Effectiveness of Hormonal Treatment in Perimenopausal Women with Adenomyosis

Background: Adenomyosis is a common benign gynecological condition associated with dysmenorrhea, heavy menstrual bleeding, and chronic pelvic pain. Symptoms may become more troublesome during the perimenopause. This study aimed to evaluate the effectiveness of hormonal treatment in perimenopausal women with adenomyosis.

This hospital -based observational study was conducted in the Department of Obstetrics and Gynecology, Netrokona Medical College and Hospital, Netrokona, Bangladesh, over a period of one year, from January 2025 to December 2025. The study included 100 premenopausal women diagnosed with adenomyosis who visited the Obstetrics and Gynecology department during the study period.

Dienogest was the m ost commonly used treatment (35.0%), followed by combined oral contraceptives (25.0%) and the levonorgestrel -releasing intrauterine system (22.0%). The mean VAS pain score decreased significantly from 6.1 ± 1.8 at baseline to 3.2 ± 1.6 at 6 months (p<0.001 ). Heavy menstrual bleeding decreased from 44.0% to 12.0%, while dysmenorrhea decreased from 82.0% to 38.0% after treatment. Overall, 78.0% of participants showed clinical improvement. The highest improvement rate was observed with dienogest (85.7%), although the difference between treatment groups was not statistically significant (p=0.083). Irregular vaginal bleeding or spotting was the most common adverse effect (27.0%), while 48.0% of participants reported no adverse effects.

Hormonal treatment was effective in reducing pain and menstrual bleeding and improving clinical symptoms among perimenopausal women with adenomyosis. These findings suggest that hormonal therapy may provide an effective conservative option for symptom control and uterine preservation. Key words: Adenomyosis, Hormonal treatment, Perimenopause, Dysmenorrhea Effectiveness of Hormonal Treatment In Perimenopausal Women With Adenomyosis ARC Journal of Gynecology and Obstetrics Page | 16 1. INTRODUCTION Adenomyosis is a benign gynecological condition characterized by the presence of endometrial ti ssue within the myometrium [1]. The prevalence of adenomyosis is estimated to range from 5% to 70%, depending on the target population and the dia gnostic method used, including transvaginal ultrasound (TVUS), magnetic resonance imaging (MRI), and histological examination [2 –5]. Notably, approximately 70 –80% of affected women are between 40 and 50 years of age, making adenomyosis particularly common during the perimenopausal period [2 –4]. Its exact pathogenesis remains unclear, although disruption of the normal junction between the basal endometrium and myometrium has been suggested as a possible mechanism [6,7]. During the perimenopausal period, wo men may experience worsening symptoms, particularly progressive dysmenorrhea and heavy menstrual bleeding, which can significantly affect their quality of life [1,8]. Clinical problems associated with adenomyosis also include chronic pelvic pain (CPP), abn ormal uterine bleeding (AUB), heavy menstrual bleeding (HMB), infertility, and recurrent pregnancy loss [9]. These clinical manifestations and the associated impact on quality of life make appropriate and effective treatment essential [9]. Although hysterectomy has traditionally been considered the definitive treatment for adenomyosis, medical management should be considered before invasive treatment [1,8]. Some perimenopausal women with severe adenomyosis may have no further childbearing plans but still prefer conservative treatment to preserve the uterus. This highlights the need for effective and safe long -term treatment options that can control symptoms and improve quality of life until menopause [10]. The rationale for medical treatment is partly based on the biological similarities between adenomyosis and endometriosis. Several hormonal and nonhormonal therapies used for endometriosis have also been investigated for the management of adenomyosis -related pain and other symptoms [8, 10-12]. Currently, there are no clear or universally accepted guidelines for the medical treatment of adenomyosis. Similar to endometriosis, several hormonal therapies are used off -label to control symptoms and reduce the need for hysterectomy [13, 14 ]. Commonly used hormonal treatments include progestins, combined oral contraceptives (COCs), hormone -releasing intrauterine systems (IUSs), and gonadotropin - releasing hormone (GnRH) agonists and antagonists [15]. However, the relative effectiveness and safety of the se treatment options have not yet been clearly established. Therefore, the present study aimed to evaluate the effectiveness of hormonal treatments for managing adenomyosis -related pain and bleeding in perimenopausal women. 