Levonorgestrel intrauterine device in the treatment of menorrhagia in Chinese women: efficacy versus acceptability

Effectiveness of Levonorgestrel Releasing Intrauterine System in Perimenopausal Women with Heavy Menstrual Bleeding: A Prospective Study at a Teaching Hospital in India

OBJECTIVES

To evaluate the effect of levonorgestrel-releasing intrauterine system (LNG-IUS) on heavy menstrual bleeding in perimenopausal women.

METHODS

This was a prospective, observational clinical study conducted on 42 perimenopausal women with heavy menstrual bleeding who met the study eligibility criteria. LNG-IUS was inserted in the postmenstrual phase following baseline evaluation. The patients were followed up at the 4, 12, and 24 weeks. Pictorial blood assessment chart (PBAC) score, hemoglobin and serum ferritin levels, and endometrial thickness were assessed before insertion and during the follow-up visits.

RESULTS

Two patients (4.8%) were lost to follow-up, three patients (7.1%) opted for hysterectomy, two women (4.8%) experienced spontaneous expulsion and 35 (83.3%) women continued the usage. Menstrual blood loss assessed using the median PBAC score (interquartile range) significantly reduced (P < 0.001) from the pre-insertion level of 280 (246-306) to 124 (60-200) at 4 weeks to 45 (34-76) at 12 weeks and further to 32 (20-50) at the end of 24 weeks. Simultaneously, a significant (P < 0.001) improvement in the mean hemoglobin and serum ferritin levels and a significant (P < 0.001) decrease in endometrial thickness were observed. The most common side effect was spotting (50.0%) and vaginal discharge (38.1%).

CONCLUSIONS

LNG-IUS causes a remarkable reduction in menstrual blood loss and marked improvement in dysmenorrhea. It also reduces anemia by improving the hemoglobin and ferritin levels. Thus, it can serve as an effective treatment option for heavy menstrual bleeding in perimenopausal women and prevent the need for a hysterectomy.

Treatment of Women With an Endometrial Polyp and Heavy Menstrual Bleeding: A Levonorgestrel-Releasing Intrauterine Device or Hysteroscopic Polypectomy?

We performed a literature review of reports comparing a levonorgestrel-releasing intrauterine device (LNG-IUD) with transcervical polyp resection (TCRP) as a treatment for heavy menstrual bleeding (HMB). Our second objective was to investigate the effectiveness of LNG-IUD and TCRP in reducing menstrual bleeding and the patient satisfaction with each technique. No previously reported studies have compared TCRP and LNG-IUD as treatment for HMB in premenopausal women with an endometrial polyp. Likewise, no studies are available on LNG-IUD as a treatment for HMB in the presence of an endometrial polyp. Several studies have found the LNG-IUD to be an effective treatment option for HMB, with high patient satisfaction rates. Evidence of the effectiveness of TCRP as treatment of HMB is scarce. Patient satisfaction is reported relatively good, although persistent or recurrent symptoms appear to be frequent. We conclude that no evidence is available on LNG-IUD as treatment for HMB in women with an endometrial polyp. We hypothesize that LNG-IUD could be a good alternative to TCRP for treating HMB in premenopausal women with a polyp; however, further evidence is needed, and a randomized controlled trial should be performed.

Therapy of heavy menstrual bleeding in Korea: Subanalysis and results from a multinational clinical trial in the Asian region investigating the levonorgestrel-releasing intrauterine system versus conventional therapy

Objective

To compare real-life clinical outcomes with the levonorgestrel-releasing intrauterine system (LNG-IUS) and conventional medical therapies (CMTs), including combined oral contraceptives and oral progestins in the treatment of idiopathic heavy menstrual bleeding (HMB) in South Korea.

Methods

This prospective, observational cohort study recruited a total of 647 women aged 18 to 45 years, diagnosed with HMB from 8 countries in Asia, including 209 women from South Korea (LNG-IUS, 169; CMTs, 40), who were followed up to one year. The primary outcome was cumulative continuation rate (still treated with LNG-IUS and CMTs) at 12 months. Secondary outcomes included bleeding pattern, assessment of the treatment efficacy by treating physician and safety profile.

Results

The continuation rate at 12 months was significantly higher with the LNG-IUS than CMTs (85.1% vs. 48.5%, respectively; P<0.0001). The 51.5% of CMTs patients discontinued treatment and 18.8% of LNG-IUS patients discontinued treatment. The most common reasons for discontinuation for CMTs were switching to another treatment and personal reasons. When compared to CMTs, the LNG-IUS offered better reduction in subjectively assessed menstrual blood loss and the number of bleeding days, tolerability and with better efficacy in HMB, as assessed by physician's final evaluation.

Conclusion

This study provides novel information on the real-life treatment patterns of HMB in South Korea. The efficacy of CMTs was inferior compared to the LNG-IUS in the clinical outcomes measured in this study. Due to the better compliance with LNG-IUS, the cumulative continuation rate is higher than CMTs. We conclude that the LNG-IUS should be used as the first-line treatment for HMB in Korean women, in line with international guidelines.

