INTRODUCTION:Danazol is a synthetic steroid approved in 1976 for the treatment of endometriosis-associated pain. Despite its established efficacy, its clinical use has markedly declined due to androgenic and metabolic adverse effects, prompting reconsideration of its role in current practice. METHODS:A systematic review was conducted according to PRISMA guidelines and registered in PROSPERO. Six electronic databases were searched up to June 2025 for studies evaluating oral danazol in women with endometriosis. Thirty studies (1,486 patients), including 22 randomized trials, were included. RESULTS:Danazol was evaluated across a wide range of dosing regimens, although most studies used 600 mg/day for 6 months. Consistent reductions in dysmenorrhea, dyspareunia and chronic pelvic pain were reported across the majority of studies. Amenorrhea rates generally increased with higher doses, whereas treatment discontinuation due to adverse events ranged from 0 to approximately 14%. Symptom recurrence after treatment discontinuation was frequently observed. Overall risk of bias was low to moderate. CONCLUSIONS:Danazol demonstrates consistent efficacy in reducing endometriosis-associated pain. Although high-dose regimens are limited by adverse effects, limited evidence suggests that lower-dose regimens may offer a more favorable balance between efficacy and tolerability. These findings support a reappraisal of danazol as a therapeutic option for carefully selected patients within contemporary management strategies. PROTOCOL REGISTRATION:International Prospective Register of Systematic Reviews (PROSPERO), CRD420251088044. Available at: https://www.crd.york.ac.uk/prospero.

Background: Uterine fibroids (UFs) are the most common benign tumors in women of reproductive age and are associated with abnormal uterine bleeding, infertility, and impaired implantation and endometrial receptivity. However, the contribution of the myometrial microbiome (MM) to fibroid biology and the broader uterine environment remains poorly understood. Materials and Methods: We characterized the paired MM of UF tissue and adjacent healthy myometrium (HM) from 21 women undergoing surgery and integrated serum free fatty acid (FFA) and cytokine profiling. Results: Taxonomic composition and microbial diversity were highly similar between tissues, with no differentially abundant taxa after multiple-testing correction. In contrast, PICRUSt2-based functional prediction indicated tissue-specific differences in microbial metabolic potential: UF tissue showed higher predicted representation of pathways related to L-tyrosine biosynthesis and aromatic amine degradation, whereas HM showed higher predicted representation of coenzyme A and arginine biosynthesis pathways. Patients also exhibited distinct circulating FFA profiles compared with healthy women, and integrative analyses identified phenotype-specific associations among microbial taxa, FFAs, and inflammatory mediators, particularly in women with heavy menstrual bleeding or specific fibroid localizations. Conclusions: These findings suggest that UFs are associated with potential functional remodeling of the MM rather than major taxonomic alterations, which may contribute to changes in the uterine environment relevant to implantation, endometrial receptivity, and reproductive health.

Introduction Endometriosis and adenomyosis are estrogen-dependent gynecological disorders that share pathogenic mechanisms. Despite their distinct histological and imaging features, the two diseases frequently co-occur and the similar symptoms often complicate diagnosis and management. The aim of the present study was to compare the symptom profiles of women diagnosed with endometriosis, or adenomyosis. Methods A retrospective analysis was conducted on 757 patients evaluated at their first visit, all of whom had not initiated hormonal therapy at the time of assessment. Patients were subdivided into three groups: Group 1 (endometriosis, n = 257), Group 2 (adenomyosis, n = 263), and Group 3 (coexisting endometriosis and adenomyosis, n = 237). Diagnosis was based on histology or imaging with transvaginal ultrasound and magnetic resonance imaging according to standardized criteria. Results Heavy menstrual bleeding was significantly more frequent in women with adenomyosis (64 %) than in those with endometriosis (19 %) (p < 0.001). When pain symptoms were evaluated, dysmenorrhea (p < 0.032), severe dysmenorrhea (p < 0.005) and chronic pelvic pain (p < 0.021) were more common in endometriosis than in adenomyosis patients. Dyspareunia showed similar prevalence in both groups of patients. Women with both diseases showed the highest overall symptom burden, with more frequent heavy bleeding, dysmenorrhea, severe dysmenorrhea, and pelvic pain. Conclusions The present findings showed a clear prevalence of heavy menstrual in patients with adenomyosis, while endometriosis patients showed more severe pain symptoms

