A cohort study of the efficacy of the dienogest and the gonadotropin-releasing hormone agonist in women with adenomyosis and dysmenorrhea

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

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

Effects of different treatment methods on clinical efficacy and fertility outcomes of patients with adenomyosis

OBJECTIVE

This trial was to investigate the effect of different treatment methods on the clinical efficacy and fertility outcome of patients with adenomyosis.

METHODS

In total, 140 patients with adenomyosis were evenly and randomly allocated into group A (laparoscopic surgery), group B (laparoscopic surgery combined with gonadotropin-releasing hormone analogs [GnRH-a]), group C (ultrasound-guided percutaneous radiofrequency ablation), and group D (ultrasound-guided percutaneous radiofrequency ablation combined with GnRH-a). On the 3rd day after surgery, patients in group B and group D were subcutaneously injected with GnRH-a (Leuprorelin Acetate SR for Injection) at 3.75 mg/time, once every 4 weeks, for a total of 3 months. The therapeutic effects of the 4 groups were compared, including menstrual volume, dysmenorrhea score, uterine volume, clinical efficacy, luteinizing hormone (LH), estradiol (E2), and follicle-stimulating hormone (FSH) levels, CA125 levels, recurrence, pregnancy status, and pregnancy outcomes.

RESULTS

After treatment, the menstrual volume of 4 groups was lowered, dysmenorrhea, Visual Analog Scale (VAS) score, LH, FSH, E2, and CA125 levels were reduced, and uterine volume was decreased. The menstrual volume, VAS score, levels of LH, FSH, E2, and CA125, and uterine volume were reduced in groups B, C, and D compared with group A, and the decrease was more significant in group D. The total effective rate of group D was 100.00%, which was higher than that of group A (71.43%), group B (80.00%), and group C (82.86%). After one year of drug withdrawal, the recurrence of hypermenorrhea, dysmenorrhea, uterine enlargement, and excessive CA125 in group D was significantly lower than that in groups A, B and C, and the recurrence in groups B and C was significantly lower than that in group A (P < 0.05). Compared with groups A, B, and C, group D had a higher pregnancy rate, natural pregnancy rate, and lower in vitro fertilization-embryo transfer rate (P < 0.05), but showed no significant difference in pregnancy outcomes.

CONCLUSION

Ultrasound-guided percutaneous radiofrequency ablation combined with Leuprorelin Acetate is effective in the treatment of adenomyosis, which can effectively relieve clinical symptoms, protect postoperative ovarian function, reduce recurrence rate, alleviate pain, and improve quality of life.

Clinical efficacy and safety of trimonthly administration of goserelin acetate 10.8 mg in premenopausal Chinese females with symptomatic adenomyosis: a prospective cohort study

OBJECTIVE

This prospective cohort study aimed to compare the clinical efficacy and safety of goserelin 10.8 mg administered trimonthly with goserelin 3.6 mg administered monthly in premenopausal females with symptomatic adenomyosis.

METHODS

We recruited 139 premenopausal females with adenomyosis who complained of dysmenorrhea and/or menorrhagia. The first group (n = 70) received a single subcutaneous injection of goserelin 10.8 mg, and the second group (n = 69) received monthly subcutaneous goserelin 3.6 mg administered for 3 months. Follow-up was performed at the outpatient department after 12 weeks.

RESULTS

Ultimately, 130 patients completed the study, including 68 and 62 patients in the goserelin 10.8 mg (n = 70) and 3.6 mg (n = 69) groups, respectively. We observed a significant decrease in the dysmenorrhea (NRS) score, uterine volume, and cancer antigen 125 (CA125) levels, and a significant increase in hemoglobin (HGB) levels in both treatment groups. There was no significant difference between the two groups. The sum of the adverse event scores was slightly higher in the goserelin 3.6 mg than in the 10.8 mg group.

CONCLUSIONS

The clinical efficacy of trimonthly administration of goserelin 10.8 mg was equivalent to monthly 3.6 mg dosing and was non-inferior regarding safety and tolerability. Hence, it can be a more cost-effective and convenient alternative treatment option in premenopausal females with symptomatic adenomyosis.

TRIAL REGISTRATION

ChiCTR2200059548.

Serum CA125 as a biomarker for dysmenorrhea in adenomyosis

OBJECTIVE

To explore the association between CA125 and dysmenorrhea in adenomyosis, and the factors affecting CA125 in adenomyosis.

METHODS

Patients were grouped a the presence of dysmenorrhea. The receiver operating characteristic (ROC) curve was applied to assess the utility of CA125 for dysmenorrhea. Binary logistic regression was employed to identify the factors associating dysmenorrhea and CA125 level.

RESULTS

Patients in the dysmenorrhea group had higher CA125 levels than those in the non-dysmenorrhea group. For those with dysmenorrhea, CA125 levels of diffuse subtype group were higher than those of the focal subtype group. The CA125 level of 35 U/mL was validated as the optimal cut-point for dysmenorrhea in ROC curves. Compared with patients whose CA125 was 35 U/mL or less, those with CA125 levels greater than 35 U/mL were more likely to have dysmenorrhea. Thereafter, the multiple regression analysis showed that adenomyotic lesion volume was positively correlated with CA125 level in the total cohort and subtype groups, while age was negatively correlated with CA125 level in the total cohort and diffuse subtype.

CONCLUSIONS

The pathogenesis of adenomyosis is not clear. CA125 was associated with dysmenorrhea in adenomyosis, and, furthermore, CA125 level is positively correlated with the severity of the disease.

