48 Usha Verma and Neil Verma
ablation is not effective for this condition as it does not penetrate deeply
enough into the myometrium. Danazol and GnRH agonist’s side effects and
the inability to use these agents in the long term make treatment with these
agents less acceptable. Use of LNG-IUD for the treatment of adenomyosis is
rapidly increasing. LNG-IUD causes decidualization and atrophy of the
endometrium and in addition it down-regulates estrogen receptors in glandular
and stromal endometrial tissues which causes adenomyosis foci within the
myometrium to atrophy. This leads to decreased blood loss during menses and
may also reduce the size of the uterus [72].
Vercellini et al. evaluated the effectiveness of the LNG-IUD in 25 women
with menorrhagia associated with adenomyosis over a period of 12 months.
The average blood loss decreased by approximately 75% (211 ± 61 to 44 ± 18
mL), resulting in a significant increase in hemoglobin, serum iron and ferritin
levels. In addition, there was a significant decrease in both uterine volume and
endometrial thickness [70].
In another study, 47 women with adenomyosis were treated with LNG-
IUD and followed for up to 36 months. At the end of 36 months, 32 women
were still enrolled in the study. In these women, serum hemoglobin and ferritin
levels significantly increased and CA-125 values significantly decreased. The
uterine volume decreased at 12 months. However there was a slight increase in
uterine volume but this was not significantly different from the initial
pretreatment volume. Pain scores decreased significantly by 6 months and
remained there at 24 months. Menstrual blood loss was also markedly reduced,
with a reduction of >90%, and remained similar at 24 months. Even though
some symptoms recurred after 3 years, they were still significantly less than
the initial presentation. The exact cause of this occurrence is not known, but it
is probably due to low levels of daily hormone released by the LNG-IUD over
time [73]. LNG-IUD is an effective treatment for adenomyosis, showing an
improvement in pain and bleeding scores over two years. Replacing the IUD
in less than 5 years may be beneficial in producing long term symptom relief.
Endometrial hyperplasia and Endometrial intraepithelial neoplasia
Management depends on whether the underlying pathology is primarily
hormonal (benign endometrial hyperplasia) or essentially a premalignant
disease (endometrial intraepithelial neoplasia). Endometrial hyperplasia
belongs to the functional category of estrogen effects and is usually treated
with hormonal treatment. Endometrial intraepithelial neoplasia is precancerous
and the management is hormonal or surgical treatment. Both conditions