2. METHODS & MATERIALS This hospital -based observational study was conducted in the Department of Obstetrics and Gynecology, Netrokona Medical College and Hospital, Netrokona, Bangladesh, over a period of one year, from January 2025 to December 2025. The study included 100 perim enopausal women diagnosed with adenomyosis and treated with hormonal therapy. 2.1. Inclusion Criteria 1. Perimenopausal women aged 40–55 years. 2. Diagnosed with adenomyosis based on clinical and imaging findings. 3. Presence of adenomyosis-related symptoms, such as dysmenorrhea, heavy menstrual bleeding, or chronic pelvic pain. 4. Received hormonal treatment for adenomyosis. 5. Willing to participate and provide informed consent. 2.2. Exclusion Criteria 1. Confirmed uterine malignancy or suspected gynecological malignancy. 2. Coexisting uterine conditions that could significantly affect symptoms, such as large or symptomatic fibroids. 3. Severe medical conditions contraindicating hormonal treatment. 4. Previous hysterectomy or other definitive surgical treatment for adenomyosis. Data Collection and Analysis: Data were collected using a structured data collection form. Baseline information included age, body mass index (BMI), parity, duration of symptoms, uterine enlargement, and presenting symptoms. Clinical symptoms, including dy smenorrhea, heavy menstrual bleeding, and chronic pelvic pain, were recorded before treatment and during follow-up. Details of the hormonal treatment received were also documented, including Effectiveness of Hormonal Treatment In Perimenopausal Women With Adenomyosis ARC Journal of Gynecology and Obstetrics Page | 17 dienogest, combined oral contraceptives (COCs), levonorgestrel -releasing intrauterine system (LNG -IUS), gonadotropin -releasing hormone (GnRH) agonists, and GnRH antagonists. Pain severity was assessed using the Visual Analog Scale (V AS). Data were entered and analyzed using SPSS version 23.0. Changes in continuous clini cal outcomes at baseline, 3 - month, and 6 -month follow -up were assessed. Categorical variables before and after treatment were compared using the chi -square test as appropriate. Differences in treatment response among the hormonal treatment groups were also assessed using ANOV A and the chi-square test. A p-value of <0.05 was considered statistically significant. 3. RESULT Table 1. Baseline Sociodemographic and Clinical Characteristics of Study Participants (n=100) Variable n P %) Age (years) 40–44 34 34.0 45–49 42 42.0 50–55 24 24.0 BMI (kg/m²) <18.5 8 8.0 18.5–24.9 61 61.0 ≥25.0 31 31.0 Parity Nulliparous 12 12.0 Primiparous 28 28.0 Multiparous 60 60.0 Duration of symptoms 5 years 25 25.0 Uterine enlargement Present 67 67.0 Absent 33 33.0 Table 1 presents the baseline sociodemographic and clinical characteristics of the study participants. Most women were aged 45 –49 years (42.0%), followed by those aged 40 –44 years (34.0%). The majority had a normal BMI (61.0%) and were multiparous (60.0%) . Nearly half of the participants (48.0%) had symptoms for 2 –5 years. Uterine enlargement was present in 67.0% of women. Figure 1. Distribution of Hormonal Treatments Used Among Study Respondents Figure 1 shows the distribution of hormonal treatments used among the study participants. Dienogest was the most used treatment (35.0%), followed by combined oral contraceptives (25.0%) and the levonorgestrel -releasing intrauterine system (22.0%). GnRH agonists and GnRH antagonists were used in 12.0% and 6.0% of participants, respectively. Effectiveness of Hormonal Treatment In Perimenopausal Women With Adenomyosis ARC Journal of Gynecology and Obstetrics Page | 18 Table 2. Change in Pain Severity Before and After Hormonal Treatment Pain severity (V AS score) Before treatment n (%) After treatment n (%) Mild (1–3) 18 (18.0) 62 (62.0) Moderate (4–6) 46 (46.0) 30 (30.0) Severe (7–10) 36 (36.0) 8 (8.0) Mean V AS score 6.1 ± 1.8 3.2 ± 1.6 p-value <0.001 P-value obtained by Chi-square test Table 2 compares pain severity before and after hormonal treatment. Before treatment, 36.0% of women reported severe pain, while only 8.0% had severe pain after treatment. The proportion of mild pain increased from 18.0% before treatment to 62.0% after tre atment. The mean V AS score decreased from 6.1 ± 1.8 before treatment to 3.2 ± 1.6 after treatment, showing a statistically significant reduction in pain severity (p<0.001). Table 3. Change in Menstrual Bleeding After Hormonal Treatment Menstrual bleeding status Before treatment n (%) After treatment n (%) Normal 21 (21.0) 59 (59.0) Moderate bleeding 35 (35.0) 29 (29.0) Heavy menstrual bleeding 44 (44.0) 12 (12.0) p-value <0.001 P-value obtained by Chi-square test Table 3 demonstrates the change in menstrual bleeding patterns following hormonal treatment. Before treatment, heavy menstrual bleeding was reported by 44.0% of participants, which decreased to 12.0% after treatment. The proportion of women with normal menstrual bleeding increased from 21.0% to 59.0%. This change was statistically significant (p<0.001). Table 4. Comparison of Clinical Symptoms Before and After Hormonal Treatment Clinical symptom Before