{"paper_id":"5ff73e66-5a25-47ca-a55a-0a1f5e541092","body_text":"ARC Journal of Gynecology and Obstetrics \nVolume 10, Issue 4, 2026, PP 15-22  \nISSN 2456-0561 (Online) \nDOI: https://doi.org/10.20431/2456-0561.1004003  \nwww.arcjournals.org  \n \n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 15 \nEffectiveness of Hormonal Treatment in Perimenopausal Women \nwith Adenomyosis \nDr. Asma Khatun1*, Dr. Tahmina Khatun2, Dr. Sharmin Akhter Shorna3, Dr. Mousumi Khan4, \nDr. Shahinur Rahman5, Dr. Mst Rukshana Pervin6, Dr. Mohammad Habibur Rahman7,                       \nDr. Rahima Sultana8 \n1Associate Professor, Department of Obstetrics and Gynecology, Mugda Medical College, Dhaka, Bangladesh \n2Medical Officer, Department of Obstetrics and Gynecology, Kurmitola Multicare Specialized Hospital, Dhaka, \nBangladesh. \n3Junior Consultant, Department of Obstetrics and Gynecology, Kurmitola Multicare Specialized Hospital, \nDhaka, Bangladesh. \n4Medical Officer, Department of Obstetrics and Gynecology, Kurmitola Multicare Specialized Hospital, Dhaka, \nBangladesh. \n5Assistant Professor, epartment of Obstetrics and Gynecology, Kurmitola Multicare Specialized Hospital, \nDhaka, Bangladesh. \n6Junior Consultant, Department of Obstetrics and Gynecology, Kurmitola Multicare Specialized Hospital, \nDhaka, Bangladesh. \n7Assistant Director, Gopalganj Medical College Hospital, Gopalganj, Bangladesh \n8Junior Consultant, Department of Obstetrics and Gynecology, Banaripara Health Complex. Barishal, \nBangladesh. \nReceived: 03 September 2026                   Accepted: 22 September 2026                    Published: 02 October 2026 \n \n*Corresponding Author: Dr. Asma Khatun, Associate Professor, Department of Obstetrics and Gynecology, \nMugda Medical College, Dhaka, Bangladesh \nAbstract:  \nBackground: Adenomyosis is a common benign gynecological condition associated with dysmenorrhea, heavy \nmenstrual bleeding, and chronic pelvic pain. Symptoms may become more troublesome during the \nperimenopause. This study aimed to evaluate the effectiveness of hormonal treatment  in perimenopausal women \nwith adenomyosis. \nMethods: This hospital -based observational study was conducted in the Department of Obstetrics and \nGynecology, Netrokona Medical College and Hospital, Netrokona, Bangladesh, over a period of one year, from \nJanuary 2025 to December 2025. The study included 100 premenopausal women diagnosed with adenomyosis \nwho visited the Obstetrics and Gynecology department during the study period.    \nResults: Dienogest was the m ost commonly used treatment (35.0%), followed by combined oral contraceptives \n(25.0%) and the levonorgestrel -releasing intrauterine system (22.0%). The mean VAS pain score decreased \nsignificantly from 6.1 ± 1.8 at baseline to 3.2 ± 1.6 at 6 months (p<0.001 ). Heavy menstrual bleeding decreased \nfrom 44.0% to 12.0%, while dysmenorrhea decreased from 82.0% to 38.0% after treatment. Overall, 78.0% of \nparticipants showed clinical improvement. The highest improvement rate was observed with dienogest (85.7%), \nalthough the difference between treatment groups was not statistically significant (p=0.083). Irregular vaginal \nbleeding or spotting was the most common adverse effect (27.0%), while 48.0% of participants reported no \nadverse effects. \nConclusion: Hormonal treatment was effective in reducing pain and menstrual bleeding and improving clinical \nsymptoms among perimenopausal women with adenomyosis. These findings suggest that hormonal therapy may \nprovide an effective conservative option for symptom control and uterine preservation. \nKey words: Adenomyosis, Hormonal treatment, Perimenopause, Dysmenorrhea\n\nEffectiveness of Hormonal Treatment In Perimenopausal Women With Adenomyosis\n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 16 \n1. INTRODUCTION \nAdenomyosis is a benign gynecological \ncondition characterized by the presence of \nendometrial ti ssue within the myometrium [1].  \nThe prevalence of adenomyosis is estimated to \nrange from 5% to 70%, depending on the target \npopulation and the dia gnostic method used, \nincluding transvaginal ultrasound (TVUS), \nmagnetic resonance imaging (MRI), and \nhistological examination [2 –5]. Notably, \napproximately 70 –80% of affected women are \nbetween 40 and 50 years of age, making \nadenomyosis particularly common during the \nperimenopausal period [2 –4].  Its exact \npathogenesis remains unclear, although \ndisruption of the normal junction between the \nbasal endometrium and myometrium has been \nsuggested as a possible mechanism [6,7].  \nDuring the perimenopausal period, wo men may \nexperience worsening symptoms, particularly \nprogressive dysmenorrhea and heavy menstrual \nbleeding, which can significantly affect their \nquality of life [1,8]. Clinical problems \nassociated with adenomyosis also include \nchronic pelvic pain (CPP), abn ormal uterine \nbleeding (AUB), heavy menstrual bleeding \n(HMB), infertility, and recurrent pregnancy loss \n[9]. These clinical manifestations and the \nassociated impact on quality of life make \nappropriate and effective treatment essential [9]. \nAlthough hysterectomy has traditionally been \nconsidered the definitive treatment for \nadenomyosis, medical management should be \nconsidered before invasive treatment [1,8]. \nSome perimenopausal women with severe \nadenomyosis may have no further childbearing \nplans but still prefer conservative treatment to \npreserve the uterus. This highlights the need for \neffective and safe long -term treatment options \nthat can control symptoms and improve quality \nof life until menopause [10].  The rationale for \nmedical treatment is partly based on the \nbiological similarities between adenomyosis and \nendometriosis. Several hormonal and \nnonhormonal therapies used for endometriosis \nhave also been investigated for the management \nof adenomyosis -related pain and other \nsymptoms [8, 10-12]. \nCurrently, there are no clear or universally \naccepted guidelines for the medical treatment of \nadenomyosis. Similar to endometriosis, several \nhormonal therapies are used off -label to control \nsymptoms and reduce the need for hysterectomy \n[13, 14 ]. Commonly  used hormonal treatments \ninclude progestins, combined oral \ncontraceptives (COCs), hormone -releasing \nintrauterine systems (IUSs), and gonadotropin -\nreleasing hormone (GnRH) agonists and \nantagonists [15]. However, the relative \neffectiveness and safety of the se treatment \noptions have not yet been clearly established. \nTherefore, the present study aimed to evaluate \nthe effectiveness of hormonal treatments for \nmanaging adenomyosis -related pain and \nbleeding in perimenopausal women. \n2. METHODS & MATERIALS  \nThis hospital -based observational study was \nconducted in the Department of Obstetrics and \nGynecology, Netrokona Medical College and \nHospital, Netrokona, Bangladesh, over a period \nof one year, from January 2025 to December \n2025. The study included 100 perim enopausal \nwomen diagnosed with adenomyosis and treated \nwith hormonal therapy.  \n2.1. Inclusion Criteria \n1. Perimenopausal women aged 40–55 years. \n2. Diagnosed with adenomyosis based on \nclinical and imaging findings. \n3. Presence of adenomyosis-related symptoms, \nsuch as dysmenorrhea, heavy menstrual \nbleeding, or chronic pelvic pain. \n4. Received hormonal treatment for \nadenomyosis. \n5. Willing to participate and provide informed \nconsent. \n2.2. Exclusion Criteria \n1. Confirmed uterine malignancy or suspected \ngynecological malignancy. \n2. Coexisting uterine conditions that could \nsignificantly affect symptoms, such as large \nor symptomatic fibroids. \n3. Severe medical conditions contraindicating \nhormonal treatment. \n4. Previous hysterectomy or other definitive \nsurgical treatment for adenomyosis. \nData Collection and Analysis: Data were \ncollected using a structured data collection form. \nBaseline information included age, body