Benefit-Risk Assessment of the Levonorgestrel Intrauterine System in Contraception

A comparison of the effects of oral dydrogesterone and levonorgestrel-releasing intrauterine device on quality of life and sexual function in patients with abnormal uterine bleeding

OBJECTIVE

The purpose of this study is to compare the effects of cyclic oral dydrogesterone treatment and levonorgestrel-releasing intrauterine device (LNG_IUD) on quality of life (QoL) and sexual function in patients diagnosed with abnormal uterine bleeding (AUB).

STUDY DESIGN

The study was conducted at the University of Health Sciences Turkey Health Istanbul Kanuni Sultan Süleyman Training and Research Hospital, on 171 sexually active patients, aged 18-45, who were under a minimum of 6 months of treatment for AUB. 85 patients were treated with oral cyclic dydrogesterone, and 86 patients received LNG-IUD. Following a minimum of 6 months of treatment, these patients were recruited to the study and were asked to complete a 36-Item Short Form Survey (SF-36) and the Female Sexual Function Index (FSFI).

RESULTS

When the FSFI scores of the patients were compared, it was observed that the total FSFI score was significantly higher in the cyclic dydrogesterone group (p < 0.05). Likewise, it was observed that sexual desire, arousal, and lubrication domains were significantly higher in the cyclic dydrogesterone group (p < 0.05). No significant differences were found between the treatment groups in 7 out of the 8 dimensions of SF-36. The energy/vitality dimension was found to be significantly higher in the cyclic dydrogesterone group.

CONCLUSION

Total FSFI score, as well as sexual desire, arousal, and lubrication scores, were significantly higher in the cyclic dydrogesterone group compared to the LNG-IUD group indicating that cyclic dydrogesterone has a more positive impact on sexual function when compared to LNG-IUD.

Thirty years of mirena: A story of innovation and change in women's healthcare

Since its introduction in 1990, the levonorgestrel-releasing intrauterine system (LNG-IUS) has played a key role in shaping the healthcare landscape of women. Here we explore the development of the first LNG-IUS (Mirena®) and the early clinical trials that demonstrated its potential. We highlight the contraceptive and therapeutic benefits of Mirena®, and discuss how clinical practice has been changed since the introduction of LNG-IUS and other long-acting reversible contraceptive methods. The history of Mirena® is rich in innovation and has also paved the way to the development of smaller intrauterine systems with lower hormone doses. Along with Mirena®, these newer LNG-IUS contribute to improving contraceptive choices for women, allowing them to select the option that is right for them and that meets their needs no matter their age, parity or circumstances.

Rational Design of a Multipurpose Bioadhesive Vaginal Film for Co-Delivery of Dapivirine and Levonorgestrel

Human immunodeficiency virus (HIV) infection and unintended pregnancy, which can lead to life-threatening complications, are two major burdens for female reproductive health. To address these pressing health issues, multipurpose prevention technologies (MPTs) are proposed to deliver two or more drugs simultaneously. MPTs could offer several benefits for users such as improved convenience, increased effectiveness, reduced cost, and decreased environmental burden. Here, we report the development, and in vitro and in vivo assessment of a bioadhesive vaginal film as a coitally-independent MPT dosage form for delivering dapivirine (DPV) and levonorgestrel (LNG) to prevent HIV infection and unintended pregnancy, respectively. After confirming the feasibility of bioadhesive film use for weekly drug delivery in vivo through colpophotography and MRI evaluation, the pharmacokinetics (PK) of DPV/LNG single entity and combination bioadhesive films was investigated in pigtailed macaques (n = 5). Both drugs from single entity or combination films were able to provide sustained drug release in vivo. The combination film showed lower local tissue clearance for DPV and exhibited significantly increased plasma concentration for LNG as compared to the single entity film. This proof-of-concept study demonstrates the ability of this novel bioadhesive film platform to deliver LNG and DPV simultaneously as an MPT product for the prevention of HIV infection and unintended pregnancy.

The comorbidities of dysmenorrhea: a clinical survey comparing symptom profile in women with and without endometriosis

Purpose

Dysmenorrhea is a common disorder that substantially disrupts the lives of young women. The frequency of 14 associated symptoms both within and outside the pelvis was determined.