BACKGROUND:Endometriosis is a chronic endocrine and inflammatory disease commonly presenting with dysmenorrhea, pelvic pain, and/or infertility. Despite the importance of menstrual symptoms, the impact of menstruation on stress is still poorly assessed. This study aims to objectively measure menstrual distress and identify its determinants in patients with endometriosis. MATERIALS AND METHODS:A cross-sectional study was conducted over one year, including 75 patients newly diagnosed with endometriosis and an age-matched control group (n = 75) of healthy women. All participants completed the Menstrual Distress Questionnaire (MEDI-Q), which explores 25 items and provides a total score along with subscales: Menstrual Symptoms (MS), Menstrual Symptoms Distress (MSD), and Menstrual Specificity Index (MESI). Scores were compared between cases and controls. A sub-analysis among endometriosis patients identified the key contributors to distress. RESULTS:Women with endometriosis showed significantly higher score for MEDI-Q Total (median = 14.00, interquartile range: [5.00---30.50] vs 12.00 [2.00---20.00], p < 0.05) as well for the subscale MSD (2.24 [1.67---2.81] vs 1.71 [1.00---2.30], p < 0.01) compared to controls. Menstrual distress was primarily associated with dyspareunia, dyschezia, dysuria, gastrointestinal symptoms (nausea, diarrhea, constipation, decreased appetite), reduced sexual drive, impaired concentration, and insomnia. A heightened perception of discomfort with bleeding, particularly in the presence of adenomyosis, further increased distress. CONCLUSION:Menstrual distress is significantly higher in women with endometriosis and involves multidimensional factors beyond pain. These findings support the need for a personalized and comprehensive approach in the clinical management of endometriosis.

OBJECTIVE:To assess the prevalence of proliferative endometrial disorders in women with histologically confirmed adenomyosis and to evaluate the independent association between adenomyosis and each lesion type. DESIGN:Retrospective cohort study. SUBJECTS:Consecutive patients undergoing hysterectomy between January 2021 and August 2024, excluding those with histologically confirmed gynecological malignancies (n = 734). EXPOSURE:None. Histological and clinical records were reviewed to identify adenomyosis and coexisting endometrial disorders. MAIN OUTCOME MEASURES:Primary outcome was the prevalence of endometrial polyps, endometrial hyperplasia without atypia, and endometrial intraepithelial neoplasia in patients with histologically confirmed adenomyosis. Secondary outcome included the independent association between adenomyosis and each endometrial disorder. RESULTS:Adenomyosis was identified in 34.7% (255/734) of cases. Proliferative endometrial disorders were more prevalent among patients with adenomyosis (37.6% vs. 25.1%). In multivariable analysis, adenomyosis was independently associated with these conditions overall (aOR 1.87, 95% CI: 1.31, 2.65), including endometrial polyps (aOR 1.69, 95% CI: 1.03, 2.79), endometrial hyperplasia without atypia (aOR 2.07, 95% CI: 1.34, 3.21), and endometrial intraepithelial neoplasia (aOR 2.06, 95% CI: 1.16, 3.66). After adjustment for established clinical risk factors for endometrial cancer (obesity, menopause, nulliparity and abnormal uterine bleeding), adenomyosis remained in the predictive model for EIN. CONCLUSION:The present study identified an independent histopathological association between adenomyosis and proliferative endometrial disorders, including endometrial intraepithelial neoplasia, the lesion with the highest malignant potential. When coexisting with other risk factors, adenomyosis may contribute to a risk profile warranting targeted endometrial assessment.

OBJECTIVE:To validate the French version of the Menstrual Distress Questionnaire (MEDI-Q) for use in French-speaking populations. METHODS:The study involved translation and cultural adaptation of the MEDI-Q from English to French, followed by a cross-sectional validation study. A sample of 266 French-speaking women aged 18-50 completed the French MEDI-Q, Brief Symptom Inventory (BSI), and Shortened Premenstrual Assessment Form (SPAF). Psychometric properties were assessed, including internal consistency, test-retest reliability, and convergent validity. RESULTS:The French MEDI-Q demonstrated good internal consistency (Cronbach's α = 0.84, McDonald's ω = 0.86) and excellent test-retest reliability (ICC = 0.94). Convergent validity was confirmed through significant correlations with age, psychological distress, and premenstrual symptoms. The French-speaking sample showed higher average MEDI-Q scores compared to previous Italian and English validations, particularly in items related to menstrual bleeding distress and feelings of being dirty. CONCLUSION:The French version of MEDI-Q exhibits robust psychometric properties, supporting its use in French-speaking populations. The observed differences in scores highlight potential cultural variations in menstrual experiences, warranting further investigation into cross-cultural perceptions of menstruation.