mass \nindex (BMI), parity, duration of symptoms, \nuterine enlargement, and presenting symptoms. \nClinical symptoms, including dy smenorrhea, \nheavy menstrual bleeding, and chronic pelvic \npain, were recorded before treatment and during \nfollow-up. Details of the hormonal treatment \nreceived were also documented, including \n\nEffectiveness of Hormonal Treatment In Perimenopausal Women With Adenomyosis\n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 17 \ndienogest, combined oral contraceptives \n(COCs), levonorgestrel -releasing intrauterine \nsystem (LNG -IUS), gonadotropin -releasing \nhormone (GnRH) agonists, and GnRH \nantagonists. Pain severity was assessed using the \nVisual Analog Scale (V AS). Data were entered \nand analyzed using SPSS version 23.0. Changes \nin continuous clini cal outcomes at baseline, 3 -\nmonth, and 6 -month follow -up were assessed. \nCategorical variables before and after treatment \nwere compared using the chi -square test as \nappropriate. Differences in treatment response \namong the hormonal treatment groups were also  \nassessed using ANOV A and the chi-square test. \nA p-value of <0.05 was considered statistically \nsignificant. \n3. RESULT  \nTable 1.  Baseline Sociodemographic and Clinical Characteristics of Study Participants (n=100) \nVariable n  P %) \nAge (years)   \n40–44 34  34.0 \n45–49 42  42.0 \n50–55 24  24.0 \nBMI (kg/m²)   \n<18.5 8  8.0 \n18.5–24.9 61  61.0 \n≥25.0 31  31.0 \nParity   \nNulliparous 12  12.0 \nPrimiparous 28  28.0 \nMultiparous 60  60.0 \nDuration of symptoms   \n<2 years 27  27.0 \n2–5 years 48  48.0 \n>5 years 25  25.0 \nUterine enlargement   \nPresent 67  67.0 \nAbsent 33  33.0 \nTable 1 presents the baseline sociodemographic \nand clinical characteristics of the study \nparticipants. Most women were aged 45 –49 \nyears (42.0%), followed by those aged 40 –44 \nyears (34.0%).  \nThe majority had a normal BMI (61.0%) and \nwere multiparous (60.0%) . Nearly half of the \nparticipants (48.0%) had symptoms for 2 –5 \nyears. Uterine enlargement was present in \n67.0% of women. \nFigure 1. Distribution of Hormonal Treatments Used Among Study Respondents \n \nFigure 1 shows the distribution of hormonal \ntreatments used among the study participants. \nDienogest was the most used treatment (35.0%), \nfollowed by combined oral contraceptives \n(25.0%) and the levonorgestrel -releasing \nintrauterine system (22.0%). GnRH agonists and \nGnRH antagonists were used in 12.0% and 6.0% \nof participants, respectively. \n\n\nEffectiveness of Hormonal Treatment In Perimenopausal Women With Adenomyosis\n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 18 \nTable 2. Change in Pain Severity Before and After Hormonal Treatment \nPain severity (V AS score) Before treatment n (%) After treatment n (%) \nMild (1–3) 18 (18.0) 62 (62.0) \nModerate (4–6) 46 (46.0) 30 (30.0) \nSevere (7–10) 36 (36.0) 8 (8.0) \nMean V AS score 6.1 ± 1.8 3.2 ± 1.6 \np-value <0.001 \nP-value obtained by Chi-square test \nTable 2 compares pain severity before and after \nhormonal treatment. Before treatment, 36.0% of \nwomen reported severe pain, while only 8.0% \nhad severe pain after treatment. The proportion \nof mild pain increased from 18.0% before \ntreatment to 62.0% after tre atment. The mean \nV AS score decreased from 6.1 ± 1.8 before \ntreatment to 3.2 ± 1.6 after treatment, showing a \nstatistically significant reduction in pain severity \n(p<0.001). \nTable 3. Change in Menstrual Bleeding After Hormonal Treatment \nMenstrual bleeding status Before treatment n (%) After treatment n (%) \nNormal 21 (21.0) 59 (59.0) \nModerate bleeding 35 (35.0) 29 (29.0) \nHeavy menstrual bleeding 44 (44.0) 12 (12.0) \np-value <0.001 \nP-value obtained by Chi-square test \nTable 3 demonstrates the change in menstrual \nbleeding patterns following hormonal treatment. \nBefore treatment, heavy menstrual bleeding was \nreported by 44.0% of participants, which \ndecreased to 12.0% after treatment. The \nproportion of women with normal menstrual \nbleeding increased from 21.0% to 59.0%. This \nchange was statistically significant (p<0.001). \nTable 4. Comparison of Clinical Symptoms Before and After Hormonal Treatment \nClinical symptom Before treatment n (%) After treatment n (%) p-value \nDysmenorrhea 82 (82.0) 38 (38.0) <0.001 \nHeavy menstrual bleeding 79 (79.0) 31 (31.0) <0.001 \nChronic pelvic pain 56 (56.0) 24 (24.0) <0.001 \nDyspareunia 28 (28.0) 15 (15.0) 0.018 \nFatigue related to bleeding 41 (41.0) 18 (18.0) <0.001 \np-value obtained by Chi-square test \nTable 4 shows that Dysmenorrhea was the most \ncommon symptom before treatment (82.0%), \nfollowed by heavy menstrual bleeding (79.0%) \nand chronic pelvic pain (56.0%). After \ntreatment, the frequency of all major symptoms \ndecreased significantly. Dysmenorrhea \ndecreased to 38.0%, heavy menstrual bleeding \nto 31.0%, and chronic pelvic pain to 24.0% (all \np<0.001). Dyspareunia and fatigue related to \nbleeding also decreased significantly after \ntreatment. \nFigure 2. Adverse Effects Reported During Hormonal Treatment \n \n\n\nEffectiveness of Hormonal Treatment In Perimenopausal Women With Adenomyosis\n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 19 \nFigure 2 summarizes the adverse effects \nreported during hormonal treatment. Irregular \nvaginal bleeding or spotting was the most \ncommonly reported adverse effect (27.0%), \nfollowed by headache (14.0%) and breast \ntenderness (11.0%). Nausea, mood changes, hot \nflushes, and weight gain were reported less \nfrequently. Nearly half of the participants \n(48.0%) reported no adverse effects during \ntreatment. \nTable 5. Treatment Outcome According to Type of Hormonal Therapy \nTreatment n Improved n (%) Not improved n (%) p-value \nDienogest 35 30 (85.7) 5 (14.3)  \nCOCs 25 18 (72.0) 7 (28.0)  \nLNG-IUS 22 18 (81.8) 4 (18.2)  \nGnRH agonists 12 9 (75.0) 3 (25.0)  \nGnRH antagonists 6 3 (50.0) 3 (50.0)  \nTotal 100 78 (78.0) 22 (22.0) 0.083 \np-value obtained by Chi-square test \nIn Table 5, 78.0% of participants showed \nimprovement. The highest proportion of \nimprovement was observed among women \nreceiving dienogest (85.7%), followed by those \ntreated with the levonorgestrel -releasing \nintrauterine system (81.8%). Improvement was \nobserved in 72.0% of women receiving \ncombined oral contraceptives and 75.0% of \nthose receiving GnRH agonists. The difference \nin treatment outcomes among the groups was \nnot statistically significant (p=0.083). \nTable 6. Changes in Clinical Outcomes During Follow-up \nOutcome Baseline 3 months 6 months p-value \nMean V AS pain score 6.1 ± 1.8 4.2 ± 1.7 3.2 ± 1.6 <0.001 \nMean menstrual blood loss score 7.2 ± 2.1 5.0 ± 1.9 3.8 ± 1.7 <0.001 \nMean uterine volume (cm³) 198.4 ± 65.2 184.6 ± 61.7 171.3 ± 58.9 0.012 \nParticipants with HMB, n (%) 44 (44.0) 23 (23.0) 12 (12.0) <0.001 \nHMB= Heavy Menstrual Bleeding, p-value obtained by Chi-square test and  ANOVA where applicable. \nTable 6 presents changes in clinical outcomes \nduring follow -up. The mean V AS pain score \nprogressively decreased from 6.1 ± 1.8 at \nbaseline to 4.2 ± 1.7 at 3 months and 3.2 ± 1.6 at \n6 months. Similarly, the mean menstrual blood \nloss score decreased from 7.2 ± 2. 1 to 3.8 ± 1.7 \nover the same period. Mean uterine volume also \nshowed a gradual reduction during follow -up. \nThe proportion of women with heavy menstrual \nbleeding decreased from 44.0% at baseline to \n12.0% at 6 months. These changes were \nstatistically significant. \n4. DISCUSSION \nAdenomyosis is a chronic gynecological \ncondition that commonly presents with \ndysmenorrhea, heavy menstrual bleeding, and \nchronic pelvic pain. Medical treatment is an \nimportant option for women who wish to control \nsymptoms while avoiding or delaying surgery. \nCurrent e vidence supports the use of hormonal \ntherapies for adenomyosis -associated pain and \nbleeding, although there is still no clear \nconsensus regarding the optimal hormonal \ntreatment [5, 13]. \nIn the present study, dysmenorrhea was the most \ncommon symptom at baseline (82.0%), followed \nby heavy menstrual bleeding (79.0%) and \nchronic pelvic pain (56.0%). After hormonal \ntreatment, these symptoms decreased to 38.0%, \n31.0%, and 24.0%, respectively. The mean V AS \npain score also decreased from 6.1 ± 1.8 at \nbaseline to 3.2 ± 1.6 after treatment. \n These findings are consistent with previous \nstudies demonstrating the effectiveness of \nhormonal therapy in reducing adenomyosis -\nrelated pain. Hirata et al. reported that dienogest \nsignificantly reduced pelvic pain in women with \nsymptomatic adenomyosis and was generally \nwell tolerated [11]. Similarly, Osuga et al., in a \nrandomized, double -blind, placebo -controlled \nstudy, found a significantly greater reduction in \npain with dienogest compared with placebo \n[12]. Recent systematic revi ews and meta -\nanalyses have also supported the effectiveness \nof dienogest in reducing adenomyosis -\nassociated pelvic pain and dysmenorrhea [16 , \n17].  \nThe reduction in menstrual bleeding observed in \nthe present study was considerable. Heavy \nmenstrual bleeding  decreased from 44.0% at \nbaseline to 12.0% after 6 months of treatment, \nwhile the mean menstrual blood loss score also \n\nEffectiveness of Hormonal Treatment In Perimenopausal Women With Adenomyosis\n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 20 \nshowed a progressive reduction during follow -\nup. These findings are consistent with previous \nevidence demonstrating the effectiveness of \nhormonal treatments in improving abnormal \nuterine bleeding and pain in women with \nadenomyosis. A randomized clinical trial \ncomparing LNG -IUS and dienogest found that \nboth treatments significantly reduced pelvic \npain, while LNG -IUS produced a greater \nreduction in heavy menstrual bleeding [18]. \nSimilarly, systematic reviews and meta -analyses \nhave reported significant improvements in \nmenorrhagia and other adenomyosis -related \nsymptoms following treatment with dienogest \nand LNG-IUS [17,19,20]. \nIn the present stu dy, dienogest was the most \ncommonly used treatment (35.0%), followed by \ncombined oral contraceptives (25.0%) and \nLNG-IUS (22.0%). The highest proportion of \nclinical improvement was observed among \nwomen receiving dienogest (85.7%), followed \nby those receiving LNG-IUS (81.8%). However, \nthe difference in treatment response between the \nhormonal treatment groups was not statistically \nsignificant (p=0.083); therefore, the present \nfindings do not establish the superiority of one \ntreatment over another. Although so me recent \nevidence suggests that dienogest may provide \ngreater improvement in pelvic pain and uterine \nvolume than LNG -IUS, both treatments have \ndemonstrated clinical benefits [20,21]. \nDifferences in study populations, treatment \nduration, and outcome measur es should also be \nconsidered when comparing the effectiveness of \ndifferent hormonal therapies [5,13, 19].  \nThe progressive improvement observed during \nthe 6 -month follow -up is another important \nfinding of the present study. The mean V AS pain \nscore decreased from 6.1 at baseline to 4.2 at 3 \nmonths and 3.2 at 6 months, while the \nproportion of women with heavy menstrual \nbleeding decreased from 44.0% to 12.0%. These \nfindings are consistent with the long -term study \nby Chen et al., which reported sustained clinic al \nimprovement among perimenopausal women \nreceiving dienogest, with a substantial \nproportion achieving good control of pain and \nother symptoms [10]. Similarly, Hirata et al. \nfound that 24 weeks of dienogest treatment \nsignificantly reduced adenomyosis -associated \npelvic pain, while Osuga et al. demonstrated \nsignificant pain reduction with dienogest \ncompared with placebo after 16 weeks [11,12]. \nA recent meta-analysis also reported that longer \ntreatment duration was associated with greater \nreductions in dysmeno