Noncontraceptive benefits of the estradiol valerate/dienogest combined oral contraceptive: a review of the literature

Combined oral contraceptives formulated to include estradiol (E2) have recently become available for the indication of pregnancy prevention. A combined estradiol valerate and dienogest pill (E2V/DNG), designed to be administered using an estrogen step-down and a progestin step-up regimen over 26 days of active treatment followed by 2 days of placebo (26/2-day regimen), has also undergone research to assess the potential for additional noncontraceptive benefits. Randomized, placebo-controlled studies have demonstrated that E2V/DNG is an effective treatment for heavy menstrual bleeding - a reduction in median menstrual blood loss approaching 90% occurs after 6 months of treatment. To date, E2V/DNG is the only oral contraceptive approved for this indication. Comparator studies have also demonstrated a reduction in hormone withdrawal-associated symptoms in users of E2V/DNG compared with a conventional 21/7-day regimen of ethinylestradiol/levonorgestrel. Other potential noncontraceptive benefits associated with E2V/DNG, like improvement in dysmenorrhea, sexual function, and quality of life, are comparable with those associated with other combined oral contraceptives and are discussed further in this review.

Different bleeding patterns with the use of levonorgestrel intrauterine system: are they associated with changes in uterine artery blood flow?

OBJECTIVE

Evaluate if different bleeding patterns associated with the use of the levonorgestrel intrauterine system (LNG-IUS) are associated with different uterine and endometrial vascularization patterns, as evidenced by ultrasound power Doppler analysis.

METHODOLOGY

A longitudinal study, with each subject acting as its own control was conducted between January 2010 and December 2012. Healthy volunteers with a history of heavy but cyclic and regular menstrual cycles were enrolled in the study. Ultrasonographic examination was performed before and after six months of LNG-IUS placement: uterine volume, endometrial thickness, and subendometrial and myometrial Doppler blood flow patterns have been evaluated.

RESULTS

A total of 32 women were enrolled out of 186 initially screened. At six months of follow-up, all subjects showed a reduction in menstrual blood loss; for analysis, they were retrospectively divided into 3 groups: normal cycling women (Group I), amenorrheic women (Group II), and women with prolonged bleedings (Group III). Intergroup analysis documented a statistically significant difference in endometrial thickness among the three groups; in addition, mean pulsatility index (PI) and resistance index (RI) in the spiral arteries were significantly lower in Group I and Group III compared to Group II. This difference persisted also when comparing--within subjects of Group III--mean PI and RI mean values before and after insertion.

CONCLUSIONS

The LNG-IUS not only altered endometrial thickness, but--in women with prolonged bleedings--also significantly changed uterine artery blood flow. Further studies are needed to confirm these results and enable gynecologists to properly counsel women, improving initial continuation rates.

Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United States

Three intrauterine devices (IUDs), one copper and two containing the progestin levonorgestrel, are available for use in the United States. IUDs offer higher rates of contraceptive efficacy than nonlong-acting methods, and several studies have demonstrated higher satisfaction rates and continuation rates of any birth control method. This efficacy is not affected by age or parity. The safety of IUDs is well studied, and the risks of pelvic inflammatory disease, perforation, expulsion, and ectopic pregnancy are all of very low incidence. Noncontraceptive benefits include decreased menstrual blood loss, improved dysmenorrhea, improved pelvic pain associated with endometriosis, and protection of the endometrium from hyperplasia. The use of IUDs is accepted in patients with multiple medical problems who may have contraindications to other birth control methods. Yet despite well-published data, concerns and misperceptions still persist, especially among younger populations and nulliparous women. Medical governing bodies advocate for use of IUDs in these populations, as safety and efficacy is unchanged, and IUDs have been shown to decrease unintended pregnancies. Dispersion of accurate information among patients and practitioners is needed to further increase the acceptability and use of IUDs.

The levonorgestrel-releasing intrauterine system in heavy menstrual bleeding: a benefit-risk review

Heavy menstrual bleeding (HMB) is a common problem in women of reproductive age and can cause irritation, inconvenience, self-consciousness and fear of social embarrassment. Our objective was to review and appraise literature identified from the MEDLINE and EMBASE databases to evaluate the clinical evidence and provide an update on the risks and benefits of using the levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of HMB. The LNG-IUS consistently reduces menstrual blood loss (MBL) in women with HMB, including those with underlying uterine pathology or bleeding disorders. The available data suggest that it reduces MBL to a greater extent than other medical therapies, including combined oral contraceptives, oral progestogens (both short- or long-cycle regimens), tranexamic acid and oral mefenamic acid. In addition, the LNG-IUS and endometrial ablation appear to reduce MBL to a similar extent. The adverse effects reported with the LNG-IUS in women with HMB are similar to those typically observed in women using the system for contraception. Uterine perforations were not reported in any of the studies reviewed, but expulsion rates may be higher than in the general population of LNG-IUS users. Overall, the LNG-IUS has a positive effect on most quality-of-life domains, at least comparable to those achieved with hysterectomy or endometrial ablation, and is consistently a cost-effective option across a variety of countries and settings. In conclusion, the LNG-IUS is an effective treatment option for women with HMB, including those with underlying organic pathology or bleeding disorders.

