Levonorgestrel-releasing (20 microgram/day) intrauterine systems (Mirena) compared with other methods of reversible contraceptives

Antiretroviral (ARV) Properties Dictate Long-Acting Release and Tissue Partitioning Behaviors in Multidrug Subcutaneous Implants

Subcutaneous implants can provide patients with long-acting, compliance-independent drug dosing. For this reason, subcutaneous implants have shown emerging interest in human immunodeficiency virus (HIV) prevention. However, any successful long-acting HIV-prevention device will require multidrug dosing, which poses a challenge for formulation considering the physicochemically diverse selection of antiretroviral (ARV) candidates. As a method that has shown the capacity of efficient multidrug delivery, we assessed electrospun fiber implants composed of three synergistically potent ARVs and a biodegradable polymer selected by in vitro release studies. In mice, subcutaneous electrospun fiber implants exhibit burst release of the more hydrophilic drugs maraviroc (MVC) and raltegravir (RAL), which could be reduced via simple prewash treatments of the implants. Over an extended 120 day time frame, fiber implants show drug-specific differences in release time frames and magnitudes in blood serum. However, end-point drug tissue concentrations show that the most hydrophobic drug etravirine (ETR) remains in high concentrations within the implant and in local skin tissue biopsies. Furthermore, ETR is found to be capable of significant partitioning into lymph nodes, the lower female reproductive tract, and the rectum. Topologically smooth film implants also exhibit the same drug-dependent trends. Therefore, we illustrate that drug release and drug tissue partitioning are largely dictated by drug properties. Further, we find that the properties of ETR enable significant drug quantities within the tissues most relevant to HIV protection. Evidence from this work emphasizes the need for a greater focus on drug properties and prodrug strategies to enable relevant, extended, and targeted drug release.

Reproductive Planning and the Choice of Long-acting Reversible Contraceptive Primary to Health: A Cross-Sectional Study

OBJECTIVE

 Evaluate the different perspectives that involve the choice of long-acting reversible contraceptives (LARCs), the issues related to this process and the consequences of deciding one method in the women's in the primary health care (PHC) center in Sousas, a district in Campinas, SP (Brazil).

METHODS

 This is an analytical cross-sectional study, it was performed at the PHC in Sousas. Data were collected through the analysis of medical records and interviews with women who live in Sousas and had the insertion of the copper intrauterine device (IUD) (D) from April 2021 to April 2022 or the etonogestrel implant (I) from May to December 2022. The study was approved by the Research Ethics Committee of the Medical Science School at the State University of Campinas (UNICAMP).

RESULTS

 Reason for choosing this LARC: medical (D: 52%; I: 100%), easy adhesion (D: 71%; I: 67%), effectiveness (D: 55%; I: 100%). Indication by health professionals (D: 65%; I: 100%). And improvement of clinical characteristics: mood (D: 77%; I: 67%), body mass index (BMI; D: 52%; I: 33%), and libido (D: 84%; I: 67%).

CONCLUSION

 It is suggested that women tend to decide between LARCs when guided by their doctor or PHC health professionals, and they select LARCs because of the ease of use and low failure rates. Therefore, this study highlights how LARCs can positively interfere in the aspects that pervade contraception, such as BMI, libido, and mood.

Long-acting biodegradable implant for sustained delivery of antiretrovirals (ARVs) and hormones

Women worldwide confront two major reproductive health challenges: the need for contraception and protection from sexually transmitted infections, including Human Immunodeficiency Virus (HIV). Multipurpose Prevention Technologies (MPTs) that simultaneously prevent unintended pregnancy and HIV could address these challenges with a single product. Here, we developed a long-acting (LA) subcutaneously administered and biodegradable implant system that provides sustained delivery of contraceptive and antiretroviral (ARV) with zero-order release kinetics. The MPT system involves two implants comprising an extruded tube of a biodegradable polymer, poly(ε-caprolactone) (PCL). Each implant is filled with a formulation of progestin [levonorgestrel (LNG) or etonogestrel (ENG)], or a formulation of a potent ARV [tenofovir alafenamide (TAF), or 4'-Ethynyl-2-fluoro-2'-deoxyadenosine (EFdA)]. We demonstrated sustained in-vitro release of LNG, ENG, and EFdA from the implant system for 13-17 months, while maintaining high stability of the drugs (>99%) within the implant reservoirs. We further elucidated the controlled release mechanism of the implant and leveraged several tunable parameters (e.g., type and quantity of the excipient, PCL properties, and implant wall thickness) to tailor the release kinetics and enhance the mechanical integrity of the MPT implant. The optimized MPT showed sustained in-vitro release of ENG and EFdA over 1 year while maintaining a high level of formulation stability and structural integrity. The MPT implant system was further evaluated in a preclinical study using a rodent model and demonstrated sustained release of EFdA (6 months) and ENG (12 months) with high stability of the drug formulation (>95%). This manuscript supports the continued advancement of LA delivery systems for MPTs.

