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Use of the Levonorgestrel Intrauterine Device in an Adolescent with Type IV Vascular Ehlers-Danlos Syndrome and Heavy Menstrual Bleeding, a Case Report. J Pediatr Adolesc Gynecol 2023; 36:331-333. [PMID: 36813023 DOI: 10.1016/j.jpag.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Ehlers-Danlos syndrome (EDS) is a group of connective tissue disorders of altered collagen synthesis. People with vascular EDS are at increased risk for vascular and hollow viscous rupture. Heavy menstrual bleeding (HMB) is common among adolescents with EDS. The levonorgestrel intrauterine device (LNG-IUD) is an effective treatment option for HMB; however, its use in patients with vascular EDS has historically been avoided due to perceived risk of uterine rupture. This is the first known case report on use of the LNG-IUD in an adolescent with vascular EDS. CASE A 16-year-old female with vascular EDS and HMB underwent placement of the LNG-IUD. Placement of the device was performed in the operating room under ultrasound guidance. At the 6-month follow-up, the patient reported significant improvement in bleeding and high satisfaction. No complications were identified at the time of placement or follow-up. SUMMARY AND CONCLUSION LNG-IUD may be a safe and effective option for menstrual management in individuals with vascular EDS.
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Demographic, Reproductive, and Medical Risk Factors for Intrauterine Device Expulsion. Obstet Gynecol 2022; 140:1017-1030. [PMID: 36357958 PMCID: PMC9665953 DOI: 10.1097/aog.0000000000005000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To explore to what extent intrauterine device (IUD) expulsion is associated with demographic and clinical risk factors. METHODS The APEX-IUD (Association of Perforation and Expulsion of IntraUterine Devices) study was a U.S. cohort study using electronic health records from three integrated health care systems (Kaiser Permanente Northern California, Southern California, and Washington) and a health care information exchange (Regenstrief Institute). These analyses included individuals aged 50 years or younger with IUD insertions from 2001 to 2018. Intrauterine device expulsion cumulative incidence and incidence rates were estimated. Using Cox regression models, hazard ratios with 95% CIs were estimated before and after adjustment for risk factors of interest (age, race and ethnicity, parity, body mass index [BMI], heavy menstrual bleeding, and dysmenorrhea) and potential confounders. RESULTS In total, 228,834 individuals with IUD insertion and no delivery in the previous 52 weeks were identified (184,733 [80.7%] with levonorgestrel-releasing intrauterine system). Diagnosis of heavy menstrual bleeding-particularly a diagnosis in both recent and past periods-was the strongest risk factor for IUD expulsion. Categories with the highest risk of IUD expulsion within each risk factor included individuals diagnosed with overweight, obesity, and morbid obesity; those in younger age groups, especially among those aged 24 years or younger; and in those with parity of four or more. Non-Hispanic White individuals had the lowest incidence and risk, and after adjustment, Asian or Pacific Islander individuals had the highest risk. Dysmenorrhea was not independently associated with expulsion risk when adjusting for heavy menstrual bleeding. CONCLUSION Most risk factors for expulsion identified in this study appear consistent with known physiologic factors that affect uterine anatomy and physiology (age, BMI, heavy menstrual bleeding, parity). The increased risk of IUD expulsion among individuals of color warrants further investigation. Intrauterine devices are an effective long-term contraceptive; expulsion is uncommon, but patients should be counseled accordingly. FUNDING SOURCE Bayer AG. CLINICAL TRIAL REGISTRATION EU PAS register, EUPAS33461.
