What is the recommended management for a reproductive‑age woman with adenomyosis causing heavy vaginal bleeding who is currently taking the drospirenone‑only pill (Slynd) and who previously expelled an intrauterine device (IUD) because of the same bleeding?

Management of Adenomyosis-Related Bleeding on Slynd After IUD Expulsion

Given the failure of both IUD and drospirenone-only pill (Slynd) to control bleeding, switch to dienogest 2 mg daily as the most effective long-term progestin for adenomyosis, or consider norethisterone acetate as a second-line option if dienogest is unavailable or not tolerated. 1, 2

Rationale for Treatment Change

Your patient has exhausted two major therapeutic options:

• IUD expulsion indicates anatomic intolerance, likely due to the enlarged adenomyotic uterus creating an unfavorable cavity 3, 4
• Drospirenone 4 mg (Slynd) has demonstrated efficacy in adenomyosis, but breakthrough bleeding suggests inadequate symptom control in this patient 1

The 2025 long-term progestin study showed that 49% of dienogest users required treatment switching after the first year, but those who continued experienced sustained reduction in dysmenorrhea, dyspareunia, and heavy menstrual bleeding over three years 1. This makes dienogest the strongest evidence-based next step.

Specific Treatment Algorithm

First-Line: Dienogest 2 mg Daily

• Start dienogest 2 mg once daily continuously (no hormone-free interval) 1, 2
• Counsel that irregular bleeding is expected in the first 3-6 months and typically improves with continued use 5
• If breakthrough bleeding occurs, add NSAIDs (ibuprofen 400-600 mg or naproxen 500 mg) for 5-7 days during bleeding episodes 5, 6
• Reassess at 3-6 months; if bleeding persists despite NSAIDs, consider adding a short course (10-20 days) of combined oral contraceptives containing 30-35 μg ethinyl estradiol 5

Second-Line: Norethisterone Acetate

• If dienogest is not tolerated or unavailable, switch to norethisterone acetate (typical dosing 5-10 mg daily) 1, 2
• This progestin has demonstrated antiproliferative and anti-inflammatory effects specifically in adenomyosis 2

Third-Line: Desogestrel 75 mcg

• Desogestrel showed higher discontinuation rates due to reduced long-term efficacy in the 2025 study, making it a less optimal choice 1
• Consider only if both dienogest and norethisterone acetate fail or are contraindicated 1

Critical Evaluation Before Treatment Change

Before switching medications, rule out the following conditions that can cause breakthrough bleeding 6, 7:

• Pregnancy (including ectopic) - obtain urine or serum hCG 7
• Sexually transmitted infections - screen for gonorrhea and chlamydia if risk factors present 6, 7
• New uterine pathology - consider transvaginal ultrasound to assess for polyps, fibroids, or worsening adenomyosis 6, 7
• Medication interactions - review all current medications, supplements, and smoking status 5

Why Not Retry the IUD?

IUD expulsion in adenomyosis patients has a 15% treatment discontinuation rate even when successfully retained, and the enlarged adenomyotic uterus creates an unfavorable environment for device retention 1, 3. The 1999 case report showed successful LNG-IUD treatment only after marked uterine size reduction, which your patient has not achieved 3. Attempting reinsertion without first medically reducing uterine size would likely result in repeat expulsion 3, 4.

Counseling Points

• Progestins do not cure adenomyosis but effectively manage symptoms long-term 2, 8
• Flexibility in switching between progestins optimizes outcomes - if one fails, another may succeed 1
• Breakthrough bleeding during the first 3-6 months is expected and not harmful 5, 6
• Amenorrhea or oligomenorrhea is a therapeutic goal, not a complication 5
• If all medical options fail and bleeding remains unacceptable, surgical options (adenomyomectomy or hysterectomy) should be discussed 9, 8

Common Pitfalls to Avoid

• Do not dismiss persistent bleeding without excluding pregnancy, infection, or new pathology 7
• Do not continue ineffective therapy beyond 3-6 months - reassess and switch treatments 6, 1
• Do not use copper IUD in adenomyosis - it worsens bleeding 9, 7
• Do not assume all progestins are equivalent - dienogest has the strongest evidence for adenomyosis specifically 1, 2