Letter to the editor: ‘the efficacy of progestins in managing pain associated with endometriosis, fibroids and pre-menstrual syndrome: a systematic review’

To the Editors,

We were highly interested in reading the article by Allen et al. [1]. Titled “The efficacy of progestins in managing pain associated with endometriosis, fibroids, and pre-menstrual syndrome: a systematic review.” This study provides a valuable, comprehensive evaluation of the analgesic effects of progestins in treating endometriosis, fibroids, and premenstrual syndrome (PMS), offering essential insights for clinical decision-making. However, there are several limitations in the study that may affect the generalizability of its conclusions. Therefore, we propose the following suggestions to guide future research improvements:

First, while the article provides a detailed assessment of the efficacy of progestins, it offers a limited analysis of other treatment approaches, such as surgical and physical therapies. The selection of a treatment plan should consider various factors, including pharmacological therapies, surgical interventions, and other nonpharmacological measures. To better guide clinical practice, we recommend that future research include systematic reviews of multiple treatment options rather than focusing exclusively on pharmacological therapies. For instance, by incorporating large-scale clinical trials and cohort studies, the efficacy of surgical and physical treatments can be systematically evaluated and compared with pharmacological therapies, thereby providing a more comprehensive basis for decision-making.

Second, owing to significant differences in study protocols, drug dosages, and routes of administration, we were unable to perform a meta-analysis. This limitation means that the authors could rely only on narrative analysis, lacking a more systematic quantitative summary and comparison. Meta-analysis often provides more convincing conclusions, and the absence of this step affects the scientific rigor and reliability of an article. High heterogeneity across different conditions, treatment regimens, drug dosages, and other variables makes it difficult to unify the analysis, further limiting the precise evaluation of the efficacy of the treatment methods. We suggest that future studies standardize treatment protocols and data collection methods at the design stage to ensure the comparability of studies and facilitate the possibility of conducting a meta-analysis.

Finally, this article provides a brief safety analysis, particularly regarding the discussion on thrombotic risks [2]. While progestins pose a lower thrombotic risk compared to combined oral contraceptives, it does not explore in-depth the differences in thrombotic risk among various types of progestins (e.g., DMPA, dienogest) [3]. Future research could include dedicated subgroup analyses to assess the differences in thrombotic risk in various populations. For example, the impact of different dosages, routes of administration, and underlying conditions (such as obesity and hypertension) on thrombotic risk can be analyzed. A detailed examination of these aspects would contribute to a better understanding of the safety profiles of the different progestins. Another important issue is that the article does not systematically assess the long-term metabolic effects of progestin therapy, such as its effects on lipid levels, blood glucose, and liver function [4]. Future studies should strengthen the analysis of these areas to provide a more comprehensive evaluation of the long-term safety of progestins future studies should strengthen the analysis of these areas.

As clinical pharmacists, we play a crucial role in optimizing patient care, so we suggest that future studies focus more on the standardization of drug dosages and routes of administration, and strengthen the safety assessment of long-term progestogen use, especially in terms of the effects on lipids, blood glucose, and liver function. In addition, individualized treatment regimens should be considered, with drug adjustments based on physiological differences in patients, and attention paid to drug interactions and patient adherence. The issue of drug cost and resource allocation also needs to be addressed in studies in low- and middle-income countries. Finally, clinical pharmacovigilance and international collaboration can further optimize the use of progestins to improve therapeutic efficacy and ensure safety.

Although this review provides a valuable reference for the management of endometriosis and uterine fibroids, there is still room for improvement in terms of the quality of the studies, methodological limitations, uneven quality of data, and long-term assessment of side effects. We hope that future studies will overcome these limitations, promote further optimization of gynecological pain management, and provide more reliable evidence for clinical decision-making.

Author contributions

Songjie Liao: methodology, formal analysis, and writing of the original draft; Di Xiao: methodology and writing of the original draft; Liqiu Kou: conceptualization, methodology, supervision, and writing review and editing.

Funding

No funding was received for this article.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Conflict of interest

The authors declare no conflict of interest.