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Getahun D, Fassett MJ, Gatz J, Armstrong MA, Peipert JF, Raine-Bennett T, Reed SD, Zhou X, Schoendorf J, Postlethwaite D, Shi JM, Saltus CW, Wang J, Xie F, Chiu VY, Merchant M, Alabaster A, Ichikawa LE, Hunter S, Im TM, Takhar HS, Ritchey ME, Chillemi G, Pisa F, Asiimwe A, Anthony MS. Association between menorrhagia and risk of intrauterine device–related uterine perforation and device expulsion: results from the Association of Uterine Perforation and Expulsion of Intrauterine Device study. Am J Obstet Gynecol 2022. [DOI: 59.e110.1016/j.ajog.2022.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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Huguelet PS, Laurin JL, Thornhill D, Moyer G. Use of the Levonorgestrel Intrauterine System to Treat Heavy Menstrual Bleeding in Adolescents and Young Adults with Inherited Bleeding Disorders and Ehlers-Danlos Syndrome. J Pediatr Adolesc Gynecol 2022; 35:147-152.e1. [PMID: 34775059 DOI: 10.1016/j.jpag.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 10/05/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE To report on the rate of amenorrhea among adolescents and young adults with a bleeding diathesis after insertion of the 52-mg levonorgestrel intrauterine system (LNG-IUS) DESIGN: Retrospective chart review SETTING: Tertiary care, multidisciplinary Gynecology-Hematology clinic or Adolescent Gynecology clinic PARTICIPANTS: The cohort included 35 females aged 12-25 years presenting from January 2010 to January 2020 with heavy menstrual bleeding, 23 with an inherited blood disorder, and 12 with Ehlers-Danlos syndrome INTERVENTIONS: The 52-mg LNG-IUS MAIN OUTCOME MEASURES: Primary outcome was bleeding profile after LNG-IUS insertion. Secondary outcomes included rates of amenorrhea, intrauterine device (IUD) expulsion, IUD discontinuation, and unplanned pregnancy. RESULTS Mean age at menarche was 11.6 years, with mean age at insertion of 16.9 (range 11-23). Most participants were white (n = 26, 74.3%). Von Willebrand disease was present in 16 patients (45.7%) and Ehlers-Danlos syndrome in 12 (34.3%). Most (91.4%) had tried at least 1 hormonal regimen prior to LNG-IUS. Most participants (81.8%) reported improvement in bleeding, with 60.6% reporting spotting or amenorrhea. LNG-IUS expulsion occurred in 3 participants (9.1%) within the first 21 days, despite hemostatic agents at time of insertion. Mean continuation was 5.08 years (95% CI, 4.24-5.92), with 79% likelihood that participants kept their IUD in place for at least 2.5 years, and some up to 6 years. CONCLUSION The 52-mg LNG-IUS is an effective treatment option for adolescents and young adults with heavy menstrual bleeding and a bleeding diathesis, with high rates of amenorrhea. Rates of IUD expulsion appeared higher during the first 30 days, but long-term continuation remained high.
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Affiliation(s)
- Patricia S Huguelet
- Section of Pediatric and Adolescent Gynecology, Children's Hospital Colorado, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - J L Laurin
- Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - D Thornhill
- Department of Pediatrics, Division of Hematology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - G Moyer
- Department of Internal Medicine, Division of Hematology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Getahun D, Fassett MJ, Gatz J, Armstrong MA, Peipert JF, Raine-Bennett T, Reed SD, Zhou X, Schoendorf J, Postlethwaite D, Shi JM, Saltus CW, Wang J, Xie F, Chiu VY, Merchant M, Alabaster A, Ichikawa LE, Hunter S, Im TM, Takhar HS, Ritchey ME, Chillemi G, Pisa F, Asiimwe A, Anthony MS. Association between menorrhagia and risk of intrauterine device-related uterine perforation and device expulsion: results from the Association of Uterine Perforation and Expulsion of Intrauterine Device study. Am J Obstet Gynecol 2022; 227:59.e1-59.e9. [PMID: 35292234 DOI: 10.1016/j.ajog.2022.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/31/2022] [Accepted: 03/06/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Intrauterine devices are effective instruments for contraception, and 1 levonorgestrel-releasing device is also indicated for the treatment of heavy menstrual bleeding (menorrhagia). OBJECTIVE To compare the incidence of intrauterine device expulsion and uterine perforation in women with and without a diagnosis of menorrhagia within the first 12 months before device insertion STUDY DESIGN: This was a retrospective cohort study conducted in 3 integrated healthcare systems (Kaiser Permanente Northern California, Southern California, and Washington) and a healthcare information exchange (Regenstrief Institute) in the United States using electronic health records. Nonpostpartum women aged ≤50 years with intrauterine device (eg, levonorgestrel or copper) insertions from 2001 to 2018 and without a delivery in the previous 12 months were studied in this analysis. Recent menorrhagia diagnosis (ie, recorded ≤12 months before insertion) was ascertained from the International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes. The study outcomes, viz, device expulsion and device-related uterine perforation (complete or partial), were ascertained from electronic medical records and validated in the data sources. The cumulative incidence and crude incidence rates with 95% confidence intervals were estimated. Cox proportional hazards models estimated the crude and adjusted hazard ratios using propensity score overlap weighting (13-16 variables) and 95% confidence intervals. RESULTS Among 228,834 nonpostpartum women, the mean age was 33.1 years, 44.4% of them were White, and 31,600 (13.8%) had a recent menorrhagia diagnosis. Most women had a levonorgestrel-releasing