Ovarian function in amenorrheic and menstruating users of a levonorgestrel-releasing intrauterine device**This work was undertaken as part of the contraceptive development program sponsored and coordinated by the International Committee for Contraception Research of the Population Council, Inc., New York, New York. The financial support provided by the Ford Foundation, the Rockefeller Foundation, the International Development Research Centre of Canada, and The Geo. J. Hecht Fund is gratefully acknowledged. The content does not necessarily reflect the policy of any of the funding sources

Hormonal Contraception and Sexual Function: A Review, Clinical Insights, and Management Considerations

Most sexually active women of reproductive age have used contraception, with hormonal methods constituting approximately 40% of contraceptive choices. Among these hormonal options, combined oral contraceptives stand out as the most selected. Within this same demographic, sexual issues are prevalent. Although specific hormonal contraceptives have been implicated in sexual dysfunction among these women, the correlation lacks consistency across studies and varies between different types of hormonal contraception. This article assesses the available literature on the associations between various hormonal contraceptive methods and sexual function and provides practical management insights.

Hormonal intrauterine devices and heat exchange during exercise

Synthetic progestins in oral contraceptives are thought to blunt heat dissipation by reducing skin blood flow and sweating. However, whether progestin-releasing intrauterine devices (IUDs) modulate heat loss during exercise-heat stress is unknown. We used direct calorimetry to measure whole-body total (dry + evaporative) heat loss in young, physically active women (mean (SD); aged 24 (4) years,V ̇ O 2 peak ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{peak}}}}$ 39.3 (5.3) ml/kg/min) with (IUD; n = 19) and without (Control; n = 17) IUDs in the follicular and luteal phases of the menstrual cycle during light- and moderate-intensity exercise at fixed rates of heat production (∼175 and ∼275 W/m2 ) in 30°C, ∼21% relative humidity. Between-group and -phase differences were evaluated using traditional hypothesis testing and statistical equivalence testing within pre-determined bounds (±11 W/m2 ; difference required to elicit a ±0.3°C difference in core temperature over 1 h) in each exercise bout. Whole-body total heat loss was statistically equivalent between groups within ±11 W m-2 (IUD-Control [90% CIs]; Light: -2 [-8, 5] W/m2 , P = 0.007; Moderate: 0 [-6, 6] W/m2 , P = 0.002), as were dry and evaporative heat loss (P ≤ 0.023), except for evaporative heat loss during moderate-intensity exercise (equivalence: P = 0.063, difference: P = 0.647). Whole-body total and evaporative heat loss were not different between phases (P ≥ 0.267), but dry heat loss was 3 [95% CIs: 1, 5] W/m2 greater in the luteal phase (P ≤ 0.022). Despite this, all whole-body heat loss outcomes were equivalent between phases (P ≤ 0.003). These findings expand our understanding of the factors that modulate heat exchange in women and provide valuable mechanistic insight of the role of endogenous and exogenous female sex hormones in thermoregulation. KEY POINTS: Progestin released by hormonal intrauterine devices (IUDs) may negatively impact heat dissipation during exercise by blunting skin blood flow and sweating. However, the influence of IUDs on thermoregulation has not previously been assessed. We used direct calorimetry to show that IUD users and non-users display statistically equivalent whole-body dry and evaporative heat loss, body heat storage and oesophageal temperature during moderate- and high-intensity exercise in a warm, dry environment, indicating that IUDs do not appear to compromise exercise thermoregulation. However, within IUD users and non-users, dry heat loss was increased and body heat storage and oesophageal temperature were reduced in the luteal compared to the follicular phase of the menstrual cycle, though these effects were small and unlikely to be practically meaningful. Together, these findings expand our understanding of the factors that modulate heat exchange in women and have important practical implications for the design of future studies of exercise thermoregulation.

The Levonorgestrel-Releasing Intrauterine Device as Emergency Contraception: Re-examining the Data

Emergency contraception methods that also deliver ongoing contraception provide the most effective options for individuals hoping to prevent pregnancy after unprotected intercourse. Although the copper intrauterine device (IUD) provides the most effective option for emergency contraception because the device prevents pregnancy when placed before implantation and offers long-acting contraception, uptake by patients has been limited. Recently, the Society of Family Planning issued new guidance recommending the levonorgestrel IUD (LNG-IUD) as an emergency contraception option along with the copper IUD. Here, we review evidence related to this recommendation and conclude that the available data do not support use of the LNG-IUD for emergency contraception. We discuss the mechanisms of action of emergency contraception methods and how these concepts interface with the current political and social landscape of contraception and abortion care. We describe limitations of the existing evidence supporting use of the LNG-IUD as emergency contraception and highlight the critical research needed to establish the device as a highly effective method of emergency contraception.

Caregiver goals and satisfaction for menstrual suppression in adolescent females with developmental disabilities: A prospective cohort study

BACKGROUND

Adolescents with developmental disabilities and their caregivers often seek menstrual management. Caregivers frequently serve as medical decision-makers, and little is known about caregiver goals for menstrual management and satisfaction over time.

OBJECTIVE

Assess caregiver reasons for initiating menstrual management in adolescents with disabilities and satisfaction over 12 months.

METHODS

Prospective cohort study of caregivers of adolescents with developmental disabilities seeking menstrual management at a pediatric and adolescent gynecology clinic. Data derive from caregiver surveys and adolescents' electronic medical records.

RESULTS

Ninety-two caregiver-adolescent pairs enrolled. The mean age of adolescents was 14.4 (±2.6). The most common method started was levonorgestrel intrauterine device (LNG-IUD; 52, 56.5%), followed by oral norethindrone acetate (21, 22.8%). Caregivers cited hygiene concerns (84.8%), behavioral problems (52.2%), and heavy/excessive bleeding (48.9%) as reasons for initiating menstrual suppression. Caregivers who identified hygiene or heavy/excessive bleeding as the most important reason for management were more likely to select LNG-IUD (p = 0.009). Caregivers who cited behavioral/mood or seizure concerns as the most important reason were more likely to choose other methods (p < 0.05). At 12 months, caregiver satisfaction with all methods was high (66.2-86.9 on a 100-point scale). For every additional day of bleeding, satisfaction decreased by 3.7 points (95% CI: 2.3-5.0).

CONCLUSIONS

Caregiver satisfaction with all methods is high; however, it negatively correlates with days of bleeding. Caregiver reasons for menstrual suppression influence the method chosen. Management may reflect both patient and caregiver priorities; research is needed to better understand shared decision-making models that promote reproductive autonomy in adolescents with a developmental disability.

Randomized controlled phase IIa clinical trial of safety, pharmacokinetics and pharmacodynamics of tenofovir and tenofovir plus levonorgestrel releasing intravaginal rings used by women in Kenya

Introduction

Globally, many young women face the overlapping burden of HIV infection and unintended pregnancy. Protection against both may benefit from safe and effective multipurpose prevention technologies.