Medical treatment of uterine leiomyoma

Uterine leiomyomas (also called myomata or fibroids) are the most common gynecologic tumors in the United States. The prevalence of leiomyomas is at least 3 to 4 times higher among African American women than in white women. Pathologically, uterine leiomyomas are benign tumors that arise in any part of the uterus under the influence of local growth factors and sex hormones, such as estrogen and progesterone. These common tumors cause significant morbidity for women and they are considered to be the most common indication for hysterectomy in the world; they are also associated with a substantial economic impact on health care systems that amounts to approximately $2.2 billion/year in the United States alone. Uterine myomas cause several reproductive problems such as heavy or abnormal uterine bleeding, pelvic pressure, infertility, and several obstetrical complications including miscarriage and preterm labor. Surgery has traditionally been the gold standard for the treatment of uterine leiomyomas and has typically consisted of either hysterectomy or myomectomy. In recent years, a few clinical trials have evaluated the efficacy of orally administered medications for the management of leiomyoma-related symptoms. In the present review, we will discuss these promising medical treatments in further detail.

Levonorgestrel-releasing intrauterine system compared to low dose combined oral contraceptive pills for idiopathic menorrhagia: a randomized clinical trial

BACKGROUND

This study compared the efficacy of the levonorgestrel-releasing intrauterine system (LNG-IUS) to low dose combined oral contraceptive pills (COC) in the management of idiopathic menorrhagia.

STUDY DESIGN

A single-center, open, randomized clinical trial. One hundred twelve women complaining of excessive menstruation who desired contraception were randomized to receive LNG-IUS or COC. Treatment failure was defined as the need for medical or surgical treatment during the follow-up. Other outcomes included: menstrual blood loss (MBL) by alkaline hematin and by pictorial blood assessment chart (PBLAC), hemoglobin levels and assessment of lost days in which physical or mental health prevented participating women from performing usual activities.

RESULTS

At baseline, LNG-IUS (n=56) and COC (n=56) groups were comparable in age (mean ± S.D.) (39.3 ± 6.7 vs. 38.7 ± 5.2 years, p=.637), parity (median and range) [3(1-6.4) vs.3(2-6), p=.802] and BMI (mean ± S.D.) (29.6 ± 5.9 vs. 31.1 ± 5.7 kg/m(2), p=.175). Time to treatment failure was longer in LNG compared to COC group with a total of 6 (11%) patients who had treatment failure in the LNG-IUS compared to 18 (32%) in COC group with a hazard ratio of 0.30 (95% CI, 0.15-0.73, p=.007). Using alkaline hematin, the reduction in MBL (mean ± S.D.) was significantly more in the LNG-IUS group (87.4 ± 11.3%) compared to the COC group (34.9 ± 76.9%) (p=.013). Utilizing PBLAC scores, the reduction in the LNG-IUS (86.6 ± 17.0%) group was significantly more compared to the COC group (2.5 ± 93.2%) (p<.001). In the LNG-IUS group, increase in the hemoglobin and ferritin levels (mean ± S.D.) were noted (from 10.2 ± 1.3 to 11.4 ± 1.0 g/dL; p<.001; with reduction of the number of lost days (from 6.8 ± 2.6 to 1.6 ± 2.4 days, p=.003).

CONCLUSION

The LNG-IUS is a more effective therapy for idiopathic menorrhagia compared to COC.

Levonorgestrel Intrauterine System: A First-Line Medical Treatment for Heavy Menstrual Bleeding

Chronic heavy menstrual bleeding is a common gynecologic condition that causes significant health problems and negatively impacts a woman's quality of life. Surgical treatments should be reserved for women who have pelvic pathology and for those who fail medical therapy. The recent US FDA approval of the levonorgestrel-releasing intrauterine system as an indicated treatment for heavy menstrual bleeding in women who want to use intrauterine devices for birth control highlights the potential that this top tier contraceptive method offers as a first-line therapy for treatment of this problem in women of any reproductive age, without sacrificing their future fertility.

Levonorgestrel intrauterine system: bleeding disorders and anticoagulant therapy

Hemostatic disorders in women are frequently associated with long-standing menorrhagia. This leads to significant morbidity and adversely affects quality of life. Management of these women poses a particular challenge; medical treatments may be contraindicated, and surgery carries additional risks. The levonorgestrel intrauterine system (LNG-IUS) has been shown to be highly efficacy in reducing menstrual blood loss in women with normal coagulation. It is also a reliable and reversible contraceptive. Data on the use of this system in women with bleeding disorders or those receiving anticoagulant therapy are limited. Analysis of data from four reported studies suggests that LNG-IUS is a viable and safe option for the management of menorrhagia in these women. Whether the underlying hemostatic disorders lead to a shorter duration of action or prolonged irregular bleeding/spotting post insertion is unknown and requires large prospective studies. Proper counselling remains crucial for patients' satisfaction.

Medical Therapies for Chronic Menorrhagia

An estimated 10%-30% of menstruating women experience menorrhagia at some time during their reproductive lives. Acute menorrhagia may present as an emergency requiring prompt medical or surgical intervention. Chronic menorrhagia affects a woman's quality of life in her work, family, and social interactions. Medical management is the first line of therapy for chronic menorrhagia. Agents that have been used to treat menorrhagia include iron, cyclooxygenase inhibitors, desmopressin, antifibrinolytics, gonadotropin-releasing hormone agonists, androgens, combined oral contraceptives, and progestins. Progestins can be administered systemically or locally and may be given cyclically or continuously. Increased use of effective medical therapies has the potential to reduce the number of surgical procedures, such as endometrial ablation and hysterectomy.