rrhea, supporting the \nprogressive improvement observed in the \npresent study [22]. Current evidence further \nsupports the use of hormonal therapies, \nparticularly dienogest and LNG -IUS, for the \nmanagement of adenomyosis -related pain and \nother symptoms [5,16,1 7]. These findings \nsuggest that continued hormonal treatment may \nprovide sustained symptom control in \nperimenopausal women with adenomyosis. \nRegarding safety, irregular vaginal bleeding or \nspotting was the most frequently reported \nadverse effect in this st udy (27.0%), while \n48.0% of participants reported no adverse \neffects. Irregular bleeding is a recognized \nadverse effect of progestin -based treatment and \nhas been reported in previous studies of \ndienogest and other hormonal therapies for \nadenomyosis [5,16].  The Asian Society of \nEndometriosis and Adenomyosis guidelines also \nnote that dienogest may be associated with \nabnormal uterine bleeding, particularly in \nwomen with a larger uterine size [5]. Thus, the \nadverse effects observed in this study were \ngenerally consistent with previously reported \nsafety profiles. \nOverall, hormonal treatment was associated \nwith meaningful improvement in the major \nsymptoms of adenomyosis, particularly pain and \nheavy menstrual bleeding. However, as the \ndifference in treatment respon se between \nindividual hormonal therapies was not \nstatistically significant, treatment selection \nshould be individualized according to symptom \nseverity, treatment tolerability, patient \npreference, and clinical circumstances [5,20]. \n5. CONCLUSION \nHormonal treat ment was effective in reducing \npain and heavy menstrual bleeding and in \nimproving other symptoms among \nperimenopausal women with adenomyosis. \nDienogest and the levonorgestrel -releasing \nintrauterine system showed favorable treatment \nresponses, although the difference in \neffectiveness among the hormonal treatment \ngroups was not statistically significant. Adverse \neffects were generally mild, and nearly half of \nthe women reported no adverse effects. These \nfindings suggest that hormonal therapy can be a \nuseful c onservative treatment option for \nsymptom control and may help women avoid or \ndelay definitive surgery. \nFurther studies with larger sample sizes and \nlonger follow-up are recommended to assess the \n\nEffectiveness of Hormonal Treatment In Perimenopausal Women With Adenomyosis\n \nARC Journal of Gynecology and Obstetrics                                                                                           Page | 21 \nlong-term effectiveness and safety of different \nhormonal treatment options. \nCONFLICT OF INTEREST  \nNone \nFUNDING \nNone \nREFERENCES \n[1] Vercellini P, Viganò P, Somigliana E, Fedele L. \nEndometriosis: pathogenesis and treatment. Nat \nRev Endocrinol. 2014;10:261–75. \n[2] Graziano A, Lo Monte G, Piva I, Caserta D, \nKarner M, Engl B, et al. Diagnostic findings in \nadenomyosis: a pictorial review on the major \nconcerns. 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Comparison \nbetween levonorges trel-releasing intrauterine \ndevice and dienogest for adenomyosis: a \nsystematic review with meta -analysis. J Obstet \nGynaecol Can. 2026;48(2):103147. \n[22] Lin S, Chen Y, Yi J, Xie X, Liu X, Guo SW. \nDienogest treatment of symptomatic \nadenomyosis: an in -depth meta-analysis. Eur J \nObstet Gynecol Reprod Biol. 2025;305:365 -\n374. \n \n \nCitation: Dr. Asma Khatun et al. “Effectiveness of Hormonal Treatment in Perimenopausal Women with \nAdenomyosis”. ARC Journal of Gynecolog y and Obstetrics. 2 026; 10(4): 15-22.                                                                  \nDOI: https://doi.org/10.20431/2456-0561.1004003. \nCopyright: © 2026 Authors. This is an open -access article distributed under the t erms of the Creative Commons \nAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the \noriginal author and source are credited.","source_license":"CC0","license_restricted":false}