Methods

Healthy women ages 18-34 years, not pregnant, seronegative for HIV and hepatitis B surface antigen, not using hormonal contraception, and at low risk for HIV were randomized 2:2:1 to continuous use of a tenofovir/levonorgestrel (TFV/LNG), TFV, or placebo intravaginal ring (IVR). In addition to assessing genital and systemic safety, we determined TFV concentrations in plasma and cervicovaginal fluid (CVF) and LNG levels in serum using tandem liquid chromatography-mass spectrometry. We further evaluated TFV pharmacodynamics (PD) through ex vivo CVF activity against both human immunodeficiency virus (HIV)-1 and herpes simplex virus (HSV)-2, and LNG PD using cervical mucus quality markers and serum progesterone for ovulation inhibition.

Results

Among 312 women screened, 27 were randomized to use one of the following IVRs: TFV/LNG (n = 11); TFV-only (n = 11); or placebo (n = 5). Most screening failures were due to vaginal infections. The median days of IVR use was 68 [interquartile range (IQR), 36-90]. Adverse events (AEs) were distributed similarly among the three arms. There were two non-product related AEs graded >2. No visible genital lesions were observed. Steady state geometric mean amount (ssGMA) of vaginal TFV was comparable in the TFV/LNG and TFV IVR groups, 43,988 ng/swab (95% CI, 31,232, 61,954) and 30337 ng/swab (95% CI, 18,152, 50,702), respectively. Plasma TFV steady state geometric mean concentration (ssGMC) was <10 ng/ml for both TFV IVRs. In vitro, CVF anti-HIV-1 activity showed increased HIV inhibition over baseline following TFV-eluting IVR use, from a median of 7.1% to 84.4% in TFV/LNG, 15.0% to 89.5% in TFV-only, and -27.1% to -20.1% in placebo participants. Similarly, anti-HSV-2 activity in CVF increased >50 fold after use of TFV-containing IVRs. LNG serum ssGMC was 241 pg/ml (95% CI 185, 314) with rapid rise after TFV/LNG IVR insertion and decline 24-hours post-removal (586 pg/ml [95% CI 473, 726] and 87 pg/ml [95% CI 64, 119], respectively).

Conclusion

TFV/LNG and TFV-only IVRs were safe and well tolerated among Kenyan women. Pharmacokinetics and markers of protection against HIV-1, HSV-2, and unintended pregnancy suggest the potential for clinical efficacy of the multipurpose TFV/LNG IVR.

Clinical Trial Registration

NCT03762382 [https://clinicaltrials.gov/ct2/show/NCT03762382].

Perspective Chapter: Modern Birth Control Methods

This chapter focuses on various modern birth control methods, including combined oral contraceptives, progestogen-only pills, progestogen-only injectables, progestogen-only implants, intrauterine devices, barrier contraceptives, and emergency contraceptive pills. Each contraceptive method is covered in detail, including mechanism of action, effectiveness, health benefits, advantages, disadvantages, risks, and side-effects.

Beyond the pill: contraception and the prevention of hereditary ovarian cancer

BRCA1 and BRCA2 mutation carriers face an elevated lifetime risk of developing ovarian cancer. Oral contraceptives have been shown to significantly decrease the risk of ovarian cancer by approximately 50% in this high-risk population. Changes in contraceptive formulations and patterns of use over time have introduced lower hormonal dosages, different steroid types and non-oral routes of administration. Specifically, there has been a considerable shift in patterns of contraceptive use and the increase in the uptake of non-oral, long-acting, reversible contraception (e.g., intrauterine devices, implants, injections) has corresponded to a decline in oral contraceptive pill use. Whether or not these other methods confer a protective effect against ovarian cancer in the general population is not clear. To our knowledge, there have been no such studies conducted among BRCA mutation carriers. Furthermore, the impact of these changes on the risk of developing ovarian cancer is not known. In this article, we will review the existing epidemiologic evidence regarding the role of contraceptives and the risk of ovarian cancer with a focus on women with a BRCA1 or BRCA2 mutation. We will discuss recent findings and gaps in the knowledge while extrapolating from studies conducted among women from the noncarrier population.

Systematic review and meta-analysis on the impact of the levonorgestrel-releasing intrauterine system in reducing risk of ovarian cancer

Background

Ovarian carcinoma (OC) is one of the most widespread tumors in the world and is characterized by low survival rates.

Objective

To determine whether the levonorgestrel‐releasing intrauterine system (LNG‐IUS) can prevent OC.

Search strategy

The literature until December 2020 were systematically reviewed according to the PRISMA Statement for Reporting Systematic Reviews (PROSPERO: CRD42019137957).

Selection criteria

Studies assessing the impact of LNG‐IUS on the risk of OC were included.

Data collection and analysis

Data were extracted independently by two authors to ensure accuracy and consistency.

Main results

A total of 34 323 records were obtained, of which three satisfied the inclusion criteria. In total, 1687 events of OC in a population of 20 461 311 person‐years were considered. Data pooling revealed that the use of LNG‐IUS did not confer a lower risk of OC relative to the never‐use of LNG‐IUS, with an estimated odds ratio of 0.66 (95% confidence interval 0.41–1.08; I² = 84%; P = 0.002).

Conclusion

The meta‐analysis did not demonstrate a preventive role of LNG‐IUS on OC. However, it was carried out on a few papers, and a definitive conclusion on the topic still cannot be drawn. Further studies are indicated in the future to define the impact of LNG‐IUS on OC.

The meta‐analysis carried out on three papers did not demonstrate a preventive role of the levonorgestrel‐releasing intrauterine device on ovarian cancer.

Impact of Combined Hormonal Contraceptive Use on Weight Loss: A Secondary Analysis of a Behavioral Weight-Loss Trial

OBJECTIVE

This study aimed to perform a preliminary investigation of the impact of combined hormonal contraceptive (CHC) use on weight loss during an 18-month behavioral weight-loss trial.

METHODS

Adults (n = 170; 18-55 years; BMI 27-42 kg/m2 ) received a weight-loss intervention that included a reduced-calorie diet, a progressive exercise prescription, and group-based behavioral support. Premenopausal women (n = 110) were classified as CHC users (CHC, n = 17) or non-CHC users (non-CHC, n = 93). Changes in weight were examined within groups using a linear mixed model, adjusted for age and randomized group assignment.

RESULTS

At 6 M, weight was reduced from baseline in both CHC (mean, -6.7 kg; 95% CI: -9.8 to -3.7 kg) and non-CHC (-9.1 kg; -9.1 to -6.4 kg). Between 6 and 18 M, CHC regained weight (4.9 kg; 0.9 to 8.9 kg), while weight remained relatively unchanged in non-CHC (-0.1 kg; -1.8 to 1.6 kg). At 18 M, weight was relatively unchanged from baseline in CHC (-1.8 kg; -7.3 to 3.6 kg) and was reduced from baseline in non-CHC (-7.9 kg; -10.2 to -5.5 kg).