treatment n (%) After treatment n (%) p-value Dysmenorrhea 82 (82.0) 38 (38.0) <0.001 Heavy menstrual bleeding 79 (79.0) 31 (31.0) <0.001 Chronic pelvic pain 56 (56.0) 24 (24.0) <0.001 Dyspareunia 28 (28.0) 15 (15.0) 0.018 Fatigue related to bleeding 41 (41.0) 18 (18.0) <0.001 p-value obtained by Chi-square test Table 4 shows that Dysmenorrhea was the most common symptom before treatment (82.0%), followed by heavy menstrual bleeding (79.0%) and chronic pelvic pain (56.0%). After treatment, the frequency of all major symptoms decreased significantly. Dysmenorrhea decreased to 38.0%, heavy menstrual bleeding to 31.0%, and chronic pelvic pain to 24.0% (all p<0.001). Dyspareunia and fatigue related to bleeding also decreased significantly after treatment. Figure 2. Adverse Effects Reported During Hormonal Treatment Effectiveness of Hormonal Treatment In Perimenopausal Women With Adenomyosis ARC Journal of Gynecology and Obstetrics Page | 19 Figure 2 summarizes the adverse effects reported during hormonal treatment. Irregular vaginal bleeding or spotting was the most commonly reported adverse effect (27.0%), followed by headache (14.0%) and breast tenderness (11.0%). Nausea, mood changes, hot flushes, and weight gain were reported less frequently. Nearly half of the participants (48.0%) reported no adverse effects during treatment. Table 5. Treatment Outcome According to Type of Hormonal Therapy Treatment n Improved n (%) Not improved n (%) p-value Dienogest 35 30 (85.7) 5 (14.3) COCs 25 18 (72.0) 7 (28.0) LNG-IUS 22 18 (81.8) 4 (18.2) GnRH agonists 12 9 (75.0) 3 (25.0) GnRH antagonists 6 3 (50.0) 3 (50.0) Total 100 78 (78.0) 22 (22.0) 0.083 p-value obtained by Chi-square test In Table 5, 78.0% of participants showed improvement. The highest proportion of improvement was observed among women receiving dienogest (85.7%), followed by those treated with the levonorgestrel -releasing intrauterine system (81.8%). Improvement was observed in 72.0% of women receiving combined oral contraceptives and 75.0% of those receiving GnRH agonists. The difference in treatment outcomes among the groups was not statistically significant (p=0.083). Table 6. Changes in Clinical Outcomes During Follow-up Outcome Baseline 3 months 6 months p-value Mean V AS pain score 6.1 ± 1.8 4.2 ± 1.7 3.2 ± 1.6 <0.001 Mean menstrual blood loss score 7.2 ± 2.1 5.0 ± 1.9 3.8 ± 1.7 <0.001 Mean uterine volume (cm³) 198.4 ± 65.2 184.6 ± 61.7 171.3 ± 58.9 0.012 Participants with HMB, n (%) 44 (44.0) 23 (23.0) 12 (12.0) <0.001 HMB= Heavy Menstrual Bleeding, p-value obtained by Chi-square test and ANOVA where applicable. Table 6 presents changes in clinical outcomes during follow -up. The mean V AS pain score progressively decreased from 6.1 ± 1.8 at baseline to 4.2 ± 1.7 at 3 months and 3.2 ± 1.6 at 6 months. Similarly, the mean menstrual blood loss score decreased from 7.2 ± 2. 1 to 3.8 ± 1.7 over the same period. Mean uterine volume also showed a gradual reduction during follow -up. The proportion of women with heavy menstrual bleeding decreased from 44.0% at baseline to 12.0% at 6 months. These changes were statistically significant. 4. DISCUSSION Adenomyosis is a chronic gynecological condition that commonly presents with dysmenorrhea, heavy menstrual bleeding, and chronic pelvic pain. Medical treatment is an important option for women who wish to control symptoms while avoiding or delaying surgery. Current e vidence supports the use of hormonal therapies for adenomyosis -associated pain and bleeding, although there is still no clear consensus regarding the optimal hormonal treatment [5, 13]. In the present study, dysmenorrhea was the most common symptom at baseline (82.0%), followed by heavy menstrual bleeding (79.0%) and chronic pelvic pain (56.0%). After hormonal treatment, these symptoms decreased to 38.0%, 31.0%, and 24.0%, respectively. The mean V AS pain score also decreased from 6.1 ± 1.8 at baseline to 3.2 ± 1.6 after treatment. These findings are consistent with previous studies demonstrating the effectiveness of hormonal therapy in reducing adenomyosis - related pain. Hirata et al. reported that dienogest significantly reduced pelvic pain in women with symptomatic adenomyosis and was generally well tolerated [11]. Similarly, Osuga et al., in a randomized, double -blind, placebo -controlled study, found a significantly greater reduction in pain with dienogest compared with placebo [12]. Recent systematic revi ews and meta - analyses have also supported the effectiveness of dienogest in reducing adenomyosis - associated pelvic pain and dysmenorrhea [16 , 17]. The reduction in menstrual bleeding observed in the present study was considerable. Heavy menstrual bleeding decreased from 44.0% at baseline to 12.0% after 6 months of treatment, while the mean menstrual blood loss score also Effectiveness of Hormonal Treatment In Perimenopausal Women With Adenomyosis ARC Journal of Gynecology and Obstetrics Page | 20 showed a progressive