device (96.4% of those with and 78.2% of those without a menorrhagia diagnosis). Women with a menorrhagia diagnosis were likely to be older, obese, and have dysmenorrhea or fibroids. Women with a menorrhagia diagnosis had a higher intrauterine device-expulsion rate (40.01 vs 10.92 per 1000 person-years) than those without, especially evident in the first few months after insertion. Women with a menorrhagia diagnosis had a higher cumulative incidence (95% confidence interval) of expulsion (7.00% [6.70-7.32] at 1 year and 12.03% [11.52-12.55] at 5 years) vs those without (1.77% [1.70-1.84] at 1 year and 3.69% [3.56-3.83] at 5 years). The risk of expulsion was increased for women with a menorrhagia diagnosis vs for those without (adjusted hazard ratio, 2.84 [95% confidence interval, 2.66-3.03]). The perforation rate was low overall (<1/1000 person-years) but higher in women with a diagnosis of menorrhagia vs in those without (0.98 vs 0.63 per 1000 person-years). The cumulative incidence (95% confidence interval) of uterine perforation was slightly higher for women with a menorrhagia diagnosis (0.09% [0.06-0.14] at 1 year and 0.39% [0.29-0.53] at 5 years) than those without it (0.07% [0.06-0.08] at 1 year and 0.28% [0.24-0.33] at 5 years). The risk of perforation was slightly increased in women with a menorrhagia diagnosis vs in those without (adjusted hazard ratio, 1.53; 95% confidence interval, 1.10-2.13). CONCLUSION The risk of expulsion is significantly higher in women with a recent diagnosis of menorrhagia. Patient education and counseling regarding the potential expulsion risk is recommended at insertion. The absolute risk of perforation for women with a recent diagnosis of menorrhagia is very low. The increased expulsion and perforation rates observed are likely because of causal factors of menorrhagia.
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Peng Y, Dai Y, Yu G, Yang X, Wen C, Jin P. Clinical evaluation of HIFU combined with GnRH-a and LNG-IUS for adenomyosis patients who failed to respond to drug therapies: two-year follow-up results. Int J Hyperthermia 2021; 38:1271-1275. [PMID: 34423729 DOI: 10.1080/02656736.2021.1967467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To investigate the clinical effect of high intensity focused ultrasound (HIFU) ablation combined with gonadotropin-releasing hormone agonist (GnRH-a) and levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of adenomyosis patients who failed to respond to drug therapies. STUDY DESIGN A total of 47 patients with adenomyosis who had failed to respond to drug therapies and had no fertility desires were treated with HIFU combined with GnRH-a and LNG-IUS. The score of dysmenorrhea and menstrual volume were measured at pre and 6-, 12-, 18-, 24-month post-HIFU. RESULTS All patients completed HIFU ablation without major postoperative complications. Compared with the symptom scores before the HIFU treatment, the score of dysmenorrhea and menstrual volume decreased significantly at 6, 12, 18 and 24 months after HIFU treatment (p < 0.05), but no significant difference was observed between 6, 12, 18 and 24 months after HIFU (p > 0.05). The clinical success rate was 100%, 100%, 95.7% and 93.6% respectively at 6, 12, 18 and 24 months after the combined treatment. CONCLUSION The combined therapeutic regimen of HIFU, GnRH-a and LNS-IUS is safe and effective, which can be an alternative treatment option for patients with adenomyosis who failed to respond to drug therapies to avoid adenomyomectomy or hysterectomy.
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Affiliation(s)
- Yan Peng
- Department of Gynecology, Shenzhen Maternity and Child Health Hospital Affiliated to Southern Medical University, Shenzhen, China
| | - Yu Dai
- Department of Gynecology, Shenzhen Maternity and Child Health Hospital Affiliated to Southern Medical University, Shenzhen, China
| | - Guiyuan Yu
- Department of Gynecology, Shenzhen Maternity and Child Health Hospital Affiliated to Southern Medical University, Shenzhen, China
| | - Xiaorong Yang
- Department of Gynecology, Shenzhen Maternity and Child Health Hospital Affiliated to Southern Medical University, Shenzhen, China
| | - Cuili Wen
- Department of Gynecology, Shenzhen Maternity and Child Health Hospital Affiliated to Southern Medical University, Shenzhen, China
| | - Ping Jin
- Department of Gynecology, Shenzhen Maternity and Child Health Hospital Affiliated to Southern Medical University, Shenzhen, China
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Abstract
Perimenopause represents a transition period of a woman's life during which physiological, affective, psychological, and social changes mark progression from a woman's fertile life to menopause, with wide sexual hormones fluctuations until the onset of hypergonadotropic hypogonadic amenorrhea. Contraception during menopause should not only avoid unwanted pregnancies, but also improve quality of life and prevent wide range of condition affecting this population. Hormonal contraceptives confer many noncontraceptive benefits for women approaching menopause: treatment of abnormal uterine bleeding, relief from vasomotor symptoms, endometrial protection in women using estrogen therapy, musculoskeletal protection, and mood disorders protection. The main point remains selecting the most adequate contraceptive option for each woman, considering her risk factor, comorbidities, and keeping in mind the possibility of continuing contraception until reaching menopause and even further, creating a bridge between perimenopause and menopause hormonal therapy. Correct perimenopause management should rely on individualized medical therapy and multidisciplinary approach considering lifestyle and food habits as part of general good health of a woman.
