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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluating the Efficacy of Levonorgestrel Intrauterine System and Danazol for Relief of Postoperative Pain in Endometriosis

INTRODUCTION

Endometriosis is an oestrogen-dependent disorder, manifests during reproductive years and is associated with pain and infertility. There is considerable debate about the effectiveness of various interventions for pain relief.

AIM

To evaluate the efficacy of Levonorgestrel Intrauterine System (LNG-IUS) and Danazol in postoperative pain relief for patients with endometriosis.

MATERIALS AND METHODS

Hundred patients with diagnosis of endometriosis, who were treated laparoscopically, entered the study to receive either danazol (600 mg once daily) or LNG-IUS (inserted during immediate post operative period) postsurgery, for pain relief. Patients were analysed for pain relief according to VAS score and recurrence of disease using ultrasonography at third and sixth months of follow up.

RESULTS

There were 50% patients in stage IV of endometriosis. Majority of them presented with complaint of infertility (49%) and pelvic pain (43%). It was observed that LNG-IUS was significantly more effective in relieving pain compared to danazol (65.2% vs 38.0%, p<0.05). Recurrence rate was significantly lower in LNG-IUS users compared to other group.

CONCLUSION

LNG-IUS was found to be more effective in relieving pain compared to danazol.