Contraceptive use at the time of and after an ectopic pregnancy: a retrospective cohort study

Objectives: Approximately, 1-2% of all pregnancies are ectopic; 25% of unintended pregnancies are conceived despite the use of contraception. The primary objective of our study was to explore the proportion of ectopic pregnancies (EPs) that were conceived during contraceptive use among women in Stockholm County. Secondary objectives were to establish the prevalence of contraceptive methods used at the time of EP and the intended contraceptive method after treatment completion.Methods: We performed a retrospective cohort study of 1180 women diagnosed with and treated for EP between 1 December 2013 and 30 April 2017 at all hospitals in Stockholm County. Demographic variables and contraceptive use before and after treatment were noted. Exclusion criteria were uncertainty about the diagnosis of EP in the patient records and planned treatment/follow-up outside Stockholm County.Results: A total of 222/1180 (18.8%) EPs were conceived during known contraceptive use. A total of 112/222 (50.5%) women with known use of contraception at the time of conception discontinued contraceptive use and 81/857 (9.5%) women with no prior use of contraception initiated contraceptive use. Among the 857 women, 520 (60.7%) expressed a desire to conceive. Results were compared using the Mann-Whitney U test or Fisher's exact test as appropriate.Conclusion: EP occurring during use of contraception is an unexplored problem. Contraceptive use decreased in women who were using contraception at the time of EP conception, leaving these women at risk of a subsequent unintended pregnancy. There should be more focus on contraceptive use after treatment for EP, in order to preserve fertility.

Oocyte donation in donors with levonorgestrel intrauterine device: a good match?

RESEARCH QUESTION

Does the levonorgestrel-releasing intrauterine device (LNG-IUD) influence cumulative live birth rate (CLBR) in oocyte donor cycles?

DESIGN

Retrospective cohort study based on prospectively collected data from 1 May 2009 to 31 December 2017, without attrition, consisting of 491 consecutive cycles of vitrified oocyte donation, none lost to follow-up (unique donor-recipient pairs). All donors underwent ovarian stimulation using gonadotrophin releasing hormone (GnRH) antagonist co-treatment and GnRH agonist trigger. CLBR was chosen as primary outcome measure.

RESULTS

In total, 103 (21.0%) cycles were carried out in donors carrying a LNG-IUD. In 388 (79.0%) cycles, no LNG-IUD was present. After confounder-adjustment, the use of an LNG-IUD did not have a statistically significant influence on CLBR.

CONCLUSIONS

The LNG-IUD does not negatively affect CLBR.

Clinically advancing and promising polymer-based therapeutics

In this review article, we will examine the history of polymers and their evolution from provisional World War II materials to medical therapeutics. To provide a comprehensive look at the current state of polymer-based therapeutics, we will classify technologies according to targeted areas of interest, including central nervous system-based and intraocular-, gastrointestinal-, cardiovascular-, dermal-, reproductive-, skeletal-, and neoplastic-based systems. Within each of these areas, we will consider several examples of novel, clinically available polymer-based therapeutics; in addition, this review will also include a discussion of developing therapies, ranging from the in vivo to clinical trial stage, for each targeted area of treatment. Finally, we will emphasize areas of patient care in need of more effective, accessible, and targeted treatment approaches where polymer-based therapeutics may offer potential solutions.

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.