Patients and methods

Symptom questionnaires were completed by 168 women with dysmenorrhea, allocated to three groups based on their diagnostic status for endometriosis confirmed (Endo+), endometriosis excluded (Endo-), or endometriosis diagnosis unknown (No Lap). Those with endometriosis confirmed were further divided into current users (Endo+ Hx+) and non-users of hormonal treatments (Endo+ Hx-). Users of hormonal treatments were further divided into users (Endo+ Hx+ LIUCD+) and non-users (Endo+ Hx+ LIUCD-) of a levonorgestrel-releasing intra-uterine contraceptive device (LIUCD). The frequency and number of symptoms within groups and the effect of previous distressing sexual events were sought.

Results

Women with and without endometriosis lesions had similar symptom profiles, with a mean of 8.5 symptoms per woman. Only 0.6% of women reported dysmenorrhea alone. The presence of stabbing pelvic pains was associated with more severe dysmenorrhea (P=0.006), more days per month of dysmenorrhea (P=0.003), more days per month of pelvic pain (P=0.016), and a diagnosis of migraine (P=0.054). The symptom profiles of the Endo+ Hx+ and Endo+ Hx- groups were similar. A history of distressing sexual events was associated with an increased number of pain symptoms (P=0.003).

Conclusion

Additional symptoms are common in women with dysmenorrhea, and do not correlate with the presence or absence of endometriosis lesions. Our study supports the role of central sensitization in the pain of dysmenorrhea. The presence of stabbing pelvic pains was associated with increased severity of dysmenorrhea, days per month of dysmenorrhea, days per month of pelvic pain, and a diagnosis of migraine headache. A past history of distressing sexual events is associated with an increased number of pain symptoms.

The Levonorgestrel Intrauterine System: Long-Term Contraception and Therapeutic Effects

The levonorgestrel intrauterine system (Mirena®) has been developed as a long-acting method of contraception. This medicated device, inserted into the uterus, delivers a small daily dose of a progestin, levonorgestrel, into the uterine cavity. It is one of the most effective methods of contraception and is approved in more than 100 countries for 5 years of use.

Embracing post-fertilisation methods of family planning: a call to action

Family planning methods that act when administered after fertilisation would have substantial benefits: they could be used longer after sex than current emergency contraceptives, and potentially a woman could use them only on relatively rare occasions when her menstrual period is delayed. Although such methods would displease abortion opponents, they would likely be welcomed by many women. Research to develop post-fertilisation fertility control agents should be pursued.

Predictors of modern contraceptive use during the postpartum period among women in Uganda: a population-based cross sectional study

BACKGROUND

The rationale for promotion of family planning (FP) to delay conception after a recent birth is a best practice that can lead to optimal maternal and child health outcomes. Uptake of postpartum family planning (PPFP) remains low in sub-Saharan Africa. However, little is known about how pregnant women arrive at their decisions to adopt PPFP.

METHODS

We used 3298 women of reproductive ages 15-49 from the 2011 UDHS dataset, who had a birth in the 5 years preceding the survey. We then applied both descriptive analyses comprising Pearson's chi-square test and later a binary logistic regression model to analyze the relative contribution of the various predictors of uptake of modern contraceptives during the postpartum period.

RESULTS

More than a quarter (28%) of the women used modern family planning during the postpartum period in Uganda. PPFP was significantly associated with primary or higher education (OR=1.96; 95% CI=1.43-2.68; OR=2.73; 95% CI=1.88-3.97 respectively); richest wealth status (OR=2.64; 95% CI=1.81-3.86); protestant religion (OR=1.27; 95% CI=1.05-1.54) and age of woman (OR=0.97, 95% CI=0.95-0.99). In addition, PPFP was associated with number of surviving children (OR=1.09; 95 % CI=1.03-1.16); exposure to media (OR=1.30; 95% CI=1.05-1.61); skilled birth attendance (OR=1.39; 95% CI=1.12-1.17); and 1-2 days timing of post-delivery care (OR=1.68; 95% CI=1.14-2.47).

CONCLUSIONS

Increasing reproductive health education and information among postpartum women especially those who are disadvantaged, those with no education and the poor would significantly improve PPFP in Uganda.