Treatment of menorrhagia with an LNG-IUS

Menorrhagia, also known as heavy menstrual bleeding, is defined as a menstrual blood loss is greater than 80 mL. The objective measurement of menorrhagia is not easy in clinical practice, but often, the subjective complaint correlates well with the measured loss. Four types of treatments - hysterectomy, endometrial resection or ablation, levonorgestrel-releasing intrauterine system (LNG-IUS) and oral medical therapy, are available for management of menorrhagia. The article reviews the efficacy of LNG-IUS on menorrhagia and compares it to other treatment methods.

The effect of levonorgestrel-releasing intrauterine system use on menstrual blood loss and the hemostatic, fibrinolytic/inhibitor systems in women with menorrhagia

BACKGROUND

Menorrhagia is known to be associated with uterine fibroids, adenomyosis, pelvic infections, endometrial polyps and clotting defects. A viable alternative therapy to hysterectomy should alleviate heavy menstrual blood flow and consequently improve the quality-of-life measures in women presenting with menorrhagia. The levonorgestrel-releasing intrauterine system (LNG-IUS) ranks higher than medical treatments in terms of efficacy, comparable improvements in quality of life and psychological well-being.

OBJECTIVE

The purpose of the study was to determine the effects of 6 months of LNG-IUS use on menstrual blood loss and the hemostatic, fibrinolytic/inhibitor systems in blood and the endometrium in women with menorrhagia with known pathologic causes.

PATIENTS AND METHODS

Samples from 41 women were analyzed. Hemoglobin, hematocrit, thrombelastography, tissue-type plasminogen activator (t-PA), urokinase plasminogen activator (u-PA), u-PA receptor (u-PAR), plasminogen activator inhibitor-1/2 (PAI-1/2), D-dimer and von Willebrand factor (VWF) were determined, and t-PA, u-PA and PAI-1/2 were also determined in endometrial tissue extracts.

RESULTS

Menorrhagia was reduced in 89% of women by 3 months; by 6 months all women had no menorrhagia, and 39% of women had become amenorrhoeic. Hemoglobin and hematocrit levels showed improvement, and reached normal reference levels by 6 months. There were no systemic changes in the fibrinolytic/inhibitor systems and VWF, except for a decreased u-PAR level. However, in the endometrium, significant elevations in PAI-1/2 together with u-PAR levels were seen at 6 months.

CONCLUSIONS

The slow levonorgestrel-release intrauterine device use results in high expression of fibrinolytic inhibitors (PAI-1/2) and upregulated u-PAR expression in the endometrium. Systemic hemostasis was not significantly altered. The study demonstrated that LNG-IUS is highly effective in the treatment of menorrhagia with known pathologic causes.

Health Status Function after Treatment with Thermal Balloon Endometrial Ablation and Levonorgestrel Intrauterine System for Idiopathic Menorrhagia: A Randomized Study

AIM

To compare patients' health status function after treatment with thermal balloon endometrial ablation (TBEA) and levonorgestrel intrauterine system (LNG-IUS) for idiopathic menorrhagia.

METHODS

Forty-four patients were recruited into a randomized trial comparing their health status after treatment with TBEA or LNG-IUS for idiopathic menorrhagia.

RESULTS

At 1 year follow-up, the mean haemoglobin was significantly higher in women treated with TBEA (12.6 g/dl vs. 10.3 g/dl, p = 0.018). Iron deficiency occurred in 13.3% from the TBEA arm and in 50% from the LNG-IUS arm (p = 0.026). The women's mean Short Form 36 Questionnaire general health perception scores (54.9 vs. 40.5, p = 0.024) and mental health scores (49.5 vs. 38.3, p = 0.021) in TBEA arm were significantly higher than in the LNG-IUS arm. The mental health domain score was also significantly lower in the LNG-IUS arm (46.1 vs. 38.3, p = 0.041).

CONCLUSION

TBEA appears to offer better health status function at 1 year follow-up and to be more acceptable to our Chinese population in the treatment of idiopathic menorrhagia following failed medical treatment.

Long-Term Treatment of Menorrhagia With Levonorgestrel Intrauterine System Versus Endometrial Resection

OBJECTIVE

The purpose of this study was to compare the long-term efficacy of the levonorgestrel intrauterine system and transcervical resection of the endometrium in the treatment of menorrhagia.

METHODS

This study was an open, randomized 3-year trial. Patients with menorrhagia were assigned randomly to either the levonorgestrel intrauterine system (n = 30) or endometrial resection (n = 29). Pictorial blood loss assessment charts were used to measure menstrual blood loss. A pictorial blood-loss assessment chart score exceeding 75 (representing menstrual blood loss >/=60 mL) was used to diagnosis the patient as having menorrhagia. Discontinuations and cases requiring repeat operations were evaluated.

RESULTS

Pictorial blood loss scores decreased from a baseline median of 261.5 (range, 60-1503) to 7 (range, 0-101; P < .001) for the levonorgestrel intrauterine system and from 311 (range, 81-2506) to 4 (range, 0-182; P < .001) for transcervical resection of the endometrium. Nineteen women of 30 using the levonorgestrel intrauterine system completed the 3-year follow-up compared with 22 of 29 for transcervical resection of the endometrium.

CONCLUSION

Both treatments efficiently reduced menstrual bleeding. The high continuation rate suggests that the levonorgestrel intrauterine system is comparable with transcervical resection of the endometrium.