CONCLUSIONS

In this secondary data analysis, CHC use was associated with weight regain after initial weight loss. Prospective studies are needed to further understand the extent to which CHC use influences weight loss and maintenance.

Is it possible to investigate menopausal age? A comparative cross-sectional study of five cohorts between 1968 and 2017 from the Population Study of Women in Gothenburg, Sweden

OBJECTIVE

The aim of this study was to examine if the previously found trend of increasing menopausal age is continuing, taking into consideration hormonal use and surgical menopause in both 38- and 50-year-old women of today.

METHODS

Cohort comparisons of five generations of population-based samples of 38- and 50-year-old women from the Prospective Population Study of Women in Gothenburg with start in 1968/1969, and with follow-ups in 1980/1981, 1992/1993, 2004/2005, and 2016/2017. Across the time periods newly recruited women as well as earlier participants were included. Use of hormonal contraceptives, estrogen plus progestogen therapy (EPT), and time for menopause was registered. Changes between different generations of 38- and 50-year-old women from 1968/1969 until today were studied. The overall sample size across the time periods was 1,873 individuals.

RESULTS

The prevalence of oral contraceptives in 38-year-old women was about 10% in 1968/1969, increasing from 16% in 2004/2005 to almost 22% in 2016/2017. From 2004/2005 the use of hormonal intrauterine contraceptive method (the Levonorgestrel-releasing intrauterine system [LNG-IUS]) increased from about 11% to 14% in 2016/2017. The same pattern was found in 50-year-old women using LNG-IUS, increasing from 6% to 15.5% between 2004/2005 and 2016/2017. The total hormonal use, including LNG-IUS, oral contraceptives, and EPT, was 28% in 50-year-old women in 2016/2017. The total proportion of hormone use in 50-year-old women increased over the years and together with surgical menopause it reached over 37% in the 2016/2017 survey.

CONCLUSIONS

This study has shown an increase in the hormonal use, in both 38- and 50-year-old women, making it difficult to determine when the actual menopause occurs. Thus, the previously found increasing secular trend in menopausal age will be more complicated to assess in female generations of today and tomorrow.

Practice Bulletin No. 186: Long-Acting Reversible Contraception: Implants and Intrauterine Devices

Intrauterine devices and contraceptive implants, also called long-acting reversible contraceptives (LARC), are the most effective reversible contraceptive methods. The major advantage of LARC compared with other reversible contraceptive methods is that they do not require ongoing effort on the part of the patient for long-term and effective use. In addition, after the device is removed, the return of fertility is rapid (1, 2). The purpose of this Practice Bulletin is to provide information for appropriate patient selection and evidence-based recommendations for LARC initiation and management. The management of clinical challenges associated with LARC use is beyond the scope of this document and is addressed in Committee Opinion No. 672, Clinical Challenges of Long-Acting Reversible Contraceptive Methods (3).

ESC expert statement on the effects on mood of the natural cycle and progestin-only contraceptives

Hormonal fluctuations during the natural cycle, as well as progestins used for hormonal contraception, can exert effects on mood especially in vulnerable women. Negative effects of levonorgestrel-releasing intrauterine contraception on mood are rare.

Levonorgestrel-Releasing Intrauterine System for the Treatment of Endometriosis: Biological and Clinical Evidence

Endometriosis-associated symptomatology can be safely and effectively treated with intrauterine-released progestin, which is associated with fewer adverse effects than other therapeutic options and may be used on a long-term basis. We have herein reviewed the current literature in relation to the biological and clinical rationale for the use of an intrauterine system releasing 20 μg/day of levonorgestrel for the treatment of pelvic pain symptoms associated with endometriosis. Levonorgestrel induces endometrial glandular atrophy and decidual transformation of the stroma, reduces endometrial cell proliferation and increases apoptotic activity. After the first year of use, a 70–90% reduction in menstrual blood loss is observed. The levonorgestrel-releasing intrauterine system has proven effective in relieving pelvic pain symptoms caused by peritoneal and rectovaginal endometriosis and in reducing the risk of recurrence of dysmenorrhea after conservative surgery. Thus, the intrauterine delivery of a potent progestin may constitute an innovative, effective, safe and convenient alternative for local delivery of a potent progestin in the long-term therapy of symptomatic endometriosis.

Safety and efficacy in parous women of a 52-mg levonorgestrel-medicated intrauterine device: a 7-year randomized comparative study with the TCu380A

OBJECTIVES

To compare rates of unintended pregnancy, method continuation and reasons for removal among women using the 52-mg levonorgestrel (daily release 20 microg) intrauterine device (LNG-IUD) or the copper T 380 A IUD (TCu380A).

STUDY DESIGN

This was an open-label 7-year randomized controlled trial in 20 centres, 11 of which in China. Data on 1884 women with interval insertion of the LNG-IUD and 1871 of the TCu380A were analysed using life tables with 30-day intervals and Cox proportional hazards models.

RESULTS

The cumulative 7-year pregnancy rate of the LNG-IUD was 0.5 (standard error 0.2) per 100, significantly lower than 2.5 (0.4) per 100 of the TCu380A, cumulative method discontinuation rates at 7 years were 70.6 (1.2) and 40.8 (1.3) per 100, respectively. Dominant reasons for discontinuing the LNG-IUD were amenorrhea (26.1 [1.3] per 100) and reduced bleeding (12.5 [1.1] per 100), particularly in Chinese women and, for the TCu380A, increased bleeding (9.9 [0.9] per 100), especially among non-Chinese women. Removal rates for pain were similar for the two intrauterine devices (IUDs). Cumulative rates of removal for symptoms compatible with hormonal side effects were 5.7 (0.7) and 0.4 (0.2) per 100 for the LNG-IUD and TCu380A, respectively, and cumulative losses to follow-up at 7 years were 26.0 (1.4) and 36.9 (1.3) per 100, respectively.

CONCLUSION

The LNG-IUD and the TCu380A have very high contraceptive efficacy, with the LNG-IUD significantly higher than the TCu380A. Overall rates of IUD removals were higher among LNG-IUD users than TCu380A users. Removals for amenorrhea appeared culturally associated.

IMPLICATIONS

The 52-mg LNG-IUD and the TCu380A have very high contraceptive efficacy through 7 years. As an IUD, the unique side effects of the LNG-IUD are reduced bleeding, amenorrhea and symptoms compatible with hormonal contraceptives.

Canadian Contraception Consensus (Part 3 of 4): Chapter 7--Intrauterine Contraception

OBJECTIVE

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.

