Use of Dienogest in endometriosis: Expert Commentary
Endometriosis affects up to 10% of women of reproductive age, and the main goal of treatment is to relieve symptoms. Progestins have been the mainstay of endometriosis suppression, of which dienogest has become an important option in many parts of the world.
A search of PubMed was conducted for papers published between 2007–2019 on the use of dienogest in endometriosis. Experts reviewed these and included those they considered most relevant in clinical practice, according to their own clinical experience.
Endometriosis is a chronic disease and, as such, medical treatment should be maximized and surgical interventions avoided and minimized, unless necessary. Dienogest 2 mg offers an effective and tolerable alternative to surgical intervention for the long-term management of endometriosis, providing several important advantages over Combined Oral Contraceptives.
Furthermore, the evidence highlights that patients are willing to accept the bleeding irregularities that often occur with dienogest 2 mg, given the pain relief experienced. In clinical practice, counseling patients regarding the expected side
effects, weighing up the efficacy and safety of each treatment approach, and following treatment guidelines to provide tailored care according to each woman’s needs and desires, are all important components of management.
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Expert Recommendations
Long-term treatment of endometriosis with dienogest 2 mg (> 15 months) should continue for as long as needed by the individual woman (e.g. until pregnancy is desired, disease recurs, or side effects occur), based on local treatment labels
The efficacy of dienogest 2 mg should be measured primarily by its impact on pain and quality of life for the woman
Small decreases in BMD have been seen with dienogest treatment of up to 52 weeks; however, there does not appear to be a cumulative decrease in BMD, and there is evidence of partial recovery in BMD following treatment cessation
In terms of cancer risk, women receiving dienogest do not need to be treated or monitored differently from other women. Women should be offered appropriate counseling and time to ask questions. Ovarian masses should be monitored and treated according to published clinical practice guidelines, which aim to minimize morbidity with conservative management, laparoscopic techniques, and appropriate referral.
Expert Recommendations
Data support the efficacy of Combined Oral Contraceptives in reducing dysmenorrhea in women with endometriosis but not the relief of other typical pain symptoms (e.g. dyspareunia, non-cyclic pelvic pain).
Evidence supports the efficacy of dienogest 2 mg in reducing multiple types of endometriosis associated pain, including pelvic pain, dysmenorrhea, dyspareunia, dysuria, and dyschezia.
Expert Recommendations
Asymptomatic ovarian endometriomas should be monitored but do not require medical or surgical treatment; if the endometrioma is large and there is a risk of rupture, then surgery should be considered.
Surgery should be considered in cases of atypical findings via ultrasound examination.
Painful ovarian cysts > 3–4 cm in diameter should be treated surgically, in line with treatment guidelines.
Medical treatments can be prescribed for symptomatic relief when awaiting surgery.
Medical treatments, including dienogest 2 mg, should be prescribed post-surgery to prevent the recurrence of endometriosis, unless there is an immediate desire for pregnancy.
Postoperative dienogest 2 mg treatment has been effective in the prevention of endometriosis symptom recurrence and endometrioma.
Long-term treatment with dienogest 2 mg has been shown to decrease recurrent endometrioma size, which may indicate an additional benefit of its use in medical treatment.
Expert Recommendations
The use of medical treatments should be maximized for patients with adenomyosis
Dienogest 2 mg treatment effectively reduces pain for patients with adenomyosis and may be an alternative treatment to LNG-IUD
Patients with symptomatic DIE can be managed with dienogest 2 mg
Where extragenital endometriosis results in urethra, bowel, or kidney obstruction, or fistulae in rectovaginal endometriosis, surgical treatment options should be considered
Management of mood disturbances and depression with dienogest 2 mg should include regular monitoring during routine follow-up appointments and may require additional steps for women with a history of depression.
Expert Recommendations
The occurrence of endometriosis and the impact of symptoms should not be underestimated in adolescent patients, to ensure timely diagnosis and treatment initiation.
In adolescent patients, surgical diagnosis of endometriosis should be avoided in favor of clinical diagnosis based on symptoms.
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