A pilot study on the acceptability of levonorgestrel-releasing intrauterine device by young, single, nulliparous Chinese females following surgical abortion

This study investigated the acceptability of the levonorgestrel-releasing intrauterine device (LNG-IUS) as contraception among young, single women after termination of pregnancy. Twenty subjects, with a median age of 21 years, had LNG-IUS inserted immediately after suction termination of first-trimester pregnancy. The subjects were followed-up at 6 weeks, 3 months, 6 months and 12 months. Fifteen subjects (75%) had other pregnancies terminated in the past. There were no serious complications or pregnancies. The acceptability of the LNG-IUS was generally above 86% during each follow-up visit. A total of seven (35%) subjects were lost to follow-up at different periods of the study. Overall, four subjects (22%) had the LNG-IUS removed. Nine subjects were seen at the end of the 1-year study period and all continued with the LNG-IUS for contraception. Side effects were commonly observed and irregular vaginal bleeding was the most common. We conclude that the LNG-IUS may be an acceptable method among selective young, single, nulliparous clients after termination of pregnancy and could be offered as an option of contraception to them. However, the small sample size and the high lost-to-follow-up rate are the major limitations of this study.

Current treatment of dysfunctional uterine bleeding

OBJECTIVES

We performed a review of the treatment modalities for dysfunctional uterine bleeding.

METHODS

Dysfunctional uterine bleeding can be treated medically or surgically. Medical treatment consists of anti-fibrinolytic tranexamic acid, non-steroidal anti-inflammatory drugs, the combined contraception pill, progestogen, danazol, or analogues of gonadotrophin releasing hormone. The levonorgestrel releasing intra uterine device is developed for contraception, but is also effective in the treatment of dysfunctional uterine bleeding. Surgical treatment includes endometrial ablation of the first and second-generation, and hysterectomy. This review contains current available evidence on the effectiveness of these therapies.

RESULTS

Antifibrinolytic tranexamic acid is the most effective medical therapy to treat dysfunctional uterine bleeding. In general medical therapy is not as effective as endometrial resection in terms of patient satisfaction and health related quality of life. The levonorgestrel releasing intra uterine device is an effective treatment for dysfunctional uterine bleeding. No difference in quality of life was observed in patients treated with a levonorgestrel releasing intra uterine device as compared to hysterectomy. Ablation techniques of the first generation are effective and safe when used by trained surgeons, but have a learning curve. Ablation techniques of the second generation are effective, but long-term follow-up data are not available. Similarly, there are no large randomised controlled trials comparing the levonorgestrel releasing intra uterine device to first and second-generation ablation techniques. Hysterectomy, the traditional standard of care, has a relatively high complication rate, but it generates a high satisfaction rate and good health related quality of life scores.

CONCLUSION

Since none of the treatments for dysfunctional bleeding is superior to one of the others, and since all treatments have their advantages and disadvantages, counselling of patients with dysfunctional bleeding should incorporate medical approach, levonorgestrel releasing IUD, endometrial ablation and hysterectomy.

Benefit-Risk Assessment of the Levonorgestrel Intrauterine System in Contraception

The levonorgestrel-releasing intrauterine system (IUS) is a long-acting, fully reversible method of contraception. It is one of the most effective forms of contraception available, and combines the advantages of both hormonal and intrauterine contraception. The levonorgestrel-releasing IUS also gives the users many non-contraceptive benefits: the amount of menstrual bleeding and the number of days of menstrual bleeding are reduced, which makes it suitable for the treatment of menorrhagia (heavy menstrual blood loss). Dysmenorrhoea (painful menstruation) and premenstrual symptoms are also relieved. In addition, the levonorgestrel-releasing IUS provides protection for the endometrium during hormone replacement therapy. The local release of levonorgestrel into the uterine cavity results in a strong uniform suppression of the endometrial epithelium as the epithelium becomes insensitive to estradiol released from the ovaries. This accounts for the reduction in menstrual blood loss. All possible patterns of bleeding are seen among users of the levonorgestrel-releasing IUS; however, most of the women who experience total amenorrhoea continue to ovulate. The first months of use are often characterised by irregular, scanty bleeding, which in most cases resolves spontaneously. The menstrual pattern and fertility return to normal soon after the levonorgestrel-releasing IUS is removed. The contraceptive efficacy is high with 5-year failure rates of 0.5-1.1 per 100 users. The absolute number of ectopic pregnancies is low, as is the rate per 1000 users. The levonorgestrel-releasing IUS is equally effective in all age groups and the bodyweight of the user is not associated with failure of the method. In Western cultures continuance rates among users of the levonorgestrel-releasing IUS are comparable with those of other long-term methods of contraception. Premature removal of the device is most often associated with heavy menstrual bleeding and pain, as with other long-term methods of contraception, and is most common in the youngest age group. When adequately counselled about the benign nature of oligo- or amenorrhoea, most women are very willing to accept life without menstruation. The risk of premature removal can be markedly diminished with good pre-insertion counselling, which also markedly increases user satisfaction. User satisfaction is strongly associated with the information given at the time of the levonorgestrel-releasing IUS insertion. Thus, the benefits of the levonorgestrel-releasing IUS make it a very suitable method of contraception for most women.

Therapeutic effects of the levonorgestrel-releasing intrauterine system in the treatment of idiopathic menorrhagia

OBJECTIVE

To investigate the effect of the levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of idiopathic menorrhagia.