OUTCOMES

Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). CHAPTER 7: INTRAUTERINE CONTRACEPTION:

SUMMARY STATEMENTS

1. Intrauterine contraceptives are as effective as permanent contraception methods. (II-2) 2. The use of levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg by patients taking tamoxifen is not associated with recurrence of breast cancer. (I) 3. Intrauterine contraceptives have a number of noncontraceptive benefits. The levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg significantly decreases menstrual blood loss (I) and dysmenorrhea. (II-2) Both the copper intrauterine device and the LNG-IUS significantly decrease the risk of endometrial cancer. (II-2) 4. The risk of uterine perforation decreases with inserter experience but is higher in postpartum and breastfeeding women. (II-2) 5. The risk of pelvic inflammatory disease (PID) is increased slightly in the first month after intrauterine contraceptive (IUC) insertion, but the absolute risk is low. Exposure to sexually transmitted infections and not the IUC itself is responsible for PID occurring after the first month of use. (II-2) 6. Nulliparity is not associated with an increased risk of intrauterine contraceptive expulsion. (II-2) 7. Ectopic pregnancy with an intrauterine contraceptive (IUC) is rare, but when a pregnancy occurs with an IUC in situ, it is an ectopic pregnancy in 15% to 50% of the cases. (II-2) 8. In women who conceive with an intrauterine contraceptive (IUC) in place, early IUC removal improves outcomes but does not entirely eliminate risks. (II-2) 9. Intrauterine contraceptives do not increase the risk of infertility. (II-2) 10. Immediate insertion of an intrauterine contraceptive (10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher continuation rate compared with insertion at 6 weeks postpartum. (I) 11. Immediate insertion of an intrauterine contraceptive (IUC; 10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher risk of expulsion. (I) The benefit of inserting an IUC immediately postpartum or post-Caesarean section outweighs the disadvantages of increased risk of perforation and expulsion. (II-C) 12. Insertion of an intrauterine contraceptive in breastfeeding women is associated with a higher risk of uterine perforation in the first postpartum year. (II-2) 13. Immediate insertion of an intrauterine contraceptive (IUC) post-abortion significantly reduces the risk of repeat abortion (II-2) and increases IUC continuation rates at 6 months. (I) 14. Antibiotic prophylaxis for intrauterine contraceptive insertion does not significantly reduce postinsertion pelvic infection. (I) RECOMMENDATIONS: 1. Health care professionals should be careful not to restrict access to intrauterine contraceptives (IUC) owing to theoretical or unproven risks. (III-A) Health care professionals should offer IUCs as a first-line method of contraception to both nulliparous and multiparous women. (II-2A) 2. In women seeking intrauterine contraception (IUC) and presenting with heavy menstrual bleeding and/or dysmenorrhea, health care professionals should consider the use of the levonorgestrel intrauterine system 52 mg over other IUCs. (I-A) 3. Patients with breast cancer taking tamoxifen may consider a levonorgestrel-releasing intrauterine system 52 mg after consultation with their oncologist. (I-A) 4. Women requesting a levonorgestrel-releasing intrauterine system or a copper-intrauterine device should be counseled regarding changes in bleeding patterns, sexually transmitted infection risk, and duration of use. (III-A) 5. A health care professional should be reasonably certain that the woman is not pregnant prior to inserting an intrauterine contraceptive at any time during the menstrual cycle. (III-A) 6. Health care providers should consider inserting an intrauterine contraceptive immediately after an induced abortion rather than waiting for an interval insertion. (I-B) 7. In women who conceive with an intrauterine contraceptive (IUC) in place, the diagnosis of ectopic pregnancy should be excluded as arly as possible. (II-2A) Once an ectopic pregnancy has been excluded, the IUC should be removed without an invasive procedure. The IUC may be removed at the time of a surgical termination. (II-2B) 8. In the case of pelvic inflammatory disease, it is not necessary to remove the intrauterine contraceptive unless there is no clinical improvement after 48 to 72 hours of appropriate antibiotic treatment. (II-2B) 9. Routine antibiotic prophylaxis for intrauterine contraceptive (IUC) insertion is not indicated. (I-B) Health care providers should perform sexually transmitted infection (STI) testing in women at high risk of STI at the time of IUC insertion. If the test is positive for chlamydia and/or gonorrhea, the woman should be appropriately treated postinsertion and the IUC can remain in situ. (II-2B) 10. Unscheduled bleeding in intrauterine contraception users, when persistent or associated with pelvic pain, should be investigated to rule out infection, pregnancy, gynecological pathology, expulsion or malposition. (III-A)

Intrauterine devices and endometrial cancer risk: a pooled analysis of the Epidemiology of Endometrial Cancer Consortium

Intrauterine devices (IUDs), long-acting and reversible contraceptives, induce a number of immunological and biochemical changes in the uterine environment that could affect endometrial cancer (EC) risk. We addressed this relationship through a pooled analysis of data collected in the Epidemiology of Endometrial Cancer Consortium. We combined individual-level data from 4 cohort and 14 case-control studies, in total 8,801 EC cases and 15,357 controls. Using multivariable logistic regression, we estimated pooled odds ratios (pooled-ORs) and 95% confidence intervals (CIs) for EC risk associated with ever use, type of device, ages at first and last use, duration of use and time since last use, stratified by study and adjusted for confounders. Ever use of IUDs was inversely related to EC risk (pooled-OR = 0.81, 95% CI = 0.74-0.90). Compared with never use, reduced risk of EC was observed for inert IUDs (pooled-OR = 0.69, 95% CI = 0.58-0.82), older age at first use (≥ 35 years pooled-OR = 0.53, 95% CI = 0.43-0.67), older age at last use (≥ 45 years pooled-OR = 0.60, 95% CI = 0.50-0.72), longer duration of use (≥ 10 years pooled-OR = 0.61, 95% CI = 0.52-0.71) and recent use (within 1 year of study entry pooled-OR = 0.39, 95% CI = 0.30-0.49). Future studies are needed to assess the respective roles of detection biases and biologic effects related to foreign body responses in the endometrium, heavier bleeding (and increased clearance of carcinogenic cells) and localized hormonal changes.

The effect of hysterectomy or levonorgestrel-releasing intrauterine system on premenstrual symptoms in women treated for menorrhagia: secondary analysis of a randomized controlled trial

OBJECTIVE

To study the effect of hysterectomy or levonorgestrel-releasing intrauterine system (LNG-IUS) on premenstrual symptoms in women treated for menorrhagia.

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Five university hospitals in Finland.

SAMPLE

A cohort of 236 women, aged 35-49 years (mean 43 years) referred for menorrhagia between 1994 and 1997. Women were not diagnosed with premenstrual syndrome.

METHODS

Women were randomized to treatment by hysterectomy (n=117) or LNG-IUS (n=119). Analyses were performed using the intention-to-treat and actual treatment principles. Women using estrogen therapy and women who underwent bilateral salpingo-oophorectomy were excluded from the analyses.

MAIN OUTCOME MEASURES

The occurrence of premenstrual symptoms evaluated by questionnaires at baseline and at follow-up visits six and 12 months after the treatment and five years after the randomization.