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Affiliation(s)
- Libera Troìa
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecology, University of Siena, Siena, Italy
| | - Simona Martone
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecology, University of Siena, Siena, Italy
| | - Giuseppe Morgante
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecology, University of Siena, Siena, Italy
| | - Stefano Luisi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecology, University of Siena, Siena, Italy
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Harris S, Kaneshiro B, Ahn HJ, Saito-Tom L. Timing of insertion affects expulsion in patients using the levonorgestrel 52 mg intrauterine system for noncontraceptive indications. Contraception 2020; 103:185-189. [PMID: 33290726 DOI: 10.1016/j.contraception.2020.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 11/25/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate levonorgestrel 52 mg intrauterine system (IUS) expulsion risk by menstrual cycle day of insertion (days 1-8 vs days 9 and beyond) in women using the IUS for noncontraceptive indications. STUDY DESIGN We performed a retrospective cohort study of patients with a levonorgestrel IUS inserted for the management of noncontraceptive, gynecologic conditions at Kaiser Permanente-Hawaii between January 2009 and December 2010. We used multivariable logistic regression models to estimate the likelihood of IUS expulsion adjusting for demographic and clinical factors and a Kaplan-Meier curve for survival analysis. RESULTS Of 176 patients identified, insertion occurred in 42 patients in cycle days 1 to 8 and 87 patients after day 8. Patient follow-up within the Kaiser system ranged from 1 to 71 months. Thirty-nine (22%) patients experienced expulsion, 16 (38%) and 15 (17%) for the 2 timing groups, respectively. Expulsion was more likely if the IUS placement occurred during the menstrual cycle days 1 to 8 (adjusted odds ratio 3.57 [95% confidence interval 1.13, 11.31]), which was consistent with the Kaplan-Meier analysis (p = 0.008). CONCLUSION Levonorgestrel IUS expulsion among women using the IUS for noncontraceptive indications occurred more frequently if insertion occurred during the first eight days of the menstrual cycle. IMPLICATIONS In women planning to use the levonorgestrel IUS to treat gynecologic conditions such as abnormal uterine bleeding, dysmenorrhea, and endometrial hyperplasia, providers should consider waiting until after cycle day 8 to perform insertion.
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Affiliation(s)
- Sara Harris
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology, and Women's Health, Honolulu, HI, United States
| | - Bliss Kaneshiro
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology, and Women's Health, Honolulu, HI, United States
| | - Hyeong Jun Ahn
- University of Hawaii, John A. Burns School of Medicine, Office of Biostatistics & Quantitative Health Sciences, Honolulu, HI, United States
| | - Lynne Saito-Tom
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology, and Women's Health, Honolulu, HI, United States.