DESIGN

Measurements of menstrual blood loss (MBL), hemoglobin, and serum ferritin before and after LNG-IUS insertion.

SETTING

National Research Institute for Family Planning and Beijing Gynecology and Obstetrics Hospital, Beijing, People's Republic of China.

PATIENT(S)

Thirty-four patients with MBL over 80 mL.

INTERVENTION(S)

Insertion of the LNG-IUS on cycle days 5-7 and follow-up at 3-month intervals for 3 years.

MAIN OUTCOME MEASURE(S)

Measurement of MBL, serum ferritin, and hemoglobin for evaluation of efficacy of treatment.

RESULT(S)

A significant reduction of MBL to 23.4 mL (78.7% decrease), 26.4 mL (83.8% decrease), 2.7 mL (97.7% decrease), and 13.7 mL (85.0% decrease) at 6, 12, 24, and 36 months, respectively. After 6 months, one-third of the patients experienced amenorrhea, and one-fourth, spotting. Hemoglobin increased significantly from 121.5 g/L preinsertion to 135.5 g/L after 36 months, while serum ferritin levels increased significantly from 21.9 ng/mL before insertion to 92.8 ng/mL after 36 months. In women using the LNG-IUS for 3-4 years, the E2 levels in 20 samples were 239.4 pmol/L, P levels were 11.1 nmol/L, and serum LNG levels were maintained at an average of 511 pmol/L.

CONCLUSION(S)

The significant reduction of MBL and the increase in hemoglobin and serum ferritin levels in the treatment of menorrhagia with the LNG-IUS has great implications for women's reproductive health, particularly in developing countries.

The effect of a levonorgestrel-releasing intrauterine device in the treatment of myoma-related menorrhagia

In this open observational study we evaluated the effectiveness of a levonorgestrel-releasing intrauterine device (LNG-IUD) in the treatment of myoma-related menorrhagia. Nineteen patients with recurrent menorrhagia lasting more than 3 months and with fibromyomatosus uterus were treated for 12 months with a LNG-IUD releasing 20 micro g/day of levonorgestrel. Menstrual blood loss, measured objectively by the pictorial blood loss assessment chart score (PBAC), level of serum hemoglobin and pattern of uterine bleeding were recorded at 3, 6, 9 and 12-month follow-up visits. Median monthly PBAC score during the two menstrual cycles before treatment was 310. After LNG-IUD, the PBAC score gradually decreased from a median value of 186 at 3 months to a median value of 155, 108 and 96 at 6, 9 and 12 months of treatment, respectively. Despite the statistically significant reduction of PBAC score, persistent menorrhagia, defined as a monthly PBAC score of 100 or higher, was observed at 12 months in 14 patients, whereas only one woman was amenorrheic and 4 were hypomenorrheic. In conclusion our study demonstrates the clinical reduced effectiveness of LNG-IUD in the treatment of myoma-related menorrhagia.

A retrospective cohort study comparing microwave endometrial ablation with levonorgestrel-releasing intrauterine device in the management of heavy menstrual bleeding

OBJECTIVE

To compare microwave endometrial ablation (MEA) with a levonorgestrel-releasing intrauterine device (Mirena) in the management of heavy menstrual bleeding.

DESIGN

A retrospective cohort study

SAMPLE

Thirty-nine women were treated with MEA and 23 women with Mirena, in the South East Regional Health Service of South Australia during 1998 to 2001; the mean duration of follow-up was 14.6 months.

MAIN OUTCOME MEASURES

Primary measures included acceptability of the treatment process, effectiveness of the treatment, and satisfaction with outcomes. Secondary measures included side effects, complications and quality of life (using the SF-36).

RESULTS

Acceptability of the treatment process and satisfaction with outcomes was very high for both procedures. Each treatment led to a statistically significant reduction in menstrual bleeding (p < 0.0001) and dysmenorrhoea scores (p < 0.002).

CONCLUSIONS

There were no statistical differences between the two treatments for any of the primary or secondary outcome measures assessed. The treatments seem equally effective in the management of heavy menstrual loss.

Intrauterine devices

The aim of this chapter is to review the worldwide use of intrauterine devices (IUDs) for contraception and the long-term contraceptive efficacy and safety of copper-bearing IUDs. The TCu380A and Multiload Cu375 have a very low failure rate (0.2-0.5%) over 10 years. The main concerns of the use of IUDs are risk of pelvic inflammatory diseases and increased menstrual blood loss and irregular bleeding. Factors associated with an increase in risk of pelvic inflammatory diseases are discussed. Preventive measures can be taken with careful screening of eligible IUD users, technical training and adequate service facilities for provision of IUDs. Levonorgestrel-releasing IUDs have the benefit of reducing menstrual blood loss in addition to high contraceptive efficacy. The copper IUD is the most effective method for emergency contraception. It can prevent over 95% of unwanted pregnancies within 5 days of unprotected intercourse.