Compare the Efficacy of Dienogest and the Levonorgestrel Intrauterine System in Women with Adenomyosis

PURPOSE

The goal of this study was to examine the efficacy and safety of the levonorgestrel intrauterine system (LNG-IUS) versus dienogest (DNG) in female subjects with symptomatic uterine adenomyosis.

METHODS

This study enrolled 117 women with symptomatic adenomyosis who visited our hospital from May 1, 2019, to June 30, 2022. Participants were randomized to either the LNG-IUS group (n = 48) or the DNG group (n = 79) in an as-controlled clinical trial for 36 months. Visual analog scale (VAS) scores, uterine volume, endometrial thickness, serum carcinoma antigen 125 level, estradiol, follicle-stimulating hormone, luteinizing hormone, and side effects were assessed to compare the efficacy of LNG-IUS and DNG.

FINDINGS

The VAS pain score was significantly decreased in both groups after 3 months of treatment. Three months later, patients receiving DNG reported significantly lower VAS scores compared with those treated with LNG- IUS (P < 0.05). Compared with LNG-IUS, DNG effectively controlled uterine volume growth after 12 months of treatment but neither significantly reduced uterine volume. During the treatment period, endometrial thickness in both groups was maintained at 0.4 to 0.7 cm.

IMPLICATIONS

Both DNG and LNG-IUS significantly improved adenomyosis-associated pain after 3 months of treatment. Compared with LNG-IUS, DNG was shown to continuously relieve the symptoms of pain and effectively control the growth of uterine volume.

Efficacy of Dienogest in Adolescent Endometriosis: A Narrative Review

Teenage endometriosis is seen as a chronic condition that can worsen if untreated. Treatment objectives include relief of symptoms, prevention of disease development, and preservation of future fertility. In many regions, dienogest (DNG), an oral progestin, has emerged as a key treatment in suppressing endometriosis. The usage of DNG for endometriosis in adolescents was researched in papers published between 2015 and 2022 using PubMed and Google Scholar. A thorough search of all identified studies' reference lists and previously published literature reviews was carried out. The study's nature and geographic scope were not restricted. After reviewing these publications, the authors decided on which ones were the most pertinent in light of their personal experiences. The final study consisted of 14 studies that satisfied inclusion requirements. The trials showed that taking DNG 2 mg daily efficiently lowers endometriotic lesions, eases painful endometriosis symptoms, and improves quality-of-life indicators. In most of these investigations, DNG was shown to be safe and tolerated, with predictable and moderate side effects, good patient compliance rates, and low withdrawal rates. Although endometrioma did not enlarge while receiving treatment, significant regression was not typical. Overall, the studies found that DNG is safe and effective in reducing symptoms of endometriosis in adolescents.

A stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage

OBJECTIVE

To propose a stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage.

DESIGN

A narrated video footage of the surgical approach of a clinical case with extensive adenomyosis and recurrent abortions. Institutional review board approval was obtained (No 3.725.458).

SETTING

A university center.

PATIENT(S)

We present a case of a 37-year-old patient, gravida 4 para 0 with a history of 3 first trimester miscarriages after spontaneous pregnancies, and a 20-week spontaneous abortion after an in vitro fertilization pregnancy. She underwent 2 laparoscopic excisions of deeply infiltrative endometriosis and was treated with gonadotropin-releasing hormone for 6 months and dienogest for a year with no improvement of her adenomyosis. Currently, she experiences moderate dysmenorrhea and desires future fertility.

INTERVENTION(S)

For 3 months, gonadotropin-releasing hormone analogues were used before performing the robotic surgery for adenomyosis resection and abdominal cerclage. (Step 1) Control the blood supply with a tourniquet placed lateral to the uterine arteries at the level of the internal cervical os, and a diluted solution of vasopressin 20% is administered at the area to be excised. (Step 2) Uterine incision: we use a vertical uterine incision with monopolar scissors, extended anteriorly and posteriorly. (Step 3) Resection of adenomyosis: carried with monopolar scissors using pure cut current. It is recommended that 0.5-1 cm of the myometrium is maintained around the uterine cavity as well as the serosa. (Step 4) Flap 1: interrupted sutures with vicryl 2.0 are used to approximate the inner myometrium close to the endometrial cavity, and a 2.0 barbed suture is used to approximate the inner myometrium of the contralateral side of the incision to the ipsilateral outer myometrium. (Step 5) Flap 2: another 2.0 barbed suture is used to approximate the outer myometrium of the contralateral side to the base of the repaired inner myometrial layer. (Step 6) Serosal closure: the serosa is approximated with a barbed suture in a baseball fashion before the tourniquet is released and hemostasis is ensured. (Step 7) Abdominal cerclage: a mersilene tape is placed medial to the uterine arteries at the level of the internal cervical os and a tape is tied anteriorly.

MAIN OUTCOME MEASURE(S)

Description of a stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage.

RESULT(S)

The operating time was 255 min with minimal estimated blood loss (250ml). She was discharged with no complaints. Three months postoperatively, dysmenorrhea significantly improved, and the magnetic resonance imaging showed a good anatomic result. An embryo transfer is planned at 6 months postoperatively.

CONCLUSION(S)

A minimally invasive approach to fertility-sparing management of diffuse adenomyosis is safe and feasible with good anatomical results. However, it should be noted that after the removal of uterine adenomyosis, the patient should be advised on the high risk of uterine rupture during pregnancy. Robotic cerclage may also be performed concomitantly in cases of 2nd-trimester recurrent abortions.