reduction during follow - up. These findings are consistent with previous evidence demonstrating the effectiveness of hormonal treatments in improving abnormal uterine bleeding and pain in women with adenomyosis. A randomized clinical trial comparing LNG -IUS and dienogest found that both treatments significantly reduced pelvic pain, while LNG -IUS produced a greater reduction in heavy menstrual bleeding [18]. Similarly, systematic reviews and meta -analyses have reported significant improvements in menorrhagia and other adenomyosis -related symptoms following treatment with dienogest and LNG-IUS [17,19,20]. In the present stu dy, dienogest was the most commonly used treatment (35.0%), followed by combined oral contraceptives (25.0%) and LNG-IUS (22.0%). The highest proportion of clinical improvement was observed among women receiving dienogest (85.7%), followed by those receiving LNG-IUS (81.8%). However, the difference in treatment response between the hormonal treatment groups was not statistically significant (p=0.083); therefore, the present findings do not establish the superiority of one treatment over another. Although so me recent evidence suggests that dienogest may provide greater improvement in pelvic pain and uterine volume than LNG -IUS, both treatments have demonstrated clinical benefits [20,21]. Differences in study populations, treatment duration, and outcome measur es should also be considered when comparing the effectiveness of different hormonal therapies [5,13, 19]. The progressive improvement observed during the 6 -month follow -up is another important finding of the present study. The mean V AS pain score decreased from 6.1 at baseline to 4.2 at 3 months and 3.2 at 6 months, while the proportion of women with heavy menstrual bleeding decreased from 44.0% to 12.0%. These findings are consistent with the long -term study by Chen et al., which reported sustained clinic al improvement among perimenopausal women receiving dienogest, with a substantial proportion achieving good control of pain and other symptoms [10]. Similarly, Hirata et al. found that 24 weeks of dienogest treatment significantly reduced adenomyosis -associated pelvic pain, while Osuga et al. demonstrated significant pain reduction with dienogest compared with placebo after 16 weeks [11,12]. A recent meta-analysis also reported that longer treatment duration was associated with greater reductions in dysmeno rrhea, supporting the progressive improvement observed in the present study [22]. Current evidence further supports the use of hormonal therapies, particularly dienogest and LNG -IUS, for the management of adenomyosis -related pain and other symptoms [5,16,1 7]. These findings suggest that continued hormonal treatment may provide sustained symptom control in perimenopausal women with adenomyosis. Regarding safety, irregular vaginal bleeding or spotting was the most frequently reported adverse effect in this st udy (27.0%), while 48.0% of participants reported no adverse effects. Irregular bleeding is a recognized adverse effect of progestin -based treatment and has been reported in previous studies of dienogest and other hormonal therapies for adenomyosis [5,16]. The Asian Society of Endometriosis and Adenomyosis guidelines also note that dienogest may be associated with abnormal uterine bleeding, particularly in women with a larger uterine size [5]. Thus, the adverse effects observed in this study were generally consistent with previously reported safety profiles. Overall, hormonal treatment was associated with meaningful improvement in the major symptoms of adenomyosis, particularly pain and heavy menstrual bleeding. However, as the difference in treatment respon se between individual hormonal therapies was not statistically significant, treatment selection should be individualized according to symptom severity, treatment tolerability, patient preference, and clinical circumstances [5,20]. 5. CONCLUSION Hormonal treat ment was effective in reducing pain and heavy menstrual bleeding and in improving other symptoms among perimenopausal women with adenomyosis. Dienogest and the levonorgestrel -releasing intrauterine system showed favorable treatment responses, although the difference in effectiveness among the hormonal treatment groups was not statistically significant. Adverse effects were generally mild, and nearly half of the women reported no adverse effects. These findings suggest that hormonal therapy can be a useful c onservative treatment option for symptom control and may help women avoid or delay definitive surgery. Further studies with larger sample sizes and longer follow-up are recommended to assess the Effectiveness of Hormonal Treatment In Perimenopausal Women With Adenomyosis ARC Journal of Gynecology and Obstetrics Page | 21 long-term effectiveness and safety of different hormonal treatment options. CONFLICT OF INTEREST None FUNDING None

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