Noncontraceptive health benefits of intrauterine devices: a systematic review

Most women and their clinicians are unaware that IUDs confer important noncontraceptive health benefits. This review summarizes the evidence from published articles on this topic. We conducted a series of systematic literature searches to identify articles on the noncontraceptive health benefits of IUD use. We reviewed the potentially pertinent ones for content, grouped them according to type of IUD, and evaluated them using the U.S. Preventive Services Task Force rating system. Over 500 titles were identified and several hundred abstracts were reviewed. Use of nonhormonal IUDs (plastic and copper) was associated with a decrease in endometrial cancer. The levonorgestrel intrauterine system can treat a variety of gynecological disorders, including menorrhagia and anemia. The levonorgestrel system has also been used successfully as part of hormone replacement therapy, as adjuvant therapy with tamoxifen, and as an alternative to hysterectomy for women with bleeding problems. Like oral contraceptives, intrauterine contraceptives confer important noncontraceptive health benefits.

The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review

OBJECTIVE

To determine whether the levonorgestrel-releasing intrauterine device (LNG-IUS), licensed at present for contraceptive use, may reduce menstrual blood loss with few side effects. If effective, surgery could be avoided with consequent resource savings.

METHODS

A systematic review addressing the effectiveness and cost effectiveness of the LNG-IUS for menorrhagia was undertaken.

RESULTS

Five controlled trials and five case series were found which measured menstrual blood loss. Nine studies recorded statistically significant average menstrual blood loss reductions with LNG-IUS (range 74%-97%). Another showed reduction in menstrual disturbance score. The LNG-IUS was more effective than tranexamic acid, but slightly less effective than endometrial resection at reducing menstrual blood loss. In one study, 64% of women cancelled surgery at six months, compared with 14% of control group women. In another, 82% were taken off surgical waiting lists at one year. No cost effectiveness studies were found.

DISCUSSION

Small studies of moderate quality indicate the LNG-IUS is an effective treatment for menorrhagia. Costs may be less than for tranexamic acid in primary and secondary care. Although its use may reduce surgical waiting lists, cost effectiveness assessment requires longer follow up.

CONCLUSION

Effectiveness and cost effectiveness relative to other treatments and the effect on surgical waiting lists can only be established in larger trials measuring patient-centred outcomes in women with menorrhagia.

The levonorgestrel intra-uterine system: therapeutic application in family planning

OBJECTIVE

To assess the non-contraceptive benefits of the levonorgestrel intra-uterine system 12 months following insertion in a family planning setting.

DESIGN

Postal questionnaire survey.

SETTING

Family planning clinics at the Ulster and Bangor Hospitals.

SUBJECTS

Eighty-six consecutive subjects fitted with the levonorgestrel intra-uterine system.

RESULTS

Response rate 87.3%. Outcome measured in terms of compliance, satisfaction and menstrual symptomatology. Reasons for insertion were as follows: 21.7% contraception only; 65.2% menorrhagia, 24.6% dysmenorrhoea and 1.4% premenstrual syndrome. Duration of menses was 8.25 days pre-insertion and 2.41 days at 12 months. Of the subjects, 59.4% experienced at least one hormonal side effect; 10.1% of systems were removed within 12 months. At 12 months 86.9% of women were satisfied and 9.8% of women planned to discontinue.

CONCLUSION

The levonorgestrel intra-uterine system was acceptable to almost 80% of women after 12 months, with significant reduction in duration of menses. Family planning clinics are an ideal setting to implement the guidelines for the initial management of menorrhagia.

Progesterone/progestogen releasing intrauterine systems versus either placebo or any other medication for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) is an important cause of ill health in women and it accounts for 12% of all gynaecology referrals in the UK. Heavy menstrual bleeding is clinically defined as greater than, or equal to, 80mls blood loss per menstrual cycle but women may complain of excessive bleeding when their blood loss is less than 80ml. Hysterectomy is often used to treat women with this complaint but medical therapy may be a successful alternative. The intrauterine coil device was originally developed as a contraceptive but the addition of uterine relaxing hormones, or progestogens, to these devices resulted in a large reduction in menstrual blood loss. Case studies of 2 types of progesterone/progestogen releasing systems, Progestasert and Mirena, report reductions of up to 90% and dysmenorrhoea may be improved. Insertion, however, may be regarded as invasive by some women affecting its acceptability as a treatment and frequent intermenstrual bleeding and spotting is likely during the first few months.

OBJECTIVES

To determine the effectiveness and acceptability of progesterone/progestogen-releasing intrauterine devices in achieving a reduction in heavy menstrual bleeding.

SEARCH STRATEGY

All studies which might describe randomised controlled trials of progesterone/progestagen-releasing intrauterine devices for the treatment of heavy menstrual bleeding were obtained by electronic searches of the MEDLINE 1966-1999, EMBASE 1980-1999 databases and the Cochrane Library. Companies producing progestogen releasing intrauterine devices and experts in the field were contacted for information on published and unpublished trials.

SELECTION CRITERIA

Randomised controlled trials in women of reproductive age treated with progesterone/progestogen-releasing intrauterine devices versus no treatment, placebo, or other medical or surgical therapy for heavy menstrual bleeding within either the primary care, family planning or specialist clinic setting were eligible for inclusion. Women with postmenopausal bleeding, intermenstrual or irregular bleeding, or pathological causes of heavy menstrual bleeding were excluded.

DATA COLLECTION AND ANALYSIS

Potential trials were independently assessed by three reviewers and five trials met the criteria for inclusion in the review. The reviewers extracted the data independently and data were pooled where appropriate. Odds ratios for dichtomous outcomes and weighted mean differences for continuous outcomes were estimated from the data. The primary outcome was reduction in menstrual blood loss but incidence of side effects, changes in quality of life and satisfaction and acceptability measures were also assessed.