Role of the levonorgestrel intrauterine system in effective contraception

Norgestrel, a synthetic progestin chemically derived from 19-nortestosterone, is six times more potent than progesterone, with variable binding affinity to various steroid receptors. The levonorgestrel-releasing intrauterine system (LNG IUS) provides a long-acting, highly effective, and reversible form of contraception, with a pearl index of 0.18 per 100 women-years. The locally released hormone leads to endometrial concentrations that are 200-800 times those found after daily oral use and a plasma level that is lower than that with other forms of levonorgestrel-containing contraception. The contraceptive effect of the LNG IUS is achieved mainly through its local suppressive effect on the endometrium, leading to endometrial thinning, glandular atrophy, and stromal decidualization without affecting ovulation. The LNG IUS is generally well tolerated. The main side effects are related to its androgenic activity, which is usually mild and transient, resolving after the first few months. Menstrual abnormalities are also common but well tolerated, and even become desirable (eg, amenorrhea, hypomenorrhea, and oligomenorrhea) with proper counseling of the patient during the choice of the method of contraception. The satisfaction rates after 3 years of insertion are high, reaching between 77% and 94%. The local effect of the LNG IUS on the endometrium and low rates of systemic adverse effects have led to its use in other conditions rather than contraception, as for the treatment of endometrial hyperplasia, benign menorrhagia, endometriosis, adenomyosis, and uterine fibroids.

[Focus on intrauterine contraception in 15 questions and answers]

In recent years, intrauterine contraception has experienced a revival, explainable as much by the broadening of its indications as by the ever increasing demand, expressed by women, for a contraceptive method that is both reliable and not binding. In this review, we establish an up-to-date and comprehensive state of intrauterine contraception in 2010, by responding to key-questions, which arise from everyday practice in gynaecology.

Sexual functioning in women using levonorgestrel-releasing intrauterine systems as compared to copper intrauterine devices

INTRODUCTION

There has been little research published on the impact of intrauterine contraceptive (IUC) methods on sexual functioning.

AIMS

This study aimed: (i) to assess different aspects of sexual functioning, including the prevalence of sexual dysfunction in women using a levonorgestrel intrauterine system (LNG-IUS); (ii) to compare this prevalence with that among copper-releasing intrauterine device (Cu-IUD) users; and (iii) to identify the relationship between psychological variables and sexual functioning in women using one of the aforementioned IUCs.

METHODS

In a multicenter cross-sectional study, 845 women with an IUC were invited to fill out a questionnaire. The latter was returned by 402 (48%) of them: 353 women were LNG-IUS users (88%) and 49 were Cu-IUD users (12%). The questions asked pertained to depression, well-being, marital relation quality, and sexual functioning.

MAIN OUTCOME MEASURES

Sexual functioning was measured with the short sexual functioning scale.

RESULTS

One-third of LNG-IUS users (33%) reported a sexual dysfunction. Of those, 20% reported an increased sexual desire, 25% a decreased sexual desire, 5% arousal problems, and 8% orgasm problems. Women using a LNG-IUS did not differ significantly in distribution, type, or prevalence (32.9% vs. 36.7%) of sexual dysfunction, nor in depressive symptoms (Beck Depression Inventory score; 4.7 vs. 3.9; P = 0.33), general well-being (WHO-5 well-being scale score; 16.8 vs. 17.7; P = 0.170), or partner relationship quality (Dyadic Adjustment Scale score; 107 vs. 108; P = 0.74) compared to Cu-IUD users. Overall, the perceived influence of IUCs on sexual functioning was in the lower range and did not differentiate LNG-IUS greatly from Cu-IUD-users.

CONCLUSION

Women using a LNG-IUS do not differ from those wearing a Cu-IUD with regard to psychological and sexual functioning. The perceived impact of IUD use on sexuality should not be overestimated.

Use of the levonorgestrel-releasing intrauterine system, quality of life and sexuality. Experience in an Italian family planning center

BACKGROUND

The levonorgestrel-releasing intrauterine system (LNG-IUS) was first marketed in 1990 in Finland. Since then, it has been approved in approximately 120 countries throughout the world, with almost 50 million women-years of cumulative experience to date. Its high contraceptive effectiveness and favorable bleeding profile, leading to significant reduction of menstrual bleeding both in women with idiopathic menorrhagia and in those with normal menstrual bleedings, have been the key to the success of the system. At the same time, women need to be provided adequate preinsertion counseling about changes in menstrual bleeding to be expected. In the Italian context, it is important to highlight during counseling that amenorrhea is not harmful but can lead to health benefits such as an increase in iron blood stores and blood hemoglobin concentration.

STUDY DESIGN

To evaluate contraceptive efficacy, compliance and the effect of changes in menstrual cyclicity on quality of life and sexuality of the LNG-IUS (Mirena®), 156 women attending the Family Planning Clinic to request contraception were enrolled in the study and inserted with the device.

