Subendometrial microvascularization and uterine artery blood flow in IUD-induced side effects (levonorgestrel intrauterine system and copper intrauterine device)

Utility of the Levonorgestrel-Releasing Intrauterine System in the Treatment of Abnormal Uterine Bleeding and Dysmenorrhea: A Narrative Review

INTRODUCTION

We undertook a literature review of the use of levonorgestrel-releasing intrauterine devices when utilized for heavy menstrual bleeding and/or dysmenorrhea.

METHODS

A narrative review of articles in the Scopus and Medline databases was conducted.

RESULTS

A number of options exist for the management of both abnormal uterine bleeding (AUB) and dysmenorrhea, and evidence is accumulating that the insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) represents a useful option for their long-term treatment. The idea of using a progestogen released in utero was initially conceived to achieve long-term contraception, but it was quickly found that these systems could be utilized for a number of therapeutic applications. The first device to be made commercially available, Progestasert, was withdrawn from the market because, in the event of contraceptive failure, it caused a disproportionate percentage of extrauterine pregnancies. On the other hand, the LNG-IUS continues to be successfully utilized in its various variants, releasing 20, 13, or 8 μg/day. These devices have a respective duration of action of 7 (possibly 8), 5, and 3 years, and there exist versions of frameless systems affixed to the myometrium of the uterine fundus. In the present review, following a brief description of the major causes of AUB and dysmenorrhea, the molecular bases for the use of the LNG-IUS are summarized. This is followed by a compendium of its use in AUB and dysmenorrhea, concluding that the insertion of the system improves the quality of life, reduces menstrual blood loss better than other medical therapies, and decreases the extent of dysmenorrhea and pelvic pain. In addition, there is no evidence of a significant difference in these outcomes when the use of the LNG-IUS was compared with improvements offered by endometrial ablation or hysterectomy. Possibly, the most important mechanism of action of the system consists of its ability to induce amenorrhea, which effectively eliminates heavy bleeding and dysmenorrhea. However, no method is ideal for every woman, and, in the case of the LNG-IUS, younger age and severe dysmenorrhea seem to be associated with a higher risk of discontinuation.

CONCLUSION

The higher-dose LNG-IUS is a useful tool for HMB and dysmenorrhea in women of all ages. The low cost and ease of use make the LNG-IUS an attractive option, especially when contraception is also desired.

Effects of the levonorgestrel-releasing intrauterine system versus the copper intrauterine device on uterine artery Doppler indices

OBJECTIVES

The aims of the study were to evaluate the effects of two types of intrauterine contraceptive device (IUCD) on uterine artery Doppler indices.

METHODS

A multicentre randomised clinical trial was conducted between November 2019 and August 2020. Sixty-six multiparous women aged 18-45 years seeking intrauterine contraception were randomly assigned to receive either the levonorgestrel-releasing intrauterine system (LNG-IUS) or the copper intrauterine device (Cu-IUD). Each group comprised 33 participants. Primary outcome measures were menstrual changes and changes in uterine artery Doppler indices 3 and 6 months after IUCD insertion. Secondary outcomes measures were the relation between Doppler indices and menstrual changes, adverse effects of the assigned contraceptive method and user acceptability of the method.

RESULTS

Uterine artery pulsatility index (PI) and resistance index (RI) were significantly higher among women in the LNG-IUS group (p < .001 at 6 months). Whereas the number of women reporting heavy menstrual bleeding decreased at 3 and 6 months in the LNG-IUS group it significantly increased in the Cu-IUD group (p < .001 at 6 months). Multiple logistic regression analysis of participant characteristics and occurrence of heavy menstrual bleeding revealed a significant association with uterine artery RI (p < .01) and the type of IUCD (p < .001).

CONCLUSION

IUCDs are associated with Doppler changes that may be associated with their reported side effects.

Vascular effect of levonorgestrel intrauterine system on heavy menstrual bleeding: is it associated with hemodynamic changes in uterine, radial, and spiral arteries?

The aim of this study was to evaluate the clinical and blood flow changes associated with the use of a levonorgestrel-releasing intrauterine device (LNG-IUD) in patients with idiopathic heavy menstrual bleeding (HMB). LNG-IUD was inserted into a total of 91 patients (39.5 ± 5.4 years) who were diagnosed with HMB. Uterine volume, ovarian volume, uterine, radial and spiral artery blood flow, Pictorial Blood Loss Assessment Chart (PBAC) scores, and other clinical and laboratory parameters were evaluated before and 12 months after insertion of LNG-IUD. Compared to pre-insertion values, LNG-IUD dramatically improved haemoglobin, PBAC scores, and endometrial thickness. Mean resistance indices of radial and spiral arteries significantly increased 12 months after insertion. Our study results suggest that a significant increase in the resistance indices of the intra-myometrial arteries in LNG-IUD users one year after insertion may be due to its local progestational effects, indicating a possible mechanism of LNG-IUD in reducing menstrual blood flow.Impact StatementsWhat is already known on this subject? The mechanisms of action of LNG-IUD on heavy menstrual bleeding include atrophy, decidualization and vascular changes of in the endometrium, resulting endometrial suppression. However, the exact mechanism to stop bleeding is not clear.What do the results of this study add? The present study suggests that one of the effects of the LNG-IUD on heavy menstrual bleeding is its ability to increase the resistance indexes of the intra-myometrial arteries.What are the implications of these findings for clinical practice and/or further research? These results will foster further studies on the effects of LNG-IUD on intra-myometrial arteries and will further assure clinicians on the vascular effect of LNG-IUD during management of heavy menstrual bleeding which includes hysterectomy as a final step.