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Bofill Rodriguez M, Lethaby A, Jordan V. Progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev 2020; 6:CD002126. [PMID: 32529637 PMCID: PMC7388184 DOI: 10.1002/14651858.cd002126.pub4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) impacts the quality of life of otherwise healthy women. The perception of HMB is subjective and management depends upon, among other factors, the severity of the symptoms, a woman's age, her wish to get pregnant, and the presence of other pathologies. Heavy menstrual bleeding was classically defined as greater than or equal to 80 mL of blood loss per menstrual cycle. Currently the definition is based on the woman's perception of excessive bleeding which is affecting her quality of life. The intrauterine device was originally developed as a contraceptive but the addition of progestogens to these devices resulted in a large reduction in menstrual blood loss: users of the levonorgestrel-releasing intrauterine system (LNG-IUS) reported reductions of up to 90%. Insertion may, however, be regarded as invasive by some women, which affects its acceptability. OBJECTIVES To determine the effectiveness, acceptability and safety of progestogen-releasing intrauterine devices in reducing heavy menstrual bleeding. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL (from inception to June 2019); and we searched grey literature and for unpublished trials in trial registers. SELECTION CRITERIA We included randomised controlled trials (RCTs) in women of reproductive age treated with LNG-IUS devices versus no treatment, placebo, or other medical or surgical therapy for heavy menstrual bleeding. DATA COLLECTION AND ANALYSIS Two authors independently extracted data, assessed risk of bias and conducted GRADE assessments of the certainty of evidence. MAIN RESULTS We included 25 RCTs (2511 women). Limitations in the evidence included risk of attrition bias and low numbers of participants. The studies compared the following interventions. LNG-IUS versus other medical therapy The other medical therapies were norethisterone acetate, medroxyprogesterone acetate, oral contraceptive pill, mefenamic acid, tranexamic acid or usual medical treatment (where participants could choose the oral treatment that was most suitable). The LNG-IUS may improve HMB, lowering menstrual blood loss according to the alkaline haematin method (mean difference (MD) 66.91 mL, 95% confidence interval (CI) 42.61 to 91.20; 2 studies, 170 women; low-certainty evidence); and the Pictorial Bleeding Assessment Chart (MD 55.05, 95% CI 27.83 to 82.28; 3 studies, 335 women; low-certainty evidence). We are uncertain whether the LNG-IUS may have any effect on women's satisfaction up to one year (RR 1.28, 95% CI 1.01 to 1.63; 3 studies, 141 women; I² = 0%, very low-certainty evidence). The LNG-IUS probably leads to slightly higher quality of life measured with the SF-36 compared with other medical therapy if (MD 2.90, 95% CI 0.06 to 5.74; 1 study: 571 women; moderate-certainty evidence) or with the Menorrhagia Multi-Attribute Scale (MD 13.40, 95% CI 9.89 to 16.91; 1 trial, 571 women; moderate-certainty evidence). The LNG-IUS and other medical therapies probably give rise to similar numbers of women with serious adverse events (RR 0.91, 95% CI 0.63 to 1.30; 1 study, 571 women; moderate-certainty evidence). Women using other medical therapy are probably more likely to withdraw from treatment for any reason (RR 0.49, 95% CI 0.39 to 0.60; 1 study, 571 women, moderate-certainty evidence) and to experience treatment failure than women with LNG-IUS (RR 0.34, 95% CI 0.26 to 0.44; 6 studies, 535 women; moderate-certainty evidence). LNG-IUS versus endometrial resection or ablation (EA) Bleeding outcome results are inconsistent. We are uncertain of the effect of the LNG-IUS compared to EA on rates of amenorrhoea (RR 1.21, 95% CI 0.85 to 1.72; 8 studies, 431 women; I² = 21%; low-certainty evidence) and hypomenorrhoea (RR 0.98, 95% CI 0.73 to 1.33; 4 studies, 200 women; low-certainty evidence) and eumenorrhoea (RR 0.55, 95% CI 0.30 to 1.00; 3 studies, 160 women; very low-certainty evidence). We are uncertain whether both treatments may have similar rates of satisfaction with treatment at 12 months (RR 0.95, 95% CI 0.85 to 1.07; 5 studies, 317 women; low-certainty evidence). We are uncertain if the LNG-IUS compared to EA has any effect on quality of life, measured with SF-36 (MD -14.40, 95% CI -22.63 to -6.17; 1 study, 33 women; very low-certainty evidence). Women with the LNG-IUS compared with EA are probably more likely to have any adverse event (RR 2.06, 95% CI 1.44 to 2.94; 3 studies, 201 women; moderate-certainty evidence). Women with the LNG-IUS may experience more treatment failure compared to EA at one year follow up (persistent HMB or requirement of additional treatment) (RR 1.78, 95% CI 1.09 to 2.90; 5 studies, 320 women; low-certainty evidence); or requirement of hysterectomy may be higher at one year follow up (RR 2.56, 95% CI 1.48 to 4.42; 3 studies, 400 women; low-certainty evidence). LNG-IUS versus hysterectomy We are uncertain whether the LNG-IUS has any effect on HMB compared with hysterectomy (RR for amenorrhoea 0.52, 95% CI 0.39 to 0.70; 1 study, 75 women; very low-certainty evidence). We are uncertain whether there is difference between LNG-IUS and hysterectomy in satisfaction at five years (RR 1.01, 95% CI 0.94 to 1.08; 1 study, 232 women; low-certainty evidence) and quality of life (SF-36 MD 2.20, 95% CI -2.93 to 7.33; 1 study, 221 women; low-certainty evidence). Women in the LNG-IUS group may be more likely to have treatment failure requiring hysterectomy for HMB at 1-year follow-up compared to the hysterectomy group (RR 48.18, 95% CI 2.96 to 783.22; 1 study, 236 women; low-certainty evidence). None of the studies reported cost data suitable for meta-analysis. AUTHORS' CONCLUSIONS The LNG-IUS may improve HMB and quality of life compared to other medical therapy; the LNG-IUS is probably similar for HMB compared to endometrial destruction techniques; and we are uncertain if it is better or worse than hysterectomy. The LNG-IUS probably has similar serious adverse events to other medical therapy and it is more likely to have any adverse events than EA.