Estimated economic impact of the levonorgestrel intrauterine system on unintended pregnancy in active duty women

Unintended pregnancy is reportedly higher in active duty women; therefore, we sought to estimate the potential impact of the levonorgestrel-containing intrauterine system (LNG-IUS) could have on unintended pregnancy in active duty women. A decision tree model with sensitivity analysis was used to estimate the number of unintentional pregnancies in active duty women which could be prevented. A secondary cost analysis was performed to analyze the direct cost savings to the U.S. Government. The total number of Armed Services members is estimated to be over 1.3 million, with an estimated 208,146 being women. Assuming an age-standardized unintended pregnancy rate of 78 per 1,000 women, 16,235 unintended pregnancies occur each year. Using a combined LNG-IUS failure and expulsion rate of 2.2%, a decrease of 794, 1588, and 3970 unintended pregnancies was estimated to occur with 5%, 10% and 25% usage, respectively. Annual cost savings from LNG-IUS use range from $3,387,107 to $47,352,295 with 5% to 25% intrauterine device usage. One-way sensitivity analysis demonstrated LNG-IUS to be cost-effective when the cost associated with pregnancy and delivery exceeded $11,000. Use of LNG-IUS could result in significant reductions in unintended pregnancy among active duty women, resulting in substantial cost savings to the government health care system.

Hormonal contraception in women with migraine: is progestogen-only contraception a better choice?

A significant number of women with migraine has to face the choice of reliable hormonal contraception during their fertile life. Combined hormonal contraceptives (CHCs) may be used in the majority of women with headache and migraine. However, they carry a small, but significant vascular risk, especially in migraine with aura (MA) and, eventually in migraine without aura (MO) with additional risk factors for stroke (smoking, hypertension, diabetes, hyperlipidemia and thrombophilia, age over 35 years). Guidelines recommend progestogen-only contraception as an alternative safer option because it does not seem to be associated with an increased risk of venous thromboembolism (VTE) and ischemic stroke. Potentially, the maintenance of stable estrogen level by the administration of progestins in ovulation inhibiting dosages may have a positive influence of nociceptive threshold in women with migraine. Preliminary evidences based on headache diaries in migraineurs suggest that the progestin-only pill containing desogestrel 75μg has a positive effect on the course of both MA and MO in the majority of women, reducing the number of days with migraine, the number of analgesics and the intensity of associated symptoms. Further prospective trials have to be performed to confirm that progestogen-only contraception may be a better option for the management of both migraine and birth control. Differences between MA and MO should also be taken into account in further studies.

Amenorrhea and BMI as independent determinants of patient satisfaction in LNG-IUD users: cross-sectional study in a Central European district

OBJECTIVE

This study investigated the satisfaction of women carrying the LNG-IUD and determined influencing factors, especially considering bleeding patterns and body mass index (BMI).

DESIGN

Cross sectional study.

SETTING

Gynecological offices in a Central European district.

PARTICIPANTS

1825 women aged between 18 and 60 years.

MEASUREMENT

While sitting in the waiting room, voluntary patients had to answer a questionnaire about their experiences with the levonorgestrel intrauterine device. One question was used to determine whether the women were current, former or not users of the intrauterine coil.

RESULTS

415 women who had some experiences with Mirena were found. Overall, 266 (65.7%) were "very satisfied," 83 (20.5%) "quite satisfied," 18 (4.4%) "moderate satisfied," 19 (4.7%) "less satisfied," and the same amount "really not satisfied" with the hormonal coil. Women with amenorrhea were more often "very satisfied" in general, than women with hypermenorrhea (178 (67.9%) vs. 3 (1.1%) p < 0.001). Concerning bleeding patterns, 295 (74.1%) were "very satisfied" and 23 (5.8%) "really not satisfied". 203 (91.0%) of all amenorrhoeic women were "very satisfied" with their bleeding patterns, but only 2 (9.5%) of all women with hypermenorrhea (p < 0.001 for α = 0.05). Amenorrhea particularly occurred in women who had a significantly lower body mass index (24.4 ± 4.4 kg/m(2) vs. 27.6 ± 6.5 kg/m(2) in women with hypermenorrhea, p = 0.018 for α = 0.05). After allocating women to the widely used BMI-categories (underweight, normal weight, overweight, obese class I and II) it was evident, that normally weighted women tend toward amenorrhea as well at the beginning of LNG-IUD use as well after 4-5 years of use. In contrast to this, overweighed and obese women tend more often to amenorrhea at the end of use, but not at the beginning (72.7% and 55.6% vs. 25.0% and 0%). Women with a lower BMI were more often "very satisfied" concerning bleeding patterns, but not concerning the general satisfaction.