MAIN RESULTS

Progesterone/progestogen-releasing intrauterine systems have not been compared to placebo or no treatment. Progestasert has been compared to a number of different medical therapies in one small study but no conclusions can be made about effectiveness. The levonorgestrel-releasing intrauterine device (LNG IUS) has been compared to oral cyclical norethisterone (NET) administered on days 5-26 in one trial and was significantly more effective although there was a large reduction from baseline in both groups and these differences were not perceived by the women undergoing the treatment. Some side effects were more common in the LNG IUS group but a significantly greater proportion of women in this group were satisfied and willing to continue with their treatment. In one trial of women awaiting hysterectomy where the LNG IUS was compared with a control group taking their existing medical therapy, a higher proportion of the women in the former group cancelled their planned surgery after 6 months of treatment. The levonorgestrel-releasing intrauterine device has been compared to a surgical procedure (transcervical resection of the endometrium (TCRE)) in two trials. (ABSTRACT TRUNCATED)

A prospective, multidisciplinary evaluation of premenopausal women with iron-deficiency anemia

OBJECTIVE

The cause of iron deficiency anemia (IDA) in premenopausal women is often presumed to be menstrual blood loss. The purpose of this study was to determine the diagnostic value of a comprehensive gynecological and gastrointestinal evaluation in premenopausal women with IDA.

METHODS

Nineteen premenopausal, nonpregnant women older than 18 yr of age with IDA defined by a hemoglobin < 12 gm/dl with serum ferritin < 10 ng/ml participated in the study. Evaluations included directed history and physical examination by a specialist in gynecology and a subspecialist in gastroenterology, esophagogastroduodenoscopy, colonoscopy, upper gastrointestinal radiography with small bowel follow-through, antiendomysial antibody, and fecal occult blood tests.

RESULTS

Seven of 19 (37%) premenopausal women with IDA were diagnosed to have a gynecological cause of anemia by a specialist in that field. Although only four of these seven patients had digestive complaints, all but one (86%) were discovered to have gastrointestinal disease by upper endoscopy; findings were duodenal ulcer and Helicobacter pylori (H. pylori) gastritis (one), esophagitis and H. pylori gastritis (one), erosive esophagitis (one), gastric arteriovenous malformations (one), and nodular/erosive H. pylori gastritis (two). Fecal occult blood testing was positive in only two (29%) subjects; upper endoscopy revealed erosive esophagitis and gastric arteriovenous malformations. Twelve of the 19 (63%) premenopausal women with IDA were not diagnosed to have a gynecological source of anemia by a specialist in that field. Fecal occult blood testing was negative among all women tested and the only digestive complaint was heartburn (pyrosis) in seven. Each was identified to have esophagitis, duodenal ulcer, or gastritis by upper endoscopy. Colonoscopic examination of the 12 subjects without gynecologic etiology for IDA revealed pan colitis (one), diverticulosis (one), diverticulosis and melanosis coli (one), hyperplastic polyps (one), and nodular lymphoid aggregates (one).

CONCLUSIONS

Significant upper gastrointestinal disease is identifiable among most premenopausal women with IDA (18 of 19 or 95%), even when careful evaluation by a specialist in gynecology suggests a gynecological source. Upper endoscopy should be considered in the evaluation of all premenopausal women with IDA expressing digestive complaints or in those with IDA refractory to iron supplementation. Lower endoscopic examination may be reserved for those women with symptoms or signs suggestive of colorectal disorders.

Levonorgestrel-releasing IUD as a method of contraception with therapeutic properties

The levonorgestrel-releasing intrauterine device LNg IUD is a new contraceptive method that combines the advantages of both hormonal and intrauterine contraception. It gives users non-contraceptive health benefits and can also be used as an effective therapy for menorrhagia. The local release of LNg within the endometrial cavity results in strong suppression of endometrial growth as the endometrium becomes insensitive to ovarian estradiol. The endometrial suppression is the reason for a significant reduction of menstrual blood loss or amenorrhea, and for the disappearance of dysmenorrhea. The bleeding pattern during the use of the LNg IUD is characterized by reduction of the blood loss and in the number of bleeding days per cycle. During the first two to three months of use, however, irregular spotting is common. The removal of the device results in a quick return of menstrual bleeding and fertility. The failure rate of copper-releasing IUDs, as with other methods of fertility regulation, is higher in young women and decreases with age. The LNg IUD, on the other hand, has the same low pregnancy rate in every age group of the users. The LNg IUD also gives protection against ectopic pregnancy and pelvic inflammatory disease and, by reducing menstrual blood loss, increases the body iron stores. The LNg IUD can be used to effectively treat menorrhagia. This has been demonstrated in studies with quantitative determination of menstrual blood loss. During the first year of use, the LNg IUD reduced menstrual blood loss by 90% from pretreatment levels. Comparative clinical trials with the LNg IUD cover more than 10,000 women-years of follow-up during use over five to seven years. The Pearl pregnancy rate in studies has been 0.0-0.2 per 100 women-years. The overall ectopic Pearl pregnancy rate is 0.02 per 100 woman-years. The LNg IUD is marketed in Denmark, Finland, Norway, Sweden and in the United Kingdom.