Background Adenomyosis is a benign uterine disease that has been associated with endometrial proliferative disorders. Adenomyosis and endometrial cancer (EC) are sex-steroid-dependent conditions that may coexist, but their estrogen receptor (ER) and progesterone receptor (PR) signaling landscape is poorly defined.Objective The present multicenter study aimed to characterize the expression of estrogen (ESR1/ESR2 plus the coregulators NCOA1, CCND1, BRCA1) and progesterone (PGR plus FOXO1, and CYP26A1) receptor pathway-related genes in hysterectomy specimens of patients with adenomyosis and coexisting EC.Methods Specimens from three groups of patients (n = 10 per group) referred to two tertiary hospitals were studied: adenomyosis plus EC (Group 1), only adenomyosis (Group 2), and only EC (Group 3). Gene expression was assessed by droplet digital PCR using a compartment-matched design. Analysis was compartment-specific, and no cross-compartment comparisons were performed.Results Compared with isolated adenomyosis, adenomyotic lesions from uteri with coexisting EC showed higher ESR2 (p = 0.0082) and BRCA1 (p = 0.0007) expression, with no differences in ESR1, NCOA1, or CCND1. PR-related gene expression (PGR, FOXO1, and CYP26A1) did not differ between adenomyosis groups.Conclusion Although preliminary, the present findings indicate that adenomyosis coexisting with EC is characterized by elevated expression of ESR2 and BRCA1, suggesting an enriched ER-related microenvironment that may be relevant to local estrogen responsiveness.

Endometriosis, traditionally viewed as a gynecological condition, is increasingly recognized as a systemic disease due to its frequent association with inflammatory and autoimmune comorbidities. Recent molecular and genetic insights reveal dysregulated hormone receptor signaling, heightened inflammatory responses, and immune dysfunction as central drivers of disease progression. These discoveries offer compelling explanations for extra-pelvic symptoms and open up avenues for targeted diagnostics and therapies. This review integrates emerging evidence to highlight endometriosis as a multisystem disorder, underscoring the need for multidisciplinary care. By redefining endometriosis beyond reproductive health, this perspective encourages a broader, systemic view of women’s health and fosters innovation in precision medicine.

RESEARCH QUESTION:How do comorbidities and their prevalence differ between patients with adenomyosis alone and patients with both adenomyosis and endometriosis? DESIGN:A prospective observational study compared the presence of comorbidities between patients with adenomyosis alone (n = 342) and patients with both adenomyosis and endometriosis (n = 347). Premenopausal patients aged 20-50 years, excluding those with malignant diseases, were studied. The diagnosis of endometriosis or adenomyosis was made by transvaginal ultrasound, magnetic resonance imaging or surgery. Comorbidities were classified as either (i) autoimmune or (ii) stress- and pain-related. RESULTS:Patients with adenomyosis alone had a significantly lower prevalence of comorbidities compared with patients with both adenomyosis and endometriosis [44.7% (152/342) versus 55.0% (191/34); P = 0.007]. Autoimmune diseases [14% (48/342) versus 23.9% (83/247); P = 0.001] and stress- and pain-related disorders [30.4% (104/342) versus 46.4% (161/347); P < 0.001] were less common in patients with adenomyosis alone compared with patients with both adenomyosis and endometriosis. Patients aged >35 years with adenomyosis alone were less likely to have autoimmune comorbidities compared with patients with both adenomyosis and endometriosis [5.8% (20/48) versus 12.6% (44/347); P = 0.002]. Co-existence of endometriosis was independently associated with the presence of comorbidities among patients with adenomyosis (OR = 1.65, 95% CI 1.12-2.42; P = 0.01). CONCLUSIONS:Patients with adenomyosis alone had a lower prevalence of comorbidities compared with patients with both adenomyosis and endometriosis, suggesting a different clinical profile. More epidemiological data will be useful to explain the low prevalence of some systemic comorbidities in patients with adenomyosis.

