Previously, the professor told us about the differences between endometriosis and adenomyosis, and now we’ll discuss available treatment options.
Dr. Becker says that the main treatments for adenomyosis are hormonal contraceptives and the Mirena IUD.
“The Mirena IUD may be an earlier approach, but having it inserted requires a small procedure. There is a smaller version of Mirena now available. It’s a slightly smaller device and therefore easier to introduce into the uterus, but it’s still invasive. So, that’s probably the main approach with adenomyosis. However, once it is in and works, the person does not have to worry about forgetting to take medication and has very reliable contraception.”
He says that there is an entire spectrum of endometriosis drugs you can use for adenomyosis, but he usually suggests Mirena as prescribed treatment.
According to Dr. Becker, the main treatment for endometriosis is exactly the same as for adenomyosis — the pill and the Mirena coil. “I’m not aware of any studies — that doesn’t mean they don’t exist — where they looked at implants for adenomyosis. Theoretically, it should work as well.”
He says there are some older studies for medroxyprogesterone acetate (better known by the brand name Depo-Provera). “A lot of patients are not necessarily happy with them. It’s nice if it works for you and your period stops. But there is a higher risk of gaining weight with that type of drug, and if you are trying to become pregnant in the foreseeable future afterward, there is often a three- to six-month lag between stopping the drug and periods returning.”
So, he says that for someone who doesn’t want to have children in the foreseeable future, that’s fine.
“With that drug, you also have to be a bit careful for younger people because of the bone mineral density, and the same is true for the GnRH agonists (medication which affects gonadotropins and sex hormones) as we have them at the moment.”
Depo-Provera is nice if it works for you and your period stops. But there is a higher risk of gaining weight with that type of drug, and if you are trying to become pregnant in the foreseeable future afterward, there is often a three- to six-month lag between stopping the drug and until your periods return.
Dr. Becker says that GnRH agonists shouldn’t be given by themselves for more than six months. At the moment, the national and international guidelines say to give it together with hormone replacement therapy (HRT) to protect the bones and alleviate menopausal symptoms.
“Practically, what we often do is treat people for two or three months without HRT, obviously telling them what’s going to happen to their general well-being, but if it helps with the pain, then we know we can add HRT afterward, which will protect the bones. If the pain doesn’t improve within two or three months, then there’s no point in continuing. Whereas if you start with HRT in the beginning, and it doesn’t work, you’re always worried, is it because you give too much estrogen, and that’s why we usually start without it,” Dr. Becker explains.
“Recently, in the US and Canada, a new class of drugs called GnRH antagonists (gonadotropin-releasing hormone antagonists) received FDA approval. There are another two or three similar drugs coming up through trials as well,” says Dr. Becker.
Antagonists don’t have to be given as a monthly or three-month injection. They can be taken orally, which some people prefer.
He says GnRH antagonists probably have very similar side effects regarding bone health and menopausal symptoms as the agonists. Although they’re similar, one potential benefit of antagonists may be that it’s possible to reduce the dosage because they’re in pill form.
Additionally, because it’s a pill you may be able to slowly change how much you take so that it’s not necessary to also do HRT because you can minimize how much estrogen levels are affected.
Dr. Becker says some places use aromatase inhibitors as a third-line approach due to their negative side effect profile. The use of these drugs is based on the observation that endometriosis tissue itself produces the enzyme aromatase, which is necessary for the final step of estrogen production.
“And looking at what the companies have in the pipeline, I think there’s a strong desire to get away from hormonal approaches just because hormones are not necessarily great, especially if you’re trying to become pregnant,” Dr. Becker explains.
He says many people who have both endometriosis and adenomyosis are young and might want to have children. To meet their needs, companies are starting to look into drugs that are more specific to the conditions, rather than just hormones.