RESULTS

Premenstrual symptoms decreased significantly in both groups by six months (p≤0.028) without significant differences between the groups, except that in the LNG-IUS group the decrease of breast tenderness was seen first by 12 months (p=0.048). Even though 42% of the women assigned to treatment with LNG-IUS were hysterectomized during the follow-up period, the results of intention-to-treat and actual treatment analyses were comparable.

CONCLUSIONS

Both hysterectomy and LNG-IUS seem to alleviate premenstrual symptoms of women treated for menorrhagia, while the effect of these treatments on premenstrual syndrome remains unsettled.

The benefits and risks of using a levonorgestrel-releasing intrauterine system for contraception

The contraceptive profile of the levonorgestrel-releasing intrauterine system (LNG-IUS; Mirena®) is well established, with efficacy similar to that achieved with sterilization and rapid return to fertility after discontinuation of use. The LNG-IUS is typically associated with transient menstrual disturbance during the first few months of use, but this usually settles with continued use, with a concomitant decrease in menstrual blood loss. Overall, the safety profile of the LNG-IUS has been well established across a wide population of women, and the available data do not suggest that the LNG-IUS adversely affects bone health or increase the risk of adverse cardiovascular events or breast and uterine cancers. This article reviews the literature to provide updated information on the risks and benefits associated with the LNG-IUS, particularly focusing on its use in contraception.

Intrauterine devices in early pregnancy: findings on ultrasound and clinical outcomes

OBJECTIVE

The objective of this study was to describe ultrasound findings, clinical symptoms, and outcomes of first-trimester pregnancies with intrauterine devices (IUDs).

STUDY DESIGN

This was a retrospective review of 42 women with history of IUD placement and positive serum human chorionic gonadotropin in the first trimester.

RESULTS

There were 31 intrauterine pregnancies (IUPs), 3 ectopic pregnancies, and 8 pregnancies of unknown location. Of 36 IUDs visualized, 15 were normally positioned and 21 malpositioned. Of 31 IUPs, 8 IUDs were within the endometrium, 17 were malpositioned, and 6 were not seen. Indications included bleeding (14 of 31), pain (12 of 31), and missing strings (5 of 31); 11 had no symptoms. Of 26 IUPs with known pregnancy outcomes, 20 were term deliveries and 6 had failed pregnancies of 20 weeks or less.

CONCLUSION

More than half of IUDs identified in the first trimester were malpositioned. IUP was 3 times as likely with a malpositioned or missing IUD. Three quarters of the IUPs with known outcomes had term deliveries. Symptoms were not predictive of IUD malposition.

Fertility and endocrine effects of intra-abdominally misplaced intrauterine system for more than 2 years: a case report and review of the literature

This case report shows with documented evidence that a misplaced Mirena intrauterine system in the abdominal cavity had an endocrine and contraceptive effect causing amenorrhea and infertility for 2 years and 5 months. This had been proved by a negative hysteroscopy in November 2004 and an abdominal X-ray showing the device which was done in May 2007. Intraabdominal misplacement of the LNG-IUS has been reported in the literature with variable consequences and effects. In this case report, we reviewed the literature and assessed the fertility and endocrine consequences.

Levonorgestrel-releasing intrauterine system--the discontinuing story

Levonorgestrel-releasing Intrauterine System (LNG-IUS) is licensed for use as a contraceptive, for the treatment of heavy menstrual bleeding and during estrogen replacement therapy. It is publicized as a local source of progestogen with minimal systemic adverse effects. However, there is overwhelming evidence of elevated serum and tissue levels of levonorgestrel, and high discontinuation and dissatisfaction rates amongst users. The guidelines of The National Institute for Health and Clinical Excellence (NICE), United Kingdom recommended that the healthcare professionals should be aware that upto 60% of women discontinue using LNG-IUS within 5 years because of unscheduled bleeding, pain, and/or systemic progestogenic adverse effects. This article highlights these issues to healthcare professionals to ensure that the rates of adverse effects are not underestimated, and full information are made available to women to enable them making an informed choice.

Effects of the levonorgestrel-releasing intrauterine system on cell proliferation, Fas expression and steroid receptors in endometriosis lesions and normal endometrium

BACKGROUND

The objectives of this study were: (i) to evaluate the effects of the levonorgestrel-releasing intrauterine system (LNG-IUS) on both proliferation and apoptosis markers and hormone receptors of the eutopic and ectopic endometrium of women experiencing pain related to endometriosis and (ii) to compare the results with those obtained with GnRH agonist (GnRHa) injections.

METHODS

Pre- and post-treatment endometrium and endometriosis specimens were obtained from 22 women experiencing pain related to endometriosis who were treated with LNG-IUS (n = 11) or GnRHa (n = 11) for 6 months. Changes in the expression of proliferating cell nuclear antigen, Fas, progesterone receptor (PRA) and estrogen receptor alpha (ER-alpha) were analyzed by immunohistochemistry.

RESULTS

The cell proliferation index was significantly reduced in the epithelium and stroma of both the eutopic and the ectopic endometrium after treatment with the LNG-IUS and GnRHa. Only LNG-IUS users showed an increased H-score for Fas in the epithelium of the eutopic and ectopic endometrium (P < 0.05). Expression of ER-alpha and PRA by the glandular epithelium was lower in the eutopic endometrium after both treatments, but this reduction was noted in the ectopic endometrium only after LNG-IUS treatments (P < 0.05). No difference was detected between groups for any of the markers.

CONCLUSIONS

LNG-IUS reduced both cell proliferation and the expression of PRA and ER-alpha and increased Fas expression in the eutopic and ectopic endometrium of patients with endometriosis. Some of these actions were not observed with GnRHa.

Serum levonorgestrel levels and endometrial thickness during extended use of the levonorgestrel-releasing intrauterine system

BACKGROUND

The levonorgestrel-releasing intrauterine system (LNG-IUS) is a contraceptive method approved for five years of use. However, there is some evidence that its life span may be longer. The aim of the study was to evaluate serum levonorgestrel (LNG) and estradiol (E(2)) levels and endometrial thickness every 6 months from 7 to 8 1/2 years after insertion.

STUDY DESIGN

At the end of the approved 5-year life span, no replacement devices were available; therefore, 86 women were allowed to retain the same device for a further 2 years. At the 7-year follow-up visit, the women who consented were again allowed to retain the same device for a further 18 months and were followed-up at six-monthly intervals. At each visit, vaginal sonography was performed to measure endometrial thickness, and a blood sample was taken to measure LNG and E(2).

