Dienogest -How useful??

Dienogest has been used as a contraceptive with estrogen for last two decades. It is a fourth generation progesterone The indication in endometriosis is a new one. As a monotherapy- like progesterone its use is relatively new. But irregular bleeding is a side effect.

Efficacy in endometriosos / adenomyosis”? Dienogest will not help all women with endometriosis e.g. 2-3 cms cysts usually will disappear with good pain relief. But there is almost equal number where it didn't work.

Indications :-1) Chocolate Cyst :- Dienogest is found particularly to be useful is pts who do not want surgery. There is no need of concomitant GnRH. But limitation is that Dienogest is not useful for fibroid . In fact in some cases with dienogest Chocolate cyst can disappear. There may be no evidence of Cho cyst. It is such an wonderful drug. Ovaries can hopefully reduce in size 2) Dysmenorrhea: good results in dysmenorrhea and concomitantly cyst size decrease only to some extent but not completely regresses but irregular spotting is one problem commonly noticed in a woman who had dysmenorrhoea now bothered with irregular vaginal bleeding noticed definitely with dienogest.

What about Bilateral endometriomas of 5-6 cm cm ?? :-First choice:-One can put women with of bilateral endometriomas of 5 cm with advise for surgery . If one put her on Dienogest surgery can be avoided Second choice is dienogest first  later if she does not conceive 6 months after completion of dienogest then she should be advised to go for surgery. In some cases preg can ensue soon after stoppage of dienogest.

Role of dienogest in Bladder endometriomas ?- One can prescribe. In fact this the most choiced drug in Urinary bladder endometriosis.

Dose of Dienogest :- Minimum 2 mg od but can be given up to 10 mg.

Duration of therapy:-Most of us prescribe for 4 months and quite often after stoppage of dienogest women with moderate sized chocolate cyst not only can become but USG preg can ensue without IUI/ ART.. May be given for 6 months.

Side effects :- 1) irregular bleeding with dienogest, 2) few women will develop amenorrhea and it is difficult to predict who will develop sec ameno like Post pill Amenorhoea .

What about Myoma or say Adenomyosis & or Myoma:- Dienogest is being used with great success in endometriosis, adenomyosis . Occasionally prescribe in cases where it is used when there is combined endometriosis and fibroid though Ulipristal and Mifepristone are better choices in established cases of myoma..

C) Indication 4:”-.Some have tried for in Adenomyosis related implantation failure provided the USG diag of adenomyosis was certain. Adenomyosis, rather, now it is the first line drug for me in Adenomyosis related implantation failure. A pre ART 6 months to even a year and then one can plan ET in HRT or even natural cycle. It is working, although it cannot be generalized.

Take home message: - Dienogest gives good results in 50 % cases of endometriosis. In the other 50 % it does not work at all. So no harm in trying more so in small lesions.

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