Effects of a levonorgestrel intrauterine system versus a copper intrauterine device on menstrual changes and uterine artery Doppler

OBJECTIVE

To compare the effects of a levonorgestrel-releasing intrauterine system (LNG-IUS) and a copper intrauterine device (Cu-IUD) on menstrual changes and uterine artery Doppler indices.

METHODS

A randomized clinical trial was conducted at Menoufia University Hospital, Egypt, between December 2016 and August 2017. 306 multiparous women desiring intrauterine contraception were randomly assigned to LNG-IUS (n=152) or Cu-IUD (n=154). Uterine artery pulsatility index (PI) and resistant index (RI) were measured before use, and 3 and 6 months after insertion, and associations with abnormal bleeding were evaluated.

RESULTS

Irregular bleeding was initially reported by 31 (74%) of 42 women in the LNG-IUS group, and heavy menstrual bleeding by 53 (67%) of 79 women in the Cu-IUD group. Incidence of abnormal bleeding decreased over the 6-month study period. Uterine artery PI was significantly correlated with abnormal bleeding at a cutoff of 1.35 with area under the curve (AUC) 0.93, sensitivity 88%, and specificity 100%, whereas uterine artery RI was significantly correlated with abnormal bleeding at a cutoff of 0.62 with AUC 0.1, sensitivity 96%, and specificity 100%.

CONCLUSION

LNG-IUS-related abnormal bleeding was associated with changes in uterine artery blood flow that were not evident among Cu-IUD users. Pan African Clinical Trials Registry: PACTR201701001900640.

Correlation between uterine artery Doppler indices and menstrual irregularities among levonorgestrel releasing intrauterine system and depot medroxyprogesterone acetate users: a prospective observational study

OBJECTIVE

To ascertain whether menstrual irregularities among users of levonorgestrel releasing intrauterine system (LNG-IUS) and depot medroxyprogesterone acetate (DMPA), were associated with changes in uterine artery Doppler indices or not.

METHODS

This three-year prospective observational study included 102 women using LNG-IUS and 104 women using DMPA for contraception. Participants were followed at regular intervals over three years with performance of transvaginal ultrasound to measure uterine artery pulsatility index (PI) and resistance index (RI) before starting the method and at six months, 12 months, two and three years thereafter. Data was collected and tabulated.

RESULTS

Significant changes in uterine artery PI and RI were detected. PI indices were reduced after six months of use in both groups and elevated significantly at 12 months in both groups compared to initial values (p < .001) while RI significantly reduced after six months in both groups and elevated significantly at 12 months, two and three years in both groups compared to initial values (p < .001). Both PI and RI significantly reduced in women suffered abnormal uterine bleeding and significantly elevated in women experienced amenorrhea irrespective of the method used (p < .001).

CONCLUSIONS

LNG-IUS and DMPA induce hemodynamic changes in the uterine arteries denoting positive correlation with menstrual irregularities. Larger multicentre studies are warranted to potentiate our findings.

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.

Three-dimensional power Doppler study of endometrial and subendometrial microvascularization in women with intrauterine device-induced menorrhagia

OBJECTIVE

To evaluate endometrial and subendometrial microvascularization, using three-dimensional (3D) power Doppler ultrasound, in women with intrauterine device (IUD)-induced menorrhagia; and whether those potential findings could predict the risk of bleeding before IUD insertion.

DESIGN

Prospective clinical trial.

SETTING

University teaching hospital.

PATIENT(S)

One hundred twenty women, who requested the insertion of a copper IUD for contraception.

INTERVENTION(S)

Endometrial thickness and volume, uterine artery pulsatility index and resistance index, and endometrial and subendometrial 3D power Doppler vascularization index, flow index, and vascularization flow index were measured twice: immediately before and 3 months after IUD insertion.

MAIN OUTCOME MEASURE(S)

Doppler indices before and after IUD insertion.

RESULT(S)

Before IUD insertion, no significant difference was detected in the clinical characteristics, endometrial thickness and volume, and Doppler indices between women who had IUD-induced menorrhagia (n = 47) and those without menorrhagia (n = 73). However, after IUD insertion, there was a significant increase in the endometrial and subendometrial vascularization index, flow index, and vascularization flow index in women with menorrhagia, whereas other parameters remained not significantly different between the two groups.

CONCLUSION(S)

Endometrial and subendometrial microvascularization increases in women with IUD-induced menorrhagia; however, this finding has no predictive value before IUD insertion.

Safety, Efficacy, and Patient Acceptability of the Copper T-380A Intrauterine Contraceptive Device

The ParaGard Copper T 380A intrauterine device (CuT380A) provides reversible contraception that is as effective as sterilization for up to 20 years. The CuT380A is a mainstream, first-line contraceptive option for most healthy women, including nulligravid women, as well as many women who have serious medical problems. Because it is the most cost-effective method of birth control, the CuT380A is the preferred IUD, except for women who desire lighter or no menstrual blood loss. Surveys reveal that 95% of US CuT380A users are “very” or “somewhat” satisfied with their method. This article describes current candidates for IUD use, discusses the mechanisms of action of the CuT380A, provides guidance to reduce barriers to IUD access, suggests counseling points for patients, and outlines techniques to reduce the risks and side effects that can be associated with use of the CuT380A.