RESULTS

Eighty-four months after insertion, 67 women aged 34.3+/-0.8 years (mean+/-SEM) (range, 25-49 years) returned for follow-up. Mean+/-SEM LNG levels decreased from an initial 253+/-27 pg/mL (range, 86-760) during the first 2 months following insertion to 137+/-12 (range, 23-393) at 84 months and 119+/-9 pg/mL (range, 110-129) at 102 months of use (+/-SEM). At 84 months of use, mean+/-SEM endometrial thickness was 2.8+/-0.1 mm, increasing to 3.8+/-0.5 mm at 102 months of use. The incidence of amenorrhea decreased from 41.8% at 84 months to 31.5% at 102 months of use. No correlation was found between LNG levels and bleeding patterns; however, a weak correlation was found between high body mass index (kg/m(2)), high weight, and low serum LNG levels. E(2) levels were similar to those of the follicular phase of the menstrual cycle of regularly menstruating women.

CONCLUSIONS

During extended use of the LNG-IUS, serum LNG levels were nearly half those found in the first 2 months of use (Wilcoxon signed rank test); serum E(2) levels were normal. Despite the very thin endometrium, menstrual bleeding was reinstated in many cases. At the end of its 5-year life span, there is a window for changing the LNG-IUS, and physicians and users should not be concerned about delaying replacement of the device for a short time beyond the approved life span; however, maintaining the same device long after its approved life span cannot be recommended.

Recent advances in hormonal contraception

PURPOSE OF REVIEW

The rapid increase in the world population makes it mandatory to develop new contraceptive methods. Disseminating reversible inexpensive and practical hormonal methods to developing countries is a target of many international agencies and funds.

RECENT FINDINGS

The safety of combined oral contraceptives is the main issue. The main guideline is to find women at risk before prescribing combined oral contraceptives. Lowering the estrogen dose should be attempted. New progestins are emerging, but their safety can be assessed only retrospectively. There is an increasing trend to extend the cycles in order to have fewer bleeding days. Progestin-only contraception seems safer than estrogen-progestin combinations in relation to thromboembolic events. A new progestin-only pill and the levonorgestrel intrauterine system have a good acceptability and high continuation rate. New administration methods are being developed and the possible role of mifepristone has been investigated.

SUMMARY

There are more contraceptive choices available than ever before. To educate healthcare providers as to the methods available and to inform and educate consumers are cornerstones for successful contraception.

Long-acting contraceptives in adolescents

PURPOSE OF REVIEW

To help clinicians guide adolescent patients to sound choices regarding long-acting contraceptives. The safety, side effects and non-contraceptive benefits of injectable, implantable and intrauterine contraception are detailed.

RECENT FINDINGS

The use of depot medroxyprogesterone acetate contraceptive injections has been associated with declines in teenage pregnancies in the United States. Although the US Food and Drug Administration has placed a black box warning concerning skeletal health and depot medroxyprogesterone acetate, data in adolescents confirm that declines in bone mineral density with depot medroxyprogesterone acetate are fully reversible. Concerns regarding skeletal health should not restrict the initiation or continuation of depot medroxyprogesterone acetate in adolescents. A highly effective, convenient, and easy to insert/remove single rod progestin-only contraceptive implant (Implanon) is now available in the United States. Although not widely used in adolescents, intrauterine devices offer selected adolescents convenient, highly effective, safe birth control. Use of the progestin-releasing intrauterine device (Mirena) is also associated with important non-contraceptive benefits.

SUMMARY

The efficacy and convenience associated with long-acting contraceptives make them indispensable for adolescent patients. This review will help clinicians guide teenage patients towards sound contraceptive choices and the successful long-term use of injectable, implantable and intrauterine methods of birth control.

Cost-utility of levonorgestrel intrauterine system compared with hysterectomy and second generation endometrial ablative techniques in managing patients with menorrhagia in the UK

OBJECTIVE

To estimate the cost-utility of levonorgestrel intrauterine system (LNG-IUS; Mirena) compared to second generation endometrial ablative techniques [i.e. microwave endometrial ablation (MEA) and thermal balloon endometrial ablation (TBEA)) and hysterectomy in the UK.

METHODS

Clinical and utility data from a 5-year randomised controlled trial comparing LNG-IUS with hysterectomy were combined with further data from published studies to construct a state-transition (Markov) model. The model depicted the movement of patients between health states over 5 years following treatment for menorrhagia. The model was used to estimate the cost-utility of LNG-IUS followed by ablation (L-A); LNG-IUS followed by hysterectomy (L-H); immediate ablation (MEA or TBEA) and immediate hysterectomy in the UK at 2004/2005 prices, from the perspective of the UK's National Health Service (NHS).

MAIN OUTCOME MEASURES AND RESULTS

The expected 5-yearly cost of treating menorrhagia with L-A, L-H, TBEA, MEA and hysterectomy was estimated to be 828 pounds sterling, 1355 pounds sterling, 1679 pounds sterling, 1812 pounds sterling and 2983 pounds sterling per patient respectively and the expected level of health gain to be 4.14, 4.12, 4.13, 4.13 and 4.01 QALYs per patient respectively. LNG-IUS followed by ablation dominated all the alternative treatments. Hysterectomy was dominated by the alternative treatments. Sensitivity analysis found the model to be sensitive to the quality of life data used.

CONCLUSION

Within the model's limitations, LNGIUS followed by ablation appears to offer the NHS a cost-effective treatment for menorrhagia, when compared to immediate surgery, affording the NHS a less expensive treatment modality without detrimental effects on resulting health gain.

The promise and reality of the intrauterine route for hormone delivery for prevention and therapy of gynecological disease

CONTEXT

Progestins delivered by a variety of routes have been demonstrated, in addition to their high contraceptive effect, to have substantial benefits in the treatment of various gynecological disorders, and the intrauterine route has particular efficacy in treating endometrial and myometrial disorders. It should be possible to extend this to prevention of disease.

THERAPY OF GYNECOLOGICAL DISEASE

Those conditions for which there is most evidence of therapeutic benefit from intrauterine release of progestins include heavy menstrual bleeding (due to most causes), endometrial hyperplasia, endometriosis and adenomyosis.

PREVENTION OF GYNECOLOGICAL DISEASE

Reasonable evidence exists to support the findings that intrauterine levonorgestrel helps to prevent the development of uterine fibroids, endometriosis, endometrial hyperplasia, acute episodes of pelvic infection and a wide range of menstrual symptoms. There is also promise of prevention of endometrial carcinoma, endometrial polyps, infertility and perhaps adenomyosis.

CONCLUSIONS

There is a need for specific studies to further explore the prevention of these gynecological conditions which can cause major health disturbances and community distress.