CONCLUSION

Our study showed much evidence, that amenorrhea occurs more often in women with lower BMI contrary to women with a higher one-especially at the beginning of LNG- IUD use. Furthermore amenorrhea was mostly considered to be a positive menstrual change.

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.

Uterine perforation with the levonorgestrel-releasing intrauterine device: analysis of reports from four national pharmacovigilance centres

BACKGROUND

Levonorgestrel-releasing intrauterine devices (LNG-IUD) are commonly used for contraception and other indications in many countries. National pharmacovigilance centres have been receiving reports from healthcare professionals and patients of uterine perforation associated with the use of these LNG-IUDs.

METHODS

National pharmacovigilance centres in the Netherlands, New Zealand, Switzerland and Germany did a search on their adverse drug reaction databases for reports of cases of uterine perforation after insertion of a LNG-IUD received between the introduction of the LNG-IUD onto the market in the late 1990s and 15 July 2007. The number of women affected and patient characteristics such as age, parity and breastfeeding status were examined. In addition, the method of detection of the perforation and the time until discovery of the perforation were analysed.

RESULTS

Between the introduction of the LNG-IUD onto the market in each country and 15 July 2007, 701 cases of uterine perforation with a LNG-IUD were reported; 8.5% of the perforations were detected at the time of insertion. Abdominal pain and control/check-up visits were the most common events that lead to the detection of a perforation. Of 462 women known to be parous, 192 (42%) were breastfeeding at the time the perforation was discovered.

CONCLUSIONS

Uterine perforations can be asymptomatic and may remain undetected for a long time after IUD insertion. Abdominal pain, control/check-up visits or changes in bleeding patterns are triggers for detection of perforation and should therefore be taken seriously.

Postpartum insertion of levonorgestrel--intrauterine system at three time periods: a prospective randomized pilot study

BACKGROUND

The study was conducted to determine the feasibility of levonorgestrel-intrauterine system (LNG-IUS) insertion at three different times postpartum.

STUDY DESIGN

From August 2009 to January 2010, all women desiring LNG-IUS for postpartum contraception were offered enrollment into our study and randomized to three insertion times: immediate (within 10 min of placenta delivery), early (10 min to 48 h postpartum) or interval (≥6 weeks postpartum).

RESULTS

Forty-six women met inclusion criteria and were analyzed. There was no difference in utilization rates at 3 and 6 months between groups (p=.931). Expulsion rates were significantly higher and pain during insertion was significantly lower in the immediate and early groups (p<.001) when compared to the interval group.

CONCLUSION

Insertion of LNG-IUS ≤48 h postpartum is feasible in our institution and may be associated with similar utilization at 6 months, increased expulsion rates and decreased pain at insertion when compared to placement after 6 weeks.

The wandering Mirena: laparoscopic retrieval

Levonorgestrel-containing intrauterine contraceptive devices, marketed as Mirena (Bayer HealthCare Pharmaceuticals, Inc. Australia) are widely used in contemporary gynecology, primarily as an effective method for contraception and for control of menstrual disorders like menorrhagia and dysmenorrhea. In this article, the authors report 2 cases of Mirena migration following intrauterine insertion by general practitioners (family physicians). In the first case, the contraceptive device had moved to the patient's right iliac fossa just anterior to the cecum and, in the second, within the peritoneal cavity close to the left leaf of the diaphragm. Both patients underwent uneventful laparoscopic retrieval of the devices.

Levonorgestrel-releasing intrauterine system for the management of heavy menstrual bleeding in women with inherited bleeding disorders: long-term follow-up

BACKGROUND

There are currently limited data on the use of the levonorgestrel-releasing intrauterine system (LNG-IUS) for the management of heavy menstrual bleeding (HMB) in women with inherited bleeding disorders (IBDs) particularly on its long-term (>12 months) efficacy.