RESULTS

Menstrual blood flow decreased in all users, in terms of both quantity and duration; although spotting was present in 93.7% of the women, it disappeared within 6 months in the majority of cases. Amenorrhea occurred in 29.5% of all women, with onset within the first six cycles postinsertion. Data from the EuroQuality of Life-5D and Female Sexual Function Index questionnaires showed improvement in the quality of life, with a decrease in intercourse-related pain and an improvement in sexual desire.

CONCLUSIONS

Although in Italy intrauterine contraception is poorly accepted, once started on LNG-IUS, women found that the device represents a safe and effective contraceptive modality, with valuable noncontraceptive benefits, especially in the presence of heavy or prolonged bleeding.

Transvaginal Doppler sonography for evaluation of irregular uterine bleeding with DMPA

BACKGROUND

The main cause for discontinuation of depot medroxyprogesterone acetate (DMPA) use is irregular menstrual bleeding. The exact pathophysiological mechanisms of irregular bleeding have remained unclear. Transvaginal Doppler is a non-invasive method for studying changes in blood flow which may highlight the underlying pathology in those cases with irregular uterine bleeding. The aim of this study was to quantify the uterine and subendometrial microvasculature in DMPA users with irregular bleeding pattern in comparison to DMPA users with amenorrhea.

STUDY DESIGN

This is a case control study. Forty users of DMPA were divided into two groups: one group included 20 users with irregular uterine bleeding and the second group included 20 amenorrheic users. Pulsatility index (PI) and resistance index (RI) of uterine and subendometrial blood vessels were determined. Power Doppler Energy was used to quantify the signal percentage of the subendometrial area.

RESULTS

There is significant reduction of PI and RI in the uterine artery and subendometrial microvasculature in cases of irregular uterine bleeding.

CONCLUSION

Irregular uterine bleeding with DMPA associated with increased perfusion of uterine and subendometrial blood vessels.

Mirena (Levonorgestrel intrauterine system): a successful novel drug delivery option in contraception

This manuscript serves as a review of Mirena, the levonorgestrel intrauterine system (LNG IUS) as a very successful drug delivery system. The LNG IUS has a very high contraceptive efficacy rate, and low rates of patient discontinuation. In addition to its contraceptive benefits, most users experience a decrease in menstrual bleeding over the 5 years of use. LNG IUS has also been used for management of menorrhagia, dysmenorrhea, adenomyosis, and endometrial hyperplasia in some cases. The LNG IUS provides long term efficacy, high rates of compliance, rapid return to fertility, and minimal adverse effects during use.

Contraceptive efficacy of intrauterine devices

To compare the contraceptive efficacy of various types of intrauterine devices (IUD; copper devices, Nova-T, intrauterine contraceptive systems, levonorgestrel-releasing devices), we reviewed all relevant publications on this subject that have been published over the last 2 decades. The first point to be highlighted by this review is the excellent effectiveness of IUDs, with a global cumulative pregnancy rate <2% at 5 years, whatever the type of device used. We observed a large variation in efficacy rate according to the type of IUD and also according to study design. Nevertheless, of all the types of IUDs, the levonorgestrel-releasing IUD and to a lesser extent the TCu380A IUD seem to be the most effective, with a cumulative pregnancy rate at 5 years of <0.5% for the levonorgestrel-releasing IUD and between 0.3% and 0.6% for the TCu380A IUD.

Predictors of oligoamenorrhea at 1-year follow-up in premenopausal women using a levonorgestrel-releasing intrauterine system

OBJECTIVE

The study was conducted to identify predictors of oligoamenorrhea at 12 months in levonorgestrel-releasing intrauterine system (LNG-IUS) users.

DESIGN

A 12-month observational study.

SETTING

Gynecologic outpatient clinic in a large regional hospital in Flanders, Belgium.

POPULATION OR SAMPLE

A total of 150 women who had made an informed decision to use a LNG-IUS either as a method of contraception or to manage menorrhagia.

METHODS

All women were premenopausal and first-time users. The variables recorded prior to insertion on Days 1 to 5 of the menstrual cycle were age, parity, body mass index, indication for LNG-IUS use, prior contraceptive use, menstrual bleeding history, length of the uterine cavity, endometrial thickness, number of antral follicles, serum follicle-stimulating hormone, inhibin B and anti-Müllerian hormone. Menstrual bleeding pattern, patient satisfaction or wish to discontinue the method was noted at 3, 6 and 12 months of follow-up visits.