Contraception today

Modern contraceptive methods represent more than a technical advance: they are the instrument of a true social revolution-the "first reproductive revolution" in the history of humanity, an achievement of the second part of the 20th century, when modern, effective methods became available. Today a great diversity of techniques have been made available and-thanks to them, fertility rates have decreased from 5.1 in 1950 to 3.7 in 1990. As a consequence, the growth of human population that had more than tripled, from 1.8 to more than 6 billion in just one century, is today being brought under control. At the turn of the millennium, all over the world, more than 600 million married women are using contraception, with nearly 500 million in developing countries. Among married women, contraceptive use rose in all but two developing countries surveyed more than once since 1990. Among unmarried, sexually active women, it grew in 21 of 25 countries recently surveyed. Hormonal contraception, the best known method, first made available as a daily pill, can today be administered through seven different routes: intramuscularly, intranasally, intrauterus, intravaginally, orally, subcutaneously, and transdermally. In the field of oral contraception, new strategies include further dose reduction, the synthesis of new active molecules, and new administration schedules. A new minipill (progestin-only preparation) containing desogestrel has been recently marketed in a number of countries and is capable of consistently inhibiting ovulation in most women. New contraceptive rings to be inserted in the vagina offer a novel approach by providing a sustained release of steroids and low failure rates. The transdermal route for delivering contraceptive steroids is now established via a contraceptive patch, a spray, or a gel. The intramuscular route has also seen new products with the marketing of improved monthly injectable preparations containing an estrogen and a progestin. After the first device capable of delivering progesterone directly into the uterus was withdrawn, a new system releasing locally 20 microg evonorgestrel is today marketed in a majority of countries with excellent contraceptive and therapeutic performance. Finally, several subcutaneously implanted systems have been developed: contraceptive "rods," where the polymeric matrix is mixed with the steroid and "capsules" made of a hollow polymer tube filled with free steroid crystals. New advances have also been made in nonhormonal intrauterine contraception with the development of "frameless" devices. The HIV/AIDS pandemic forced policy makers to look for ways to protect young people from sexually transmitted diseases as well as from untimely pregnancies. This led to the development of the so-called dual protection method, involving the use of a physical barrier (condom) as well as that of a second, highly effective contraceptive method. More complex is the situation with antifertility vaccines, still at a preliminary stage of development and unlikely to be in widespread use for years to come. Last, but not least, work is in progress to provide effective emergency contraception after an unprotected intercourse. Very promising in this area is the use of selective progesterone receptor modulators (antiprogestins).

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.

Medicated intrauterine systems for treatment of endometriosis-associated pain

Medicated intrauterine systems (IUSs) are intrauterine devices that act by means of the local release of a medication. The levonorgestrel (LNG)-IUS is a T-shaped device that releases the progestogen LNG directly into the uterine cavity. The LNG-IUS can be used with noncontraceptive, therapeutic intent for idiopathic menorrhagia, hormonal replacement therapy in conjunction with oral or transdermal estrogens, and endometriosis or adenomyosis-associated pain. For this last indication, however, the use of the LNG-IUS is still under clinical investigation.

The role of the levonorgestrel-releasing intrauterine device in the management of symptomatic endometriosis

PURPOSE OF REVIEW

The aim of this article is to evaluate the biological rationale for the use of an intrauterine device releasing 20 mug/day of levonorgestrel in women with endometriosis, and to assess its efficacy in relieving pelvic pain symptoms.

RECENT FINDINGS

Levonorgestrel induces endometrial glandular atrophy and extensive decidual transformation of the stroma, downregulates endometrial cell proliferation, increases apoptotic activity, and has antiinflammatory and immunomodulatory effects. Up to 85% of patients wearing the device have anovulatory cycles during the first 3 months of use, but the proportion falls to below 35% by 12 months. After the first year of use, a 70-90% reduction in monthly blood loss is observed; few women report intermenstrual bleeding and about 20-30% amenorrhea. This is advantageous in patients experiencing dysmenorrhea. Although it is maintained that the hormonal activity of the levonorgestrel intrauterine device is local, a systemic effect secondary to uterine absorption of levonorgestrel is probable. The levonorgestrel intrauterine device has proven effective in relieving pelvic pain symptoms caused by peritoneal and rectovaginal endometriosis and in reducing the risk of recurrence of dysmenorrhea after conservative surgery.

SUMMARY

Intrauterine administration of levonorgestrel with direct distribution to pelvic tissues would imply a local concentration greater than plasma levels. This could result in a superior effectiveness with limited adverse effects and increased patient compliance during long-term treatment. Further trials are needed, however, to verify whether the good results observed are maintained during an entire 5-year period, to confirm the efficacy on dyspareunia and dyschezia, and to compare the effects of the levonorgestrel intrauterine device with those of other treatment options.

Randomized controlled trial of the effect of hysterectomy or LNG-IUS use on bone mineral density: a five-year follow-up

A 72-year-old female with scirrhous-type advanced gastric cancer was treated with TS-1/CDDP as neoadjuvant chemotherapy. TS-1 (80 mg/m(2)/day) was orally administered for 3 weeks and CDDP (60 mg/m(2)) was administered by intravenous drip on day 8. Partial response (PR) was obtained after the first course, and total gastrectomy was performed. The histological diagnosis revealed complete disappearance of cancer cells in the stomach and a few regional lymph node metastases (3/67). The patient has now been in good health without a recurrence for 1 year and 9 months after surgery.

Endometrial histology, microvascular density and caliber, and matrix metalloproteinase-3 in users of the Nestorone®-releasing contraceptive implant with and without endometrial breakthrough bleeding

OBJECTIVE

This descriptive study evaluated endometrial histology, microvascular density and caliber, and quantification of matrix metalloproteinase (MMP-3) expression in long-term users of the Nestorone (NES)-releasing implant who presented or not endometrial breakthrough bleeding (BTB).

METHODS

Endometrial biopsies were obtained from 32 healthy women with unpredictable BTB. The quantitative analysis was performed only in 20 samples.

RESULTS

The mean duration of use of the implant among the 14 women with BTB was 19.6+/-1.0 months, and the other six women had used the implant for 17.7+/-2.3 months (mean+/-S.E.M.). Histological analysis of the endometrial tissue showed a predominance of progestogenic pattern followed by atrophic and proliferative endometrium in both groups. Mucosal breakdown and glandular pseudostratification were observed in half of the cases. Endometrial vascular density was 73.1+/-10.0 and 57.5+/-24.1 vessels/mm(2), and maximum vessel diameter was 923.3+/-86.0 and 1038.0+/-404 microm (mean+/-S.E.M.) in the group with and without BTB, respectively, without significance, and the rate of cells expressing MMP-3x1000 counted stromal cells was 155.8+/-24.8 and 127.0+/-19.0 (mean+/-S.E.M.) in both groups, respectively, without significance.

CONCLUSIONS

This study provides information about some endometrial aspects of women using NES in contraceptive implants. In addition, the endometrium was similar during long-term use of NES-releasing contraceptive implants in women with and without endometrial bleeding.

