Objective: To compare the efficacy of dienogest (DNG) and levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of intrinsic and extrinsic subtypes of adenomyosis. Methods: Totally 232 patients were enrolled in the study who were diagnosed as adenomyosis by ultrasound or pelvic magnetic resonance imaging (MRI), and were classified into intrinsic and extrinsic subtypes according to different locations of lesions in MRI, treated with DNG (DNG group) or LNG-IUS (LNG-IUS group) in Peking University Third Hospital from July 2019 to December 2023. Clinical data of patients were retrospectively collected to analyze the clinical and imaging characteristics of different MRI subtypes of adenomyosis and whether there were differences in the therapeutic effects of DNG and LNG-IUS. Results: (1) Among the 232 patients enrolled, 129 were intrinsic subtype and 103 were extrinsic subtype. Among the 129 patients treated with DNG, the numbers of intrinsic and extrinsic subtype were 69 and 60, respectively. And among the 103 patients treated with LNG-IUS, the numbers of intrinsic and extrinsic subtype were 60 and 43, respectively. The mean age in DNG group [(37.5±5.6) years] was lower than that in LNG-IUS group [(40.3±4.3) years, P<0.001]. There were no significant differences in other clinical features (all P>0.05). (2) The visual analog scale (VAS) scores of dysmenorrhea and cancer antigen 125 (CA125) levels in DNG group and LNG-IUS group were significantly decreased after treatment (all P<0.001), and hemoglobin levels were increased (both P<0.01). Compared between the two groups, the VAS score after treatment was lower in DNG group (P<0.001), and the hemoglobin level was increased more significantly in DNG group (P=0.016). The complete remission rates of dysmenorrhea in DNG group and LNG-IUS group were 73.0% (89/122) and 29.5% (28/95), respectively (P=0.039). The incidence of irregular bleeding in DNG group was higher than LNG-IUS group, but there was no statistical significance [62.8% (81/129) vs 52.4% (54/103), P=0.112]. (3) Among patients with intrinsic adenomyosis, the incidence of menorrhagia was significantly higher than in those with extrinsic adenomyosis (P<0.001), while the incidence and severity of dysmenorrhea were lower compared to extrinsic adenomyosis (P=0.004, P=0.007, respectively). After treatment with DNG and LNG-IUS, there were no statistically significant differences in VAS scores between patients with intrinsic and extrinsic adenomyosis (all P>0.05). The incidence of irregular bleeding after DNG treatment was 78.3% (54/69) in intrinsic adenomyosis, which was higher than the 45.0% (27/60) observed in extrinsic adenomyosis (P<0.01). Similarly, the incidence of irregular bleeding after LNG-IUS treatment was 63.3% (38/60) in intrinsic adenomyosis, higher than the 37.2% (16/43) in extrinsic adenomyosis (P=0.009). (4) DNG treatment (OR=19.163, 95%CI: 7.564-48.544; P<0.01) and duration of treatment (OR=1.043, 95%CI: 1.012-1.075; P=0.007) were independent positive factors for complete remission of dysmenorrhea, while VAS score before treatment (OR=0.654, 95%CI: 0.454-0.942; P=0.023) was negative factor. Intrinsic subtype was an independent risk factor for irregular bleeding (OR=0.436, 95%CI: 0.235-0.811; P=0.009). Conclusions: DNG demonstrates greater advantages over LNG-IUS in terms of complete relief of dysmenorrhea and the degree of symptom alleviation. The incidence of irregular vaginal bleeding in patients with intrinsic adenomyosis is higher than in those with extrinsic adenomyosis. For patients with extrinsic adenomyosis, particularly those with prominent dysmenorrhea symptoms, DNG treatment offers greater benefits. However, for patients with intrinsic adenomyosis and those with significant menstrual disorders, a more cautious approach is required when selecting progestin therapy, along with enhanced monitoring and management.
目的： 对比地诺孕素（DNG）与左炔诺孕酮宫内释放系统（LNG-IUS）治疗内生型和外生型子宫腺肌病的疗效差异。 方法： 纳入2019年7月至2023年12月在北京大学第三医院就诊、经超声及磁共振成像（MRI）检查诊断为子宫腺肌病，并根据MRI检查结果分为内生型、外生型，且接受DNG（DNG组）或LNG-IUS（LNG-IUS组）治疗的患者232例为观察对象。回顾性收集患者的临床资料，分析不同MRI分型子宫腺肌病的临床特征、影像学特征及应用DNG、LNG-IUS的疗效是否存在差异。 结果： （1）纳入的232例子宫腺肌病患者中内生型129例、外生型103例。采用DNG、LNG-IUS治疗的患者例数分别为129、103例，其中采用DNG治疗的内生型、外生型例数分别为69、60例，采用LNG-IUS的内生型、外生型例数分别为60、43例。DNG组患者的年龄为（37.5±5.6）岁，低于LNG-IUS组［（40.3±4.3）岁；P<0.001］，其余特征均无显著差异（P均>0.05）。（2）DNG组和LNG-IUS组患者接受治疗后的痛经视觉模拟评分法（VAS）评分、癌相关抗原125（CA125）水平均较治疗前明显下降（P均<0.001），血红蛋白含量均明显升高（P均<0.01）。两组间对比，DNG组治疗后的VAS评分更低（P<0.001），血红蛋白含量升高更明显（P=0.016）。DNG组和LNG-IUS组的痛经完全缓解率分别为73.0%（89/122）和29.5%（28/95），两组比较，差异有统计学意义（P=0.039）。DNG组的不规则出血发生率高于LNG-IUS组，但差异无统计学意义［分别为62.8%（81/129）、52.4%（54/103），P=0.112］。（3）内生型患者合并月经量增多的比例明显高于外生型（P<0.001），痛经比例及VAS评分明显低于外生型（P=0.004，P=0.007）。在内生型与外生型子宫腺肌病患者之间比较，无论DNG治疗后还是LNG-IUS治疗后的痛经VAS评分均无显著差异（P均>0.05）。内生型患者使用DNG后不规则出血发生率为78.3%（54/69），明显高于外生型的发生率（45.0%，27/60），两者比较，差异有统计学意义（P<0.01）。内生型患者使用LNG-IUS后不规则出血发生率为63.3%（38/60），高于外生型的发生率（37.2%，16/43），两者比较，差异有统计学意义（P=0.009）。（4）多因素分析发现，采用DNG治疗（OR=19.163，95%CI为7.564~48.544；P<0.01）、治疗时长（OR=1.043，95%CI为1.012~1.075；P=0.007）是达到痛经完全缓解的正相关独立影响因素，而治疗前痛经VAS评分（OR=0.654，95%CI为0.454~0.942；P=0.023）是其负相关独立影响因素。内生型是发生不规则出血的独立危险因素（OR=0.436，95%CI为0.235~0.811；P=0.009）。 结论： DNG在痛经完全缓解以及缓解程度方面较LNG-IUS更有优势。内生型子宫腺肌病患者的不规则出血发生率高于外生型。针对外生型尤其是痛经症状较为突出的子宫腺肌病患者，DNG治疗具有更大优势；而针对内生型子宫腺肌病以及存在明显月经紊乱的患者，临床需要更为谨慎地选择孕激素类药物并加强监测管理。.