MAIN OUTCOME MEASURES

Menstrual bleeding pattern (amenorrhea, oligomenorrhea, menorrhagia) at 12 months was taken as the primary outcome measurement. Patient satisfaction was followed as a secondary outcome.

RESULTS

Oligoamenorrhea was associated with a high patient satisfaction. A bleeding period less than 5 days, absence of severe uterine bleeding at baseline, LNG-IUS use for contraception and oligoamenorrhea at 3 months were predictors of a favorable outcome at 12 months in a univariate analysis. The absence of severe bleeding prior to LNG-IUS insertion was the only clinically useful predictor of favorable outcome in the multivariate analysis (odds ratio 0.13, 95% confidence interval 0.02-0.66).

CONCLUSIONS

Patient profiling as described is not helpful in counselling women for intentional LNG-IUS use, especially not if it is planned as a method of managing menorrhagia.

Innovations in contraception: a review

New forms of contraception have been developed to improve the safety and tolerability of contraceptive methods without compromising efficacy. The newest developments in contraception including low and ultra-low doses of estrogen, less-androgenic 19 nor-testosterone progestins, and the nonsteroidal progestin drospirenone, the Quick Start method to improve compliance of oral contraceptives, and the contraceptive transdermal patch, the vaginal estrogen-progestin ring, the levonorgestrel intrauterine system, and the hysteroscopic transcervical sterilization techniques are discussed.

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).

[Levonorgestrel-releasing intrauterine device (Mirena) and breast cancer: what do we learn from literature for clinical practice?]

Annual occurrence of breast cancer is constantly increasing in France. In 2000, the number of breast cancer cases for women of 30-49 years was estimated at 9,918, which represents 23.7% of all breast cancer cases diagnosed that year. The levonorgestrel-releasing intrauterine device (IUD LNG) is one of the most frequently used coils in France. Because contraception is an important matter for women whose ovarian function survived cancer treatments, the question of whether to use such device on a woman with breast cancer has become a frequent and controversial gynaecological issue. With the review of available literature as a basis, we have tried to answer the following questions. First, whether the use of IUD LNG increases the risk of breast cancer: there is at the moment no "A" level answer available. According to the only study published, which may be considered "C" level, there is no such increase. Second, whether the use of IUD LNG counterbalances the endometrial effects of Tamoxifene: based on a limited level of evidence via a single randomised controlled trial on a small number of patients for one year only, this device appears to be able to prevent benign endometrial modifications. However, there is no conclusive study regarding its effectiveness on the prevention of endometrium adenocarcinoma caused by Tamoxifene. In addition, there are numerous uncertainties as to whether levonorgestrel presence in the plasma would have a systemic prejudicial impact. Third, whether a woman with a personal antecedent of breast cancer can safely use DIU LNG: it is necessary to remove it promptly upon suspicion or diagnosis, to dissuade its use in case of current cancer, and, in the event of cancer remission for more than 5 years, to generally avoid this contraceptive method except on a case by case basis and with a regular medical follow-up. In the latter situation, the use of IUD LNG can be considered only after a multidisciplinary collective formal decision and after the woman gave her informed consent.

Risk factors for IUD failure: results of a large multicentre case-control study

BACKGROUND

This study was conducted to identify the risk factors for intrauterine device (IUD) failure.

METHODS

A retrospective case-control study was carried out between 1999 and 2002. Cases (women with an IUD and a confirmed pregnancy) and controls (women with an IUD and who were not pregnant) were recruited by gynaecologists. An anonymous questionnaire was filled in during the consultation, with specific items regarding any type of drugs used before the predicted fertile period for cases and within the cycle that ended in menses for controls.

RESULTS

Two hundred and sixteen cases were compared with 657 controls. Age was associated with IUD failure, with a significantly lower failure risk in women>35 years. A significant relationship was observed between a history of IUD expulsion and IUD failure risk (age-adjusted odds ratio 3.31, 95% CI 1.40-7.81). No relationship was observed between the risk of IUD failure and gynaecological background (fibroma, polyps and miscarriage), nor with any type of medicine taken by the woman.