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Affiliation(s)
| | - Anne Lethaby
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Vanessa Jordan
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
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10
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Abstract
Family planning represents a key component of reproductive health care. Accordingly, the provision of contraception must span the reproductive age spectrum, including perimenopause. The risk of pregnancy is decreased, but not trivial, among women over 40 years of age. Evidence-based guidelines for contraceptive use can assist clinicians in counseling their patients in this population. Intrauterine contraception is one of the most effective methods and is safe to use in midlife women with few exceptions. Progestin-only contraception is another safe option for most midlife women because it is not associated with an increased risk of cardiovascular complications. Combined (estrogen-containing) contraception can be safely used by midlife women who do not have cardiovascular risk factors. Unique noncontraceptive benefits for this population include: improvement in abnormal uterine bleeding, decreased hot flashes, and decreased cancer risk. Finally, guidelines state that contraception can be used by midlife women without medical contraindications until the age of menopause, at which time they may consider transition to systemic hormone therapy.
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Hayes SN, Kim ESH, Saw J, Adlam D, Arslanian-Engoren C, Economy KE, Ganesh SK, Gulati R, Lindsay ME, Mieres JH, Naderi S, Shah S, Thaler DE, Tweet MS, Wood MJ. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e523-e557. [PMID: 29472380 PMCID: PMC5957087 DOI: 10.1161/cir.0000000000000564] [Citation(s) in RCA: 695] [Impact Index Per Article: 115.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.
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13
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Carvalho NM, Chou V, Modesto W, Margatho D, Garcia EAL, Bahamondes L. Relationship between user satisfaction with the levonorgestrel-releasing intrauterine system and bleeding patterns. J Obstet Gynaecol Res 2017; 43:1732-1737. [PMID: 28833891 DOI: 10.1111/jog.13441] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 05/11/2017] [Accepted: 05/28/2017] [Indexed: 11/29/2022]
Abstract
AIM Satisfaction with a contraceptive method constitutes an important factor in its acceptance and long-term use. The objective of this study was to assess the relationship between user satisfaction with the 20-μg/day levonorgestrel-releasing intrauterine system (LNG-IUS) and the bleeding patterns reported at two different time-points during follow-up. METHODS A total of 251 LNG-IUS users aged 18-45 years were invited to answer a questionnaire on their return to the clinic for a routine follow-up visit and again 1 year later. Data were collected face-to-face. RESULTS Twenty women discontinued prematurely; therefore, the analysis was performed on 231 women. Most users were either highly satisfied (66.6% and 66.2% at the first and second interviews, respectively) or satisfied (26.4% and 26.4% at the first and second interviews, respectively) with the LNG-IUS. Satisfaction was related to amenorrhea (P < 0.001) and duration of use (P < 0.001). Prolonged bleeding and spotting were the main causes of dissatisfaction with the device. CONCLUSION Most LNG-IUS users in this sample were satisfied with the device. The only two factors associated with satisfaction were amenorrhea and duration of use, while prolonged bleeding and spotting were the main causes of dissatisfaction. These findings could be useful for health-care professionals and policy-makers when developing information material for women. The study provides insight into the profile of satisfied LNG-IUS users; however, this information is not suitable for counseling women who are considering using an LNG-IUS.