Tamoxifen treatment after adjuvant chemotherapy has opposite effects on bone mineral density in premenopausal patients depending on menstrual status

PURPOSE

Adjuvant chemotherapy followed by tamoxifen is a standard treatment option for women with intermediate or high-risk hormone receptor-positive breast cancer. Premenopausal women treated with chemotherapy often develop early menopause and thus, enter a period of accelerated bone loss. We conducted a prospective study of the effect of sequential adjuvant therapy with chemotherapy followed by tamoxifen on bone mineral density (BMD) in premenopausal patients.

PATIENTS AND METHODS

One hundred eleven premenopausal women with early breast cancer were treated with adjuvant chemotherapy. Patients with hormone receptor-positive tumors went on to tamoxifen 6 months after the beginning of the chemotherapy (tamoxifen group), while those with hormone receptor-negative tumors received no further therapy (control group). The effect of tamoxifen and menstrual status on BMD was studied.

RESULTS

Tamoxifen treatment and menopausal status correlated significantly with the changes in lumbar spine BMD (P < .0001). A significant bone loss was noted in those tamoxifen-treated patients who continued to menstruate after chemotherapy. At 3 years of follow-up, menstruating patients on tamoxifen had lost -4.6% of their baseline BMD values, while a modest gain of +0.6% was noted in the control group. In contrast, bone loss was reduced among tamoxifen-treated women as compared with controls in patients who developed chemotherapy-induced early menopause. In amenorrheic patients, the lumbar spine BMD values decreased -6.8% in tamoxifen users and -9.5% in the controls, respectively.

CONCLUSION

We conclude that tamoxifen usage was associated with bone loss in patients who continued to menstruate after adjuvant chemotherapy. On the contrary, tamoxifen decreased bone loss in those women who developed chemotherapy-induced amenorrhea.

A cross-sectional study of the forearm bone density of long-term users of levonorgestrel-releasing intrauterine system

BACKGROUND

There are concerns about the effect of hormonal contraceptives on bone mineral density (BMD), but there is currently no information available on the effect of the levonorgestrel-releasing intrauterine system (LNG-IUS) on BMD. The objective of this study was to compare the BMD of LNG-IUS users with that of controls using the TCu380A intrauterine device (IUD).

MATERIALS AND METHODS

A cross-sectional study paired 53 women, aged 25-51 years, who had been using the LNG-IUS for 7 years, with 53 IUD users, according to age (+/-1 year) and body mass index (BMI; kg/m2) (+/-1). BMD was evaluated at the midshaft of the ulna and the distal radius of the nondominant forearm using double X-ray absorptiometry.

RESULTS

Mean age of women was 34 years. BMI was slightly over 25 in both groups. Estradiol was normal. Mean BMD was 0.469 +/- 0.008 and 0.467 +/- 0.009 and 0.409 +/- 0.009 and 0.411 +/- 0.009 at the midshaft of the ulna and distal radius in LNG-IUS and IUD users, respectively, without significant differences.

CONCLUSIONS

Women aged 25-51 years, using the LNG-IUS for 7 years, had a mean BMD similar to that of the control group of TCu380A IUD users.

Contraceptive and Therapeutic Effects of the Levonorgestrel Intrauterine System: An Overview

The levonorgestrel intrauterine system (LNG IUS), a steroid-releasing intrauterine system, is a T-shaped device that releases levonorgestrel directly into the uterine cavity at an initial rate of 20 mug per day. The contraceptive and therapeutic benefits of the LNG IUS stem primarily from its local effects. The local hormone delivery causes high levonorgestrel levels in the endometrial tissue but low levels in the systemic circulation. This leads to strong endometrial suppression and, in many cases, a dramatic reduction in menstrual blood loss. The high contraceptive efficacy is well documented through extensive international clinical research. This review article provides an overview of the LNG IUS and addresses the following topics: mechanisms of action, contraceptive efficacy, changes in bleeding patterns, principal safety issues, potential noncontraceptive benefits, and implications for women's reproductive health.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to explain that the levonorgestrel intrauterine system (LNG IUS) has contraceptive and therapeutic benefits, identify the main site of action as the endometrium, and to recall that the safety of the system has been validated over time.

Levonorgestrel hormone releasing intrauterine system (Mirena) as a contraceptive in egg donors: case report

We report the safe use of levonorgestrel hormone releasing intra uterine system (Mirena) as a contraceptive in egg donors during a treatment cycle. In the first case report, a 29-year-old egg donor using the Mirena coil for contraception and two egg recipients, aged 41 years and 32 years respectively underwent standard IVF treatment, oocyte retrieval in the egg donor and in vitro fertilization followed by embryo transfer in the recipient. The outcome of IVF cycle using donor eggs was satisfactory with successful pregnancy in the egg recipient. The second case involved a 34-year-old egg donor using the Mirena coil and a 44-year-old recipient. Our findings suggest that egg donors can safely use the (Mirena) as a contraceptive device during treatment, without compromising follicular development and oocyte quality.

Expression of vascular endothelial growth factors and their receptors in human endometrium from women experiencing abnormal bleeding patterns after prolonged use of a levonorgestrel-releasing intrauterine system

BACKGROUND

Menstrual bleeding disturbances are a common initial complaint among users of the levonorgestrel-releasing intrauterine system (LNG-IUS). In this study, women who experienced bleeding disturbances recurring after a previous period of problem-free use and who therefore wanted removal of their LNG-IUD were investigated. Vascular endothelial growth factors (VEGFs) and their receptors are thought to be involved in normal endometrial angiogenesis. The aim of the study was to elucidate the possible association of these VEGF and receptors with bleeding disturbances among users of LNG-IUS.

METHODS

Endometrial biopsies were obtained from users of the LNG-IUS who complained of bleeding disturbances (n = 17) and from women without such problems (n = 14). The endometrial expression of these VEGFs and their receptors was analysed using immunohistochemistry.

RESULTS

Endometrial endothelial cells from LNG-IUS users with menstrual bleeding disturbances exhibited significantly higher immunoreactivity for VEGFR-1 and VEGFR-3 than those from women without bleeding disturbances. Stromal cells showed significantly lower immunoreactivity for VEGF-A in samples from LNG-IUS users with bleeding disturbances than in those without.

CONCLUSION

Changes in the expression of these angiogenic growth factors and their receptors in LNG-IUS-exposed endometrium might be involved in the formation of fragile and dysfunctional blood vessels that subsequently give rise to bleeding disturbances.

Role of progestins in contraception

Progestins have been used for contraception for more than 30 years. The main goal was to develop a contraceptive method devoid of the metabolic or clinical side-effects associated with the use of estrogens. The development of new contraceptive methods and formulations is time-consuming and requires devotion, belief, and also strong economical basis. As a result of this endeavor new methods have been developed: oral progestins, implants, injectables, intrauterine hormonal systems, and vaginal rings. Progestin-only contraceptives may be preferable in some situations, which have absolute or relative contraindications to estrogen, side-effects to estrogen containing hormonal contraception, lactation, and comfort and feasibility of formulations for long-term use. At present, emergency contraception is also performed with progestin.