STUDY DESIGN

This study involves a case series of women with IBDs who received the LNG-IUS as treatment for HMB. Menstrual blood loss before its insertion and at the time of follow-up was assessed by the pictorial blood-loss assessment chart (PBAC) and hemoglobin (Hb) concentrations. A questionnaire was used to evaluate quality of life (QOL) during menstruation before and after insertion of the LNG-IUS.

RESULTS

Twenty-six women were included. The median duration of LNG-IUS use at follow-up was 33 months (range, 14-103). The median PBAC score decreased from 255 (range, 134-683) to 35 (range, 0-89) with LNG-IUS use. The median Hb concentrations (11.2 to 13.2 g/dL) and QOL scores (median, 26 to 52) improved significantly with LNG-IUS use (p<.01).

CONCLUSION

The LNG-IUS appears to be an effective long-term treatment for HMB in women with IBDs.

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

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

Why do women experience untimed pregnancies? A review of contraceptive failure rates

Contraceptive failure contributes to a substantial proportion of unintended pregnancy, particularly in the developed world. A number of socio-demographic factors seem to impact on the risk of a woman experiencing contraceptive failure. Many of the issues exist across cultural boundaries and are complex to address. In discussing the failure rates for individual contraceptive methods, this article will highlight the advantage of improving uptake of long-acting reversible methods of contraception which have a high efficacy and are less user-dependent than many of the other available methods.

Reproductive health in women with systemic lupus erythematosus compared to population controls

OBJECTIVE

To study the reproductive health history in women with systemic lupus erythematosus (SLE) compared to population controls.

METHODS

A total of 206 female SLE patients were interviewed regarding demographic and disease data, menstruation, use of contraception and hormone replacement therapy (HRT), infertility, and pregnancies. The control group consisted of 1037 women from the general population of similar age and socioeconomic status living in the same region.

RESULTS

In SLE women compared to population controls, mean age at menarche (13.3 vs. 13.2 years) and frequency of infertility (16% vs. 16%) were similar but menopause occurred earlier (44.9 vs. 46.8 years, p = 0.01). Current use of oral contraceptives (OCs) was less common than in controls [18% vs. 28%, odds ratio (OR) 0.55, 95% CI 0.3-1.0] while previous use of progesterone-containing intrauterine devices (IUDs) was more common (13% vs. 5%, OR 3.2, 95% CI 1.9-5.4). Current use of HRT was similar (22% vs. 21%) but SLE patients had started the use earlier (43.2 vs. 47.1 years, p = 0.003). Mean number of pregnancies was lower in SLE patients compared to controls (2.3 vs. 2.5, p = 0.046) and in lupus nephritis patients compared to SLE patients without nephritis (1.9 vs. 2.5, p = 0.01). No difference was found in the occurrence of spontaneous and induced abortions compared to controls, but pregnancy-associated complications were more common in SLE women.

CONCLUSION

When compared to population controls women with SLE are normally fertile, use less OCs and more IUDs, have earlier menopause and use HRT as frequently. Family size is reduced, especially in lupus nephritis patients, and pregnancy-associated complications are more common.

Determinants of ferritin and soluble transferrin receptors as iron status parameters in young adult women

Objective

To investigate associations between nutritional and non-nutritional variables and Fe status parameters, i.e. serum ferritin and soluble transferrin receptors (sTfR).

Design

Cross-sectional design. Fe status parameters were determined on a fasting venous blood sample. Nutritional variables were assessed using a 2 d food record and non-nutritional variables by a general questionnaire. A general linear model was used to investigate associations between the variables and Fe status parameters.

Setting

Region of Ghent, Dutch-speaking part of Belgium.

Subjects

Random sample of 788 women (aged 18–39 years).

Results

Median (interquartile range) ferritin and sTfR were 26·3 (15·9, 48·9) ng/ml and 1·11 (0·95, 1·30) mg/l, respectively. BMI and alcohol intake were positively associated and tea intake was negatively associated with serum ferritin. Women who used a non-hormonal intra-uterine device, who gave blood within the past year or who had been pregnant within the past year had lower serum ferritin values than their counterparts. Significant determinants of sTfR were smoking habit and pregnancy, with higher values for non-smokers and women who had been pregnant within the past year.