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Affiliation(s)
- Nelsilene M Carvalho
- Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Campinas, São Paulo, Brazil
| | - Victoria Chou
- Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Campinas, São Paulo, Brazil
| | - Waleska Modesto
- Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Campinas, São Paulo, Brazil
| | - Deborah Margatho
- Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Campinas, São Paulo, Brazil
| | - Elaine A L Garcia
- Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Campinas, São Paulo, Brazil
| | - Luis Bahamondes
- Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Campinas, São Paulo, Brazil
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Yao X, Stewart EA, Laughlin-Tommaso SK, Heien HC, Borah BJ. Medical therapies for heavy menstrual bleeding in women with uterine fibroids: a retrospective analysis of a large commercially insured population in the USA. BJOG 2016; 124:322-330. [PMID: 27770484 DOI: 10.1111/1471-0528.14383] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To report patterns and patient characteristics associated with initiation of and persistence with medical therapies for uterine fibroid-related heavy menstrual bleeding. DESIGN Retrospective cohort study. SETTING US commercial insurance claims database. POPULATION 41 561 women aged 18-54 years with uterine fibroids and heavy menstrual bleeding who initiated medical therapies from January 2000 through December 2013. METHOD Multinomial logistic regression was used to assess patient characteristics associated with initiation and persistence. Cox proportional hazards regression was used on propensity score-matched cohorts to examine change from index medication. MAIN OUTCOMES MEASURES Initiation of and persistence with four first-line medical therapies: short- and long-acting reversible contraceptive steroids, leuprolide acetate, and tranexamic acid. RESULTS Most women (79.4%) took short-acting reversible contraceptive steroids as first-line therapy (index medication), whereas 9.5%, 8.5%, and 2.7% used long-acting reversible contraceptive steroids, leuprolide acetate, and tranexamic acid, respectively. During follow-up, 16 594 women (39.9%) switched to nonindex medication (18.4%) or procedural treatment (81.6%). In comparison with women taking short-acting steroids, those receiving long-acting steroids were less likely to switch [hazard ratio (HR) 0.84, 95% CI 0.79-0.91], whereas women taking leuprolide acetate (HR 2.44, 95% CI 2.27-2.62) or tranexamic acid (HR 1.44, 95% CI 1.26-1.65) were more likely to switch. Older age, emergency department visits, anaemia, and inflammatory disease diagnoses at baseline were associated with increased probability of discontinuing the index medication or switching to another therapy. CONCLUSIONS Women with uterine fibroid-related heavy menstrual bleeding were more likely to persist with their initial therapy of long-acting reversible contraceptive steroid compared with other medical options. TWEETABLE ABSTRACT 80% women with fibroid-related heavy menstrual bleeding use SARC, but LARC users are more persistent.
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Affiliation(s)
- X Yao
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.,The Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - E A Stewart
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | | | - H C Heien
- The Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - B J Borah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.,The Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
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15
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Nelson AL, Massoudi N. New developments in intrauterine device use: focus on the US. Open Access J Contracept 2016; 7:127-141. [PMID: 29386944 PMCID: PMC5683151 DOI: 10.2147/oajc.s85755] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Many more women in the US today rely upon intrauterine devices (IUDs) than in the past. This increased utilization may have substantially contributed to the decline in the percentage of unintended pregnancies in the US. Evidence-based practices have increased the number of women who are medically eligible for IUDs and have enabled more rapid access to the methods. Many women enjoy freedom to use IUDs without cost, but for many the impact of the Affordable Care Act has yet to be realized. Currently, there are three hormonal IUDs and one copper IUD available in the US. Each IUD is extremely effective, convenient, and safe. The newer IUDs have been tested in populations not usually included in clinical trials and provide reassuring answers to older concerns about IUD use in these women, including information about expulsion, infection, and discontinuation. On the other hand, larger surveillance studies have provided new estimates about the risks of complications such as perforation, especially in postpartum and breastfeeding women. This article summarizes significant features of each IUD and provides a summary of the differences to aid clinicians in the US and other countries in advising women about IUD choices.
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Affiliation(s)
- Anita L Nelson
- Department of Obstetrics and Gynecology, Los Angeles BioMedical Research Institute at Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, CA, USA
| | - Natasha Massoudi
- American University of the Caribbean School of Medicine, Cupecoy, Sint Maarten
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16
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Relationship between uterine volume and discontinuation of treatment with levonorgestrel-releasing intrauterine devices in patients with adenomyosis. Arch Gynecol Obstet 2016; 294:561-6. [DOI: 10.1007/s00404-016-4105-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 04/20/2016] [Indexed: 12/17/2022]
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Abstract
Approximately 30% of women will experience abnormal uterine bleeding (AUB) during their life time. Previous terms defining AUB have been confusing and imprecisely applied. As a consequence, both clinical management and research on this common problem have been negatively impacted. In 2011, the International Federation of Gynecology and Obstetrics (FIGO) Menstrual Disorders Group (FMDG) published PALM-COEIN, a new classification system for abnormal bleeding in the reproductive years. Terms such as menorrhagia, menometrorrhagia, metrorrhagia, dysfunctional uterine bleeding, polymenorrhea, oligomenorrhea, and uterine hemorrhage are no longer recommended. The PALM-COEIN system was developed to standardize nomenclature to describe the etiology and severity of AUB. A brief description of the PALM-COEIN nomenclature is presented as well as treatment options for each etiology. Clinicians will frequently encounter women with AUB and should report findings utilizing the PALM-COEIN system.
