Medical therapy for adenomyosis refers to medications or pills aimed at easing symptoms. These treatments, however, are not addressing the underlying disease itself. They consist of treatments for period pain and heavy bleeding. Like all medications, there are potential short- and long-term side effects.
Adenomyosis Medication
When symptoms are severe, these medical therapies are usually used as a short-term fix while a long-term solution is being organised.
Pain-relieving medications
Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to be effective in reducing period pain. Examples include ibuprofen (Nurofen), mefenamic acid (Ponstan), naproxen (Naprogesic), and diclofenac (Voltaren). These drugs work by blocking prostaglandin production and can reduce uterine cramps. They also have a mild effect on reducing the heaviness of menstrual bleeding. However, none of these drugs have been tested specifically for effectiveness in the setting of adenomyosis.
NSAIDs are over-the-counter medications, and they’re generally safe. Common side effects are stomach upset with pain, nausea, and heartburn. Some people can develop bleeding ulcers in the stomach and duodenum (the first part of the small bowel). Also, blood pressure might be raised, and asthma triggered. Serious rare side effects have been reported, including kidney failure, and even heart attacks and stroke. There’s no evidence to determine which one is more effective or safer.
Menstrual-flow-reducing medication:
Tranexamic acid (Cyklokapron) has been shown to be effective in reducing heavy menstrual bleeding. It works by slowing down the breakdown of clots that are formed by the body to stop bleeding. Clot formation and breakdown is a dynamic process. Tranexamic acid shifts the balance towards thrombosis by slowing the breakdown of clots, so they last longer. It’s also used in trauma, post-partum haemorrhage, and during surgery.
Side effects from this medication are rare but include nausea, diarrhoea, and visual disturbance. The major concern of tranexamic acid is the potential for deep venous thrombosis. In a case-control study using data from the British General Practice Research Database, women taking tranexamic acid had a 3-fold higher risk of developing deep vein thrombosis (DVT). Tranexamic acid should not be taken together with combined oral contraceptive pills, which by themselves increase the risk of DVT. Tranexamic acid should be avoided in women with known pre-existing conditions that make them prone to developing a thrombosis.
Menstrual cycle suppression
When external sex hormones are administered, the production of ovarian-stimulating hormones, FSH and LH from the pituitary gland at the base of the brain, is suppressed. Therefore, cyclic changes in the ovaries are also suppressed, and there are no mid-cycle oestrogen surges.
Sex hormone pills in the form of combined oestrogen and progestogen pills (so-called combined oral contraceptives pills or COCPs), or progestogen-only pills (Minipills), can be used for this purpose. Many COCPs contain a mixture of active pills with drugs in them, and a number of sugar pills that have no active drugs in them, to mark the days when a woman is expected to have a period. The active pills can be used continuously for several months. By skipping periods, a woman can avoid period-related issues. However, the withdrawal bleed could be heavy and difficult to manage. There are currently no well-conducted trials to support this strategy for adenomyosis, and therefore it should probably not be considered as a long-term solution. As there are more than thirty COCP brands available in Australia, choosing the right one might not be an easy task, and it’s best to discuss this with your GP.
Medically induced temporary menopause
We know that adenomyosis is an oestrogen-dependent condition. Hormonal manipulation to turn off oestrogen production might cause regression of adenomyosis. This can be achieved by using Gonadotropin-Releasing Hormone Agonists (GnRHa) acting act at the pituitary level. They turn off the stimulating hormone directed towards the ovary, which will then stop making sex hormones and prevent a woman from having a period. It’s like a medically induced temporary menopause. These drugs can therefore shrink the adenomyotic tissue and the overall size of the uterus. GnRHa can be administered as a twice daily nasal spray or monthly/3-monthly depot injection.
Woman might have side effects like those experienced when going through menopause: hot flushes, mood changes, and reduced bone density. These side effects limit the duration of treatment to 3-6 months.
Once the treatment is stopped, a woman’s adenomyosis might bounce back. Symptoms can recur, and the uterus may increase to pre-treatment size.
Pregnancy is possible soon after cessation of the treatment. Therefore, GnRHa can be used as a temporary solution for women who are severely symptomatic but want to conceive. GnRHa can also be used as pre-treatment with the hope to increase the success of IVF.
Should you wait for menopause?
Is telling women to wait for menopause good advice? Probably not.
Since adenomyosis is an oestrogen-dependent condition, symptoms should subside after menopause. On average, an Australian woman would expect to enter menopause at around the age of 52, so depending on how far she is from menopause, and for all the years leading up to it, adenomyosis is not going to get better by itself. In fact, symptoms can get worse the nearer she gets to menopause, as adenomyosis becomes more extensive after each month’s cyclical oestrogen stimulation. Furthermore, the closer she is to menopause, a woman’s cycle can become irregular and unpredictable. This can be difficult to manage for those suffering from heavy menstrual bleeding. Accidental leak-through and embarrassment are real concerns. Not knowing when her heavy flooding period is going to come is particularly stressful. At this stage, medical therapies might no longer be effective.
In the past, hysterectomy was the only solution. Nowadays, we have progesterone-releasing IUDs (Mirena and Kyleena), and UAE, which can be used alone or in conjunction with each other, especially when medical therapies are not effective or are undesirable.
References
- Pharmacovigilance Centre Prescriber Update on Tranexamic acid 24(2): 26-27 October 2003 http://www.medsafe.govt.nz/profs/puarticles/txaclot.htm Accessed 9 August 2015
- Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Marjoribanks J, Proctor M, Farquhar C, et al. Cochrane Database Syst Rev 2010(1):CD001751
- Role of medical therapy in the management of uterine adenomyosis. Vannuccini, Silvia; Luisi, Stefano; Tosti, Claudia; Sorbi, Flavia; Petraglia, Felice Fertility and Sterility, March 2018, Vol.109(3), pp.398-405
- Treatment of endometriosis with estrogen-progestin combination and progestogens alone. Moghissi KS Clin Obstet Gynecol 1988; 31:8238.
- Choosing a combined oral contraceptive pill. M Stewart, K Black. Australian Prescriber 2015; 38:6-111 Feb 2015
- Effects of short course buserelin therapy on adenomyosis: a report of two cases. Huang FJ, Kung FT, Chang SY, Hsu TY. J Reprod Med Obstet Gynecol. 1999; 44:741744.
- Treatment of adenomyosis with long-term GnRH analogues: a case report. Grow DR, Filer RB. Obstet Gynecol. 1991;78(3 Pt 2):538539.
- Adenomyosis: review of the literature. Garcia L, Isaacson K. J Minim Invasive Gynecol. 2011; 18:428437.