CONCLUSION

This study is clearly reassuring, as we found that anti-inflammatory drugs and any other medicines taken by the woman were not implicated in IUD failure. Only a history of previous IUD expulsion was found to be a risk factor for failure, indicating that these women should have regular medical and echographical follow-up. Comparing the efficacy rate of various types of IUDs, we found a clear advantage for levonorgestrel-releasing devices.

Non-contraceptive uses of levonorgestrel-releasing hormone system (LNG-IUS)--a systematic enquiry and overview

Levonorgestrel releasing-intrauterine systems (LNG-IUS) were originally developed as a method of contraception in the mid 1970s. The only LNG-IUS approved for general public use is the Mirena LNG-IUS, which releases 20 mcg of levonorgestrel per day directly in to the uterine cavity. However, new lower dose (10 and 14 mcg per day) and smaller sized LNG-IUS (MLS, FibroPlant-LNG) are currently under clinical development and investigation. Research into the non-contraceptive uses of LNG-IUS is rapidly expanding. In the UK, LNG-IUS is licensed for use in menorrhagia and to provide endometrial protection to perimenopausal and postmenopausal women on estrogen replacement therapy. There is limited evidence to suggest that LNG-IUS may also be beneficial in women with endometriosis, adenomyosis, fibroids, endometrial hyperplasia and early stage endometrial cancer (where the patient is deemed unfit for primary surgical therapy). This systematic enquiry and overview evaluates the quality of evidence relating to the non-contraceptive therapeutic uses of LNG-IUS in gynaecology.

The levonorgestrel-releasing intrauterine system in modern gynaecology

The levonorgestrel-releasing intrauterine system was initially developed for contraception but is now widely used for a variety of gynaecological conditions. Compliance can sometimes be hampered by troublesome side effects (principally breakthrough bleeding) but appropriate counselling can reduce unnecessary discontinuation.

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.

Delivery options for contraceptives

Although a steady increase in contraceptive use has been observed in developed and less-developed countries, the contraceptive needs of a significant proportion of couples have not yet been met, resulting in an increase in unplanned pregnancies. Several new contraceptive products have reached the market during the past few years. Among these are new implants, a medicated intrauterine device, contraceptive vaginal rings, transdermal patches and several new regimen of combined oral contraceptives. These new or improved methods have been developed to expand the contraceptive choices available to women and men as well as to respond to the unmet need for contraceptives with long-term activity. New targets are being identified both in the ovary and the testes for a more specific non-hormonal contraception. This futuristic approach still keeps in mind the need for better access to existing contraceptive methods, as well as the discovery of new contraceptives that are simple to use, safe, reversible and inexpensive. In recent years, there has been great interest in agents that provide dual protection against pregnancy and sexually transmitted infections (STI), especially human immunodeficiency virus (HIV). A contraceptive method providing dual medical benefits might increase motivation for consistent use, thus reducing contraceptive failures and unwanted pregnancies.

Gynecological health of females with congenital heart disease

Because of major advances in diagnostic and surgical methods, females with congenital heart disease (CHD) now survive into and beyond their reproductive years. Management of pregnancy in this patient population is well described, but gynecologic management such as menstruation, contraception and menopause have received scanty attention. Accordingly, the gynecologic health issues confronting these patients are described. Menstrual patterns in acyanotic females with CHD are similar to the general population, but cyanotic females have menstrual irregularities including amenorrhea, which implies anovulation and an increased risk of uterine carcinoma. Anticoagulants predispose to heavy vaginal bleeding and corpus luteum rupture. Contraceptives must be selected according to individual patient profiles. Hormone replacement therapy is warranted for relief of menopausal symptoms as in the general population and should be relatively safe because estrogen dose is low.

Contraception for the adolescent and young adult with congenital heart disease

Increasing numbers of females born with congenital heart disease are reaching childbearing age. Practitioners involved in the management of the adolescents or adults must be aware not only of the risks of pregnancy associated with varying types of CHD but with other issues involving the reproductive cycle to provide appropriate care, counseling, and education.

Recent developments in hormone delivery systems

Women who want safe, effective contraception have many more options than they did only a few years ago. Each option must be weighed carefully according to the needs and lifestyle of each particular woman. One method that provides long-term convenience with a side-effect profile that is comparable to that of oral contraceptives is the once-a-month injectable contraceptive containing 25 mg medroxyprogesterone acetate and 5 mg estradiol cypionate. Another option is the levonorgestrel-releasing intrauterine contraceptive system that offers pregnancy prevention for 5 years. Finally, hormonal implants that release low doses of progestins have been used for more than 30 years by a total of 10 million women, and easier-to-use implants will soon be available.

