What are the recommended medications for managing pain associated with adenomyosis?

Pain Medication Management for Adenomyosis

For patients with adenomyosis-related pain, non-steroidal anti-inflammatory drugs (NSAIDs) should be used as first-line treatment, followed by hormonal therapies such as progestins, oral contraceptives, or levonorgestrel-releasing intrauterine systems if NSAIDs are insufficient. 1, 2

First-Line Treatment: NSAIDs

• NSAIDs are the first-choice medication for controlling pain associated with adenomyosis, particularly for patients with recent fertility requirements 1
• Common NSAIDs include:
  • Ibuprofen (400-600 mg every 6 hours, maximum 3200 mg daily) 3
  • Naproxen (250-500 mg twice daily, maximum 1000 mg daily) 3
  • Diclofenac (25-50 mg 2-3 times daily, maximum 150 mg daily) 3
• NSAIDs should be used with caution in patients at high risk for:
  • Renal toxicities (age >60, compromised fluid status, concomitant nephrotoxic drugs) 3
  • GI toxicities (age >60, history of peptic ulcer disease, significant alcohol use) 3
  • Cardiac toxicities (history of cardiovascular disease) 3

Second-Line Treatment: Hormonal Therapies

If NSAIDs provide inadequate relief, hormonal therapies should be considered:

Progestins

• Oral progestins such as dienogest and norethindrone acetate have antiproliferative and anti-inflammatory effects 2
• Depot medroxyprogesterone acetate is effective compared to placebo for pain relief 3

Combined Oral Contraceptives

• Oral contraceptives are effective for treating pain and abnormal bleeding in adenomyosis 2, 4
• Can be given continuously to suppress menstruation and associated pain 4

Levonorgestrel-Releasing Intrauterine System (LNG-IUS)

• Highly effective for controlling abnormal uterine bleeding and reducing uterine volume 2
• Provides long-term management with localized hormone delivery 5
• Reduces systemic side effects compared to oral hormonal treatments 3

Third-Line Treatment: GnRH Agonists

• For patients with severe symptoms not responding to NSAIDs or hormonal therapies:
  • GnRH agonists are effective for at least three months of treatment 3
  • Add-back therapy should be considered to reduce bone mineral loss with continued GnRH agonist use 3
  • Particularly useful before fertility treatments to improve pregnancy chances in infertile women with adenomyosis 2

Fourth-Line Treatment: Other Options

• Selective progesterone receptor modulators are under investigation for adenomyosis treatment 2, 4
• Aromatase inhibitors may be considered in refractory cases 4
• Danazol can be effective but has significant androgenic side effects 2

Treatment Considerations

• Pain medication should be prescribed on a regular basis rather than "as needed" for chronic pain 3
• The oral route of administration should be the first choice when possible 3
• For breakthrough pain, rescue doses of medications should be prescribed in addition to regular therapy 3
• If medical therapy fails, surgical options including hysterectomy may be considered, though uterine-sparing procedures are increasingly available for women desiring fertility 6, 5

Monitoring and Follow-up

• Regular assessment of pain intensity using visual analog scales (VAS) or numerical rating scales (NRS) 3
• Monitor for medication side effects, particularly with long-term NSAID use:
  • Baseline blood pressure, renal function, liver function tests, and CBC 3
  • Repeat monitoring every 3 months with continued NSAID use 3
• If two NSAIDs are tried in succession without efficacy, consider advancing to hormonal therapy 3