More than one third of Saudi women are known to have IDA and at least 30% are known to have AUB. AUB is a common cause of ID/IDA therefore, a panel of experts from the Arabian gulf and Europe met in Riyadh in May 2023 aiming to provide a practical guidance and highlight the importance of ID and IDA screening and treatment among women with AUB to improve their quality of life and to decrease the perioperative morbidity and mortality when surgery is planned, and to provide a guide and context to gynecologists to understand the rationale for the diagnostic and management strategies for a common cause of ID/IDA which is AUB.

Endometriosis is a chronic gynecologic disease of reproductive-age women, causing menstrual pain and infertility. Endocrine and inflammatory mechanisms drive its development, with estrogen/progesterone imbalance contributing to extrauterine implantation and persistence of ectopic endometrial cells. Chronic pain also induces stress-related disorders, worsening the quality of life. Infertility results from inflammatory, ovarian, and endometrial changes, and adverse pregnancy outcomes are reported. Diagnosis of endometriosis is clinical and imaging based. Furthermore, gastrointestinal, urinary, or autoimmune comorbidities complicate endometriosis management. Hormonal treatments, including progestins, estro-progestins, gonadotropin-releasing hormone analogs (GnRH-a), or oral antagonists, suppress menstruation and relieve pain. The relevant endocrine aspects and the systemic comorbidities make endometriosis a syndrome that requires a multidisciplinary diagnostic and therapeutic approach.

Autoimmune and inflammatory rheumatic diseases (RDs) are more prevalent in women and often affect gynecological health. Particularly, heavy menstrual bleeding (HMB) and dysmenorrhea are more common in patients with RD. A link between RDs and endometriosis has been shown, whereas the association with adenomyosis remains unexplored. The present study evaluates the prevalence of adenomyosis in women of reproductive age with RD (n = 76) who were referred to the Gynecology Unit, compared with an age-matched control population (n = 305). A detailed clinical history and pelvic imaging findings obtained via transvaginal ultrasound were collected, excluding menopausal women and those with endometriosis or gynecological malignancies. Adenomyosis was significantly more prevalent in RD patients than in controls (40.8% vs. 19.7%, OR 2.81, 95% CI 1.64–4.82; p < 0.001), whereas the prevalence of uterine fibroids did not differ significantly between groups. These findings highlight the need for greater awareness of adenomyosis among both rheumatologists and gynecologists, as timely and adequate recognition is crucial to improving quality of life and reproductive health in patients with RDs.

Parturition is a coordinated process of transition from a quiescent myometrium to an active rhythmically contractile state, requiring complex interplay between placental, fetal, and maternal compartments. It involves the synchronization of myometrial activity and structural changes of the cervix, leading to regular coordinated uterine contractions, cervical effacement and dilatation and rupture of membranes. Multiple endocrine, paracrine and autocrine events and overlapping maternal/fetal control mechanisms trigger parturition. In fact, hormonal, neuroendocrine, inflammatory, and immune mechanisms are involve in the activation of labor. Placenta endocrine function contributes to labor onset and progression. Progesterone withdrawal, increased estrogen bioavailability, corticotrophin releasing hormone (CRH) and neuroendocrine mediators rise, increased prostaglandins, and oxytocin are key events in parturition.

Adenomyosis, a menstruation-related uterine disorder, refers to the presence of endometrial stroma and glands within the myometrium and is typically observed in reproductive-age women. The pathogenesis explaining the migration, persistence, proliferation and differentiation of ectopic endometrial cells includes a genetic and epigenetic background, an oestrogen/progesterone receptor imbalance and an inflammatory reaction driven by local immune dysfunction, along with fibrosis and neuroangiogenesis within the myometrium. In the past, it was thought that adenomyosis almost exclusively affected multiparous women after 40 years of age and the diagnosis was generally confirmed upon hysterectomy. Nowadays, using imaging techniques such as transvaginal ultrasonography and magnetic resonance imaging, adenomyosis is increasingly identified in young women with dysmenorrhoea, dyspareunia, abnormal uterine bleeding and heavy menstrual bleeding, and also in infertile patients. Furthermore, adenomyosis often coexists with other gynaecological conditions, such as endometriosis and uterine fibroids. Despite the improvement of non-invasive diagnostic tools, the awareness of the condition is still poor and the diagnosis is often missed, due also to a heterogeneity in clinical presentation and imaging criteria. In addition, medical and surgical management do not follow shared recommendations, even though adenomyosis requires a lifelong management plan, including pain and bleeding control, fertility preservation and pregnancy complications.