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.

The Levonorgestrel Intrauterine System: A Clinical Perspective from the UK

The main contraceptive effects of this valuable product [the levonorgestrel intrauterine system (LNG-IUS)] are by endometrial suppression and changes to the cervical mucus and uterotubal fluid that impair sperm migration. The blood levels of LNG are very low, so progestogenic symptoms are uncommon. Most women still ovulate and in the remainder sufficient estrogen for health is produced from the ovary, even if they become amenorrhoeic, as many do; this is primarily a local end-organ effect and should be seen as a benefit. Although usable by selected nulliparae, it is ideal for the parous woman. It has unsurpassed efficacy, and return of fertility is rapid. Combining the best features of hormonal and intrauterine contraception, its gynecological benefits are impressive: the LNG-IUS user can expect a dramatic reduction in the amount and, after the first few occasionally troublesome months, in the duration of blood loss. Hemoglobin levels rise and dysmenorrhea is usually greatly benefited, unlike with current uterine ablation techniques. In perimenopausal women, it can protect the endometrium from overstimulation when estrogen replacement therapy (ERT) is added, by any chosen route. It thus provides a contraceptive modality of ERT with, usually, no bleeding and few progestogenic side effects-and is applicable before final ovarian failure. In summary, adverse side effects are few and in general they are not in the "hazardous" category. Regarding the admitted inconvenience of the first weeks of light postinsertion bleeding and the early phase low incidence of steroidal side effects: good counseling is paramount, since forewarned is forearmed!

Family planning needs: new opportunities, emergency contraception and other new technologies

Modern contraception is considered to be one the major advances of the 20th century. Yet, as the next century begins, it is estimated that there is still a largely unmet need for contraception, with millions of couples worldwide who express a wish to limit the number of their children but do not use or are not satisfied with their contraceptive method. While the reasons are numerous, it is clear that there is a need for improved and new methods which are easier to use, under the user's control, with fewer side-effects and responding to the needs of different groups of users, including men. To respond to this need, current contraceptive research and development efforts focus on five main areas: emergency post-coital methods, user-controlled long-acting methods, dual protection methods against both pregnancy and sexually transmitted infections, methods for men, and methods with fewer side-effects including some that are more targeted to specific reproductive biological events. A number of leads are presented which are at various stages of development. Concluding remarks stress the numerous challenges of contraceptive development, not the least of which is the vision required of what the needs of future generations will be, since it takes 10-15 years to bring a new contraceptive to the market. More fundamentally, overall progress towards reducing the unmet need for contraception will depend on the status of women, specifically their decision-making power, and access to education and income.

The local progestational effect of the levonorgestrel-releasing intrauterine system: a sonographic and Doppler flow study

BACKGROUND

We aimed to evaluate the effect of the levonorgestrel-releasing intrauterine system (LNG-IUS) on the uterine vasculature and the endometrium.

METHODS

The study was a prospective controlled study evaluating the local effects of LNG-IUS compared with the copper intrauterine device (IUD). Forty-seven women carrying LNG-IUS (group A) were compared with 35 women carrying copper IUD in a control group (group B). Clinical measures of menstrual bleeding, endometrial thickness and Doppler flow of the cervical branch of the uterine artery and spiral artery were evaluated and compared between the two groups.

RESULTS

Doppler flow in the cervical branch of the uterine artery did not reveal any changes between the groups (resistance index = 0.6 +/- 0.01 in both groups). Endometrial width was significantly thinner in group A (4.1 +/- 0.2 mm) compared with group B (7.3 +/- 0.2 mm) (P < 0.0001). Subendometrial flow in the spiral artery was significantly reduced in 35 women of group A (75%) and in none of group B (P < 0.0001).

CONCLUSIONS

The present study offers an explanation for the oligomenorrhoea in LNG-IUS users, i.e. a local progestational effect on the endometrium with no change in the blood flow in the uterine artery. This should be presented to the women in the pre-contraceptive counselling in order to lessen the discontinuation rate.

Progestin contraceptives

Progestin contraceptives offer unique advantages, allowing the clinician to tailor optimum regimens for selected women. This article reviews the various progestational drugs, regimens, and delivery systems available presently and in development, with reference to the clinical benefits and limitations of each method.