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Cristobal I, Lete LI, Viuda EDL, Perulero N, Arbat A, Canals I. One year quality of life measured with SEC-QoL in levonorgestrel 52 mg IUS users. Contraception 2016; 93:367-371. [PMID: 26764120 DOI: 10.1016/j.contraception.2015.12.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 12/23/2015] [Accepted: 12/30/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The present study aims to prospectively evaluate quality of life (QoL) of women using 52-mg levonorgestrel intrauterine system (LNG-IUS) for contraception determined through the Sociedad Española de Contracepción (Spanish contraception Society) (SEC)-QoL, a questionnaire specifically designed to assess the impact of contraceptive methods on QoL of fertile women. STUDY DESIGN We conducted a prospective observational multicenter study of 201 reproductive age women who initiated the LNG-IUS for contraception. Sociodemographic and clinical data were collected at baseline and 12 months afterwards. Participants filled in the SEC-QoL questionnaire at both visits. SEQ-QoL scores range from 0 (worst QoL) to 100 (best QoL). RESULTS Participants claimed an increased QoL 12 months after insertion in all five dimensions of SEC-QoL due to its high contraceptive efficacy and its capability to reduce other menstrual symptoms (e.g., heavy menstrual bleeding or dysmenorrhoea), overall exerting a positive impact on user's satisfaction. SEC-QoL general overall score went from a mean (S.D.) score of 46.3 (17.3) at baseline to 72.2 (14.8) 12 months afterwards (p<.001). Overall, 94.6% of women claimed having found additional benefits other than contraception. No pregnancies were reported during the 12 months of study duration, and only 14 women discontinued use of LNG-IUS (only two of them due to an adverse event), representing a continuation rate of 93%. CONCLUSIONS Women using LNG-IUS for contraception have an increased QoL after 12 months of use, demonstrated by the increased score in all dimensions of the SEC-QoL questionnaire. IMPLICATIONS The present study prospectively evaluated QoL of women using LNG-IUS for contraception through the SEC-QoL questionnaire. Participants claimed increased QoL 12 months afterwards, implying that women using LNG-IUS for contraception in usual clinical practise also benefit from the reduction of period-related symptoms, overall leading to very low discontinuation rates.
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Affiliation(s)
- Ignacio Cristobal
- Obstetrics and Gynaecology, Hospital La Zarzuela Madrid, Universidad Francisco de Vitoria, C/Pleyades, 25, 28023, Madrid, Spain.
| | - Luis Ignacio Lete
- Obstetrics and Gynaecology, University Hospital Araba, School of Medicine, Basque Country University, 01009, Vitoria, C/Jose Atxotegi, s/n, 01009, Vitoria-Gasteiz, Álava, Araba, Spain.
| | - Esther de la Viuda
- Obstetrics and Gynaecology, Hospital de Guadalajara, School of Medicine and Health Science, Alcala University, Guadalajara, C/Donante de Sangre, s/n, 19002, Guadalajara, Spain.
| | - Nuria Perulero
- Health Economics and Outcomes Research Real World Evidence Solutions, IMS Health, C/Dr Ferran, 25-27, 08020, Barcelona, Spain.
| | - Agnes Arbat
- Medical Department, Bayer Hispania, Avda. Baix Llobregat 3-5, 08970, Sant Joan Despí, Spain.
| | - Ignasi Canals
- Medical Department, Bayer Hispania, Avda. Baix Llobregat 3-5, 08970, Sant Joan Despí, Spain.
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19
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van Dijk MM, van Hanegem N, de Lange ME, Timmermans A. Treatment of Women With an Endometrial Polyp and Heavy Menstrual Bleeding: A Levonorgestrel-Releasing Intrauterine Device or Hysteroscopic Polypectomy? J Minim Invasive Gynecol 2015; 22:1153-62. [PMID: 26151760 DOI: 10.1016/j.jmig.2015.06.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 06/12/2015] [Accepted: 06/17/2015] [Indexed: 11/25