PROBLEM:Immunological abnormalities are well recognized in the pathogenesis of endometriosis and the co-existence of endometriosis with inflammatory bowel disease (IBD) and celiac disease (CD), along with other systemic immune disorders, is clinically relevant. Recent genetic studies revealed some shared genetic traits associated with the co-occurrence of endometriosis with different gastrointestinal or autoimmune disorders, highlighting common biological pathways. Since class II human leukocyte antigen (HLA) genes, HLA-DQ2 and -DQ8, show the strongest and best-characterized genetic susceptibility for CD, the present study aims to explore the presence of these haplotypes in non-celiac patients with endometriosis. METHOD OF STUDY:A group of patients with endometriosis (n = 126) participated in the study and were compared to healthy women (n = 379), as controls. Subjects who were diagnosed with CD or who tested positive for CD antibodies were excluded. All patients and controls were genotyped for HLA haplotypes predisposing to CD (DQ2, DQ8). In the group of endometriosis patients who tested positive for DQ2 and/or DQ8, symptoms were also investigated. RESULTS:At least one of the HLA-DQ2 and -DQ8 genotypes was detected in 43.3% of non-celiac endometriosis patients (OR: 1.82, 95% CI: 1.11-2.81), whereas 29.5% (p < 0.01) of healthy women presented HLA haplotypes predisposing to CD. In endometriosis patients, no significant difference was shown between positive and negative in terms of endometriosis phenotype, or gynecological, and non-gynecological symptoms. CONCLUSIONS:Our data revealed a significantly greater prevalence of predisposing haplotypes for CD in non-celiac patients with endometriosisthan in healthy subjects, suggesting that a common genetic background may explain the co-occurrence of endometriosis and CD.

INTRODUCTION:Dysmenorrhea is a painful symptom associated with uterine contractions and menstrual bleeding and is treated by administering analgesic drugs. Since progesterone receptors (PRs) have a major role in regulating uterine tissues (myometrium and endometrium) physiology, oral contraceptives are used off-label for treating primary or secondary dysmenorrhea. The development of selective progesterone receptor modulators (SPRMs), a class of synthetic steroids with agonistic, antagonistic, or mixed effects in targeting PRs in different tissues, stimulated their possible clinical use for treating secondary dysmenorrhea related to uterine diseases (endometriosis, adenomyosis, uterine fibroids). AREAS COVERED:The present review examines the development of the clinical trials and observational studies done with the different SPRMs for the treatment of dysmenorrhea in patients with uterine diseases. EXPERT OPINION:Mifepristone, telapristone acetate and vilaprisan have antagonistic activity on PRs, whereas ulipristal acetate and asoprisnil have both potent antagonist and partial agonist effects.Since no studies have been done on primary dysmenorrhea, the different SPRMs have been evaluated in the treatment of endometriosis, adenomyosis and uterine fibroid-related dysmenorrhea.

OBJECTIVE:To assess the effects of relugolix combination therapy in women with uterine fibroids (UFs) and concomitant ultrasound-diagnosed adenomyosis. DESIGN:This post hoc analysis used pooled data from completers of the pivotal LIBERTY studies. The subgroup of women with adenomyosis and UFs was compared with the overall study population on selected efficacy and safety endpoints. SUBJECTS:Premenopausal women (aged 18-50 years) with diagnosed UFs (confirmed by ultrasonography) and heavy menstrual bleeding (assessed by the alkaline hematin method). INTERVENTION:Once-daily relugolix combination therapy (40 mg relugolix, 1 mg estradiol, and 0.5 mg of norethindrone acetate) or placebo for 24 weeks, or delayed relugolix combination therapy (40 mg of relugolix monotherapy for 12 weeks, followed by relugolix combination therapy for 12 weeks). MAIN OUTCOME MEASURES:Endpoints included the percentage of women with concomitant adenomyosis, the proportion of treatment responders (achieved or maintained a menstrual blood loss <80 mL and ≥50% reduction in menstrual blood loss volume from baseline over the last 35 days of treatment), the proportion of women achieving or maintaining amenorrhea over the last 35 days of treatment, and the change from baseline to week 24 in uterine volume and adverse events. RESULTS:A total of 111 women (18.2%) had a baseline diagnosis of concomitant adenomyosis (37 in the relugolix combination therapy group, 45 in the delayed relugolix combination therapy group, 29 in the placebo group) and were included in this analysis. Of women with adenomyosis, 83.8% in the relugolix combination therapy group were treatment responders compared with 27.6% in the placebo group. Amenorrhea was achieved in 64.9% of women with adenomyosis treated with relugolix combination therapy and in 6.9% of women treated with placebo. The least square mean uterine volume of women with adenomyosis decreased by 22.2% and 5.8% in the relugolix combination therapy and placebo groups, respectively. Results for the above outcomes in the relugolix combination therapy population were similar to the delayed relugolix combination therapy group. CONCLUSION:Efficacy outcomes in women with adenomyosis and UFs were comparable with those in women from the overall LIBERTY study population. CLINICAL TRIAL IDENTIFICATION NUMBER:LIBERTY 1, 2016-003727-27 (EudraCT) and NCT03049735; LIBERTY 2, 2016-005113-50 (EudraCT) and NCT03103087.

