire to retain fertility.

INTERVENTION(S)

Aromatase inhibitor anastrozole given orally (1.0 mg or 2.0 mg daily) for 16 weeks and GnRH agonist given monthly (injected SC, 1.8 mg) for 4 months.

MAIN OUTCOME MEASURE(S)

Measurements of uterine volume and levels of serum E(2), estrone, A, dehydroepiandrosterone sulfate, LH, FSH, and CA125.

RESULT(S)

Uterine volume was reduced. The reduction rate of uterine volume estimated by magnetic resonance imaging and ultrasonography was 60% after 8 weeks of treatment.

CONCLUSION(S)

Aromatase inhibitor with GnRH agonist therapy was useful for the management of a severely adenomyotic woman whose desire was for conservative treatment.

Medical and surgical management of adenomyosis

Adenomyosis of the uterus is a common condition amongst women in their reproductive years. It is defined as the presence of heterotopic endometrial glands and stroma in the myometrium with adjacent smooth muscle hyperplasia. The common presenting symptoms are painful and heavy periods and infertility, although many women are asymptomatic. Adenomyosis is thought to affect 1% of women and is typically diagnosed in the 4th and 5th decades of life. The aetiology is unclear, and until recently a diagnosis was made only after invasive and destructive surgery. With the advent of improved imaging of the pelvic organs, and in particular magnetic resonance imaging, the diagnosis of adenomyosis is being made more frequently. Unfortunately, because the disease has been infrequently diagnosed prior to hysterectomy, there are few well-designed studies of medical or surgical management. Management with hormonal treatment that aims to reduce the proliferation of endometrial cells is promising, but there is a paucity of well-designed studies to guide treatment. Hysterectomy or use of the levonorgestrel intrauterine system (LNG-IUS) remains the mainstay of treatment.

Adenomyosis: the pathophysiology of an oestrogen-dependent disease

Adenomyosis uteri is a common gynaecological disorder that is characterized by the presence of ectopic endometrial glands and stroma in the myometrium. Although adenomyosis and endometriosis are different diseases, both of them grow and regress in an oestrogen-dependent fashion. Polymorphisms in the oestrogen receptor alpha gene are associated with a risk of adenomyosis. Adenomyotic tissue contains steroid receptors as well as aromatase and sulphatase enzymes. Together with the circulating oestrogen, locally produced oestrogens stimulate the growth of tissue mediated by the oestrogen receptors. Oestrogen metabolism, including the expression pattern of aromatase and the regulation of 17beta-hydroxysteroid dehydrogenase type 2 is altered in the eutopic endometrium of women with endometriosis, adenomyosis, and/or leiomyomas compared to that in the eutopic endometrium of women without disease. In addition to the conventional hormonal treatment with gonadotropin-releasing hormone agonists and danazol, the use of steroid-releasing intrauterine devices may be applicable to clinics.

[Adenomyosis: update on a frequent but difficult diagnosis]

Adenomyosis is a frequent entity, with difficult diagnosis, often obtained by pathological analysis performed after hysterectomy. This condition can cause abnormal uterine bleeding and dysmenorrhea, frequent reasons for consultation and hysterectomy. The development of ultrasonographic and magnetic resonance imaging techniques allow preoperative diagnosis. They also permit the use of hysteroscopic techniques for conservative uterine surgery, and have brought diagnosis and management of this disease to the front of the scene. This article reviews the pathological description of the disease, its epidemiology, clinical presentations, useful and necessary explorations, etiopathogeny and available therapies.

Adenomyosis: what is the impact on fertility?

PURPOSE OF REVIEW

This review is timely and relevant for several reasons. The incidence of adenomyosis begins to rise from the mid-thirties. Moreover, more women are delaying their first pregnancy until later in their thirties or forties, and consequently adenomyosis is encountered more frequently in the fertility clinic during diagnostic work-up. Furthermore, it is difficult to diagnose adenomyosis before surgery, because there are no pathognomonic signs, symptoms or physical findings. Finally, reference data are very limited.

RECENT FINDINGS

This review refers to adenomyosis of the uterus as a factor in female infertility. The clinical presentation of adenomyosis uteri is also reviewed, as well as animal and human studies concerning the effect of adenomyosis in female infertility. Different treatment options are discussed, especially those referring to patients who wish to maintain their fecundity.

SUMMARY

Uterine adenomyosis remains a fairly frequent and debilitating disease that will be encountered with increasing incidence in the infertile female population. While spectacular advances have been made in recent years in the non-invasive diagnosis of the condition, non-surgical treatment options for infertile patients with adenomyosis arise but need to be confirmed in larger series.

Évolutions physiopathologiques, diagnostiques et thérapeutiques dans la prise en charge de l’adénomyose : revue de la littérature

OBJECTIVE

Adenomyosis is a relatively frequent disease of unknown origin, which is difficult to diagnose. Appropriate treatment for women who want to preserve or improve their fertility remains to be defined.

METHODS

This review summarized the reports found on Medline database about pathophysiology, diagnosis and management of adenomyosis.

RESULTS

Many pathophysiological factors may be involved in the occurrence of adenomyosis: immunological factors, estrogen sulfatase activity, tenascin which is a fibronectin inhibitor and angiogenesis and growth factors such as EGF, VEGF and GM-CSF. Endovaginal ultrasonography seems to be as effective as MRI for the diagnosis of adenomyosis. GnRH agonist decreases symptoms and uterine volume; however, the symptoms reappear after discontinuation of agonist therapy, and side effects limit their prolonged use. Progesterone receptor modulators, anti-progestative and danazol or levonorgestrel-releasing intra-uterine system have been used as therapeutic modalities for adenomyosis, but the lack of controlled studies make their efficacy difficult to quantify. Some women with superficial adenomyosis may theoretically benefit from hysteroscopic myometrial or endometrial resection, but these procedures would be limited to women not wishing to conceive. Laparoscopic myometrial electrocoagulation or excision has proven to be effective but pregnancy following these techniques poses special problems, particularly the increased risk of uterine rupture.

CONCLUSION

Transvaginal ultrasonography can successfully diagnose adenomyosis. Medical and conservative surgical treatments are already available.

A danazol-loaded intrauterine device decreases dysmenorrhea, pelvic pain, and dyspareunia associated with endometriosis

A danazol-loaded intrauterine device (IUD) containing 300-400 mg of danazol was inserted for 6 months in a group of women (n = 18) (median age 36.6 years; age range: 30 to 46 years) with a histologic diagnosis of endometriosis, referred for recurrent pelvic pain. Dysmenorrhea, dyspareunia, and pelvic pain significantly decreased after the first month, with a persistent effect during the 6 months of IUD insertion. These results show that a danazol-loaded IUD is an effective conservative therapy for patients with endometriosis-related pelvic pain.

Pregnancy complicated by adenomyosis resulted in miscarriage in three cases of in vitro fertilization-embryo transfer

Three women with adenomyosis conceived by in vitro fertilization-embryo transfer (IVF-ET), but miscarried in the second trimester. The uterus in each case was inflamed post-partum and one patient underwent total abdominal hysterectomy as treatment for the severe inflammation. Although the mechanism of the miscarriages is unclear, these cases strongly suggest that it is related to the inflammation of the myometrium associated with adenomyosis, and that such pregnancies have a high risk of not continuing to term. Preventing inflammation could result in a live birth. (Reprod Med Biol 2004; 3: 95-98).