Conclusions

The present study indicates that contraceptive use, time since last blood donation, time since last pregnancy, BMI, alcohol and tea intake are determinants of Fe stores, whereas smoking habit and time since last pregnancy are determinants of tissue Fe needs. When developing strategies to improve Fe status, special attention should be given to women who use a non-hormonal intra-uterine device, gave blood within the past year and had been pregnant within the past year.

Hormonal contraception and HIV-positive women: metabolic concerns and management strategies

As HIV-positive women live longer lives, and as testing for HIV becomes more routine, clinicians can expect to see more HIV-positive women in their practices. The need to be aware of management issues particular to this population becomes increasingly important. Metabolic dysregulation is a common, long-term complication associated with HIV and is one of the most difficult to manage. Hormonal contraception also is associated with metabolic dysregulation. As more HIV-positive women choose long-term, reversible contraception, the potential for concomitant and additive side effects, and the need for careful, proactive management strategies to avoid these complications, will become more important. This article reviews research detailing the metabolic dysfunction associated with hormonal contraception and with HIV-seropositivity. It highlights reasons for concern regarding the potential, although as yet theoretical, increased risk for metabolic dysfunction when hormonal contraception is used in the presence of HIV. Suggestions for management strategies for women living with HIV who choose to use hormonal contraception are presented. These strategies should be viewed as suggestions for management until substantitive research becomes available.

Two for the price of one

This case is about an HIV seropositive young woman referred for the treatment of severe menorrhagia causing anaemia due to adenomyosis where the levonorgestrel-releasing intrauterine system (Mirena) proved useful in treating her heavy periods and also provided effective contraception without interference from the liver enzyme-inducing effects of antiretroviral medications.

Hair loss with use of the levonorgestrel intrauterine device

BACKGROUND

The levonorgestrel intrauterine device (IUD) has associated systemic side effects. However, there is little published information about the risk of alopecia.

STUDY DESIGN

Review of both the New Zealand Intensive Medicines Monitoring Programme (IMMP) data on alopecia associated with levonorgestrel IUD and the international evidence.

METHODS

The IMMP uses Prescription Event Monitoring to study the safety of medicines during the postmarketing period. All reported cases of alopecia with levonorgestrel IUD use were identified in the IMMP databases and assessed for causality. World Health Organization (WHO) spontaneous reporting data were also obtained.

RESULTS

Five reports of alopecia associated with the levonorgestrel IUD were identified in the IMMP database. From the cohort of insertions during 2000-2001, the estimated cumulative incidence of alopecia was 0.33% (95% CI 0.07-0.95) in the responder population. The WHO database contained a further 68 reports.

CONCLUSIONS

Counselling prior to insertion of the levonorgestrel IUD should include information on systemic effects, including the possibility of alopecia.

[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.

Cost-effectiveness of treatments for dysfunctional uterine bleeding in women who need contraception

OBJECTIVE

This study aims to compare the cost-effectiveness of oral contraceptives (OCs), the levonorgestrel-releasing intrauterine system (LNG-IUS) and surgical management in treating dysfunctional uterine bleeding (DUB) in women not desiring additional children.

METHOD

A Markov model was constructed from the perspective of the health services payers for a 5-year period. Treatment costs, DUB treatment success rates and contraception success rates were obtained through a literature review.

RESULTS

In women not responding to an initial trial of OCs, surgical management was more effective than the LNG-IUS (95.5% vs. 92%) but at higher cost (US$4853 vs. US$2796 per woman). Among responders to OCs, continuing treatment with the LNG-IUS instead of OCs was more effective (92% vs. 90.4%) and less expensive (US$2796 vs. US$4711). For women naïve to medical therapy, the LNG-IUS and OCs had similar effectiveness, but cost for the LNG-IUS was lower (US$2796 vs. US$4895). In all scenarios, surgery followed if medical therapy failed; rates of primary method failure were 62.5% with OCs and 34% with the LNG-IUS at 12 months.

CONCLUSIONS

Treatment strategies employing the LNG-IUS are the most cost-effective in managing DUB, regardless of whether a woman has previously tried OC therapy.

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.