Objective To compare the clinical and anamnestic characteristics of women with endometriosis alone versus those with both endometriosis and comorbid fibromyalgia, in order to identify distinguishing features between the two groups. Materials and methods A prospective observational study was conducted on a cohort of 668 patients diagnosed with endometriosis. Patients reporting symptoms suggestive of fibromyalgia were assessed using the Patient Self-Report Survey for the Assessment of Fibromyalgia. Those with positive screening scores were referred for a rheumatologic evaluation. In a subgroup of 47 patients, the diagnosis of fibromyalgia was confirmed using the 2016 ACR diagnostic criteria. Patients’ history and clinical profiles were compared between subjects with only endometriosis versus those with co-existent fibromyalgia. Results Fibromyalgia was diagnosed in 7% (n = 47) of patients with endometriosis. In 72.3% of cases, the diagnosis of endometriosis preceded the onset of fibromyalgia. Deep infiltrating endometriosis (DIE) was the most common phenotype (55%) among patients with comorbid fibromyalgia. Chronic pelvic pain was significantly more prevalent in patients with fibromyalgia compared to those with only endometriosis (48.9% vs 24%; p < 0.05). Autoimmune comorbidities (51.1% vs 12.9%) and psychiatric disorders (17% vs 7.6%) were significantly more frequent in patients with both conditions (p < 0.05). Conclusion Endometriosis patients with comorbid fibromyalgia represent a distinct phenotypic subgroup, marked by a higher prevalence of autoimmune diseases, psychiatric disorders, and conditions related to central sensitization. Investigating early risk factors—such as chronic pelvic pain, surgical history, and coexisting comorbidities—may facilitate earlier identification and more targeted management of this population.

Background Adenomyosis is a uterine disorder causing menstruation-related symptoms such as dysmenorrhea, heavy menstrual bleeding (HMB) and dyspareunia. A long-term management of the disease is required. Hormonal drugs are the most used, including a variety of progestins, even though few data are available on their long-term use in adenomyosis.Objective To evaluate the long-term efficacy of different progestins, including progestin-only pills (POP), for the management of adenomyosis-related symptoms.Methods A total of 140 patients (18-45 years) with adenomyosis were treated with progestins for at least three years. The treatment groups included dienogest (2 mg, n = 71), levonorgestrel-releasing intrauterine device (52 mg, n = 25), desogestrel (75 mcg, n = 20), and drospirenone (4 mg, n = 24). Symptoms were assessed using the Visual Analogue Scale (VAS) for pain and the Pictorial Blood Assessment Chart (PBAC) method for bleeding.Results Dienogest significantly reduced dysmenorrhea, dyspareunia, and HMB, with efficacy maintained over three years in most patients. However, after the first year 49% of patients required a switch to other treatments due to side effects or contraception need. The levonorgestrel-releasing intrauterine device also effectively managed HMB and pain, with 15% of patients switching treatment due to side effects. Both drospirenone and desogestrel improved HMB and dysmenorrhea, but desogestrel had a higher discontinuation rate due to reduced long-term efficacy. Norethisterone acetate was used as a second-line treatment in cases of intolerance or inadequate response.Conclusion Progestins are effective for the long-term management of adenomyosis symptoms. The flexibility in switching between different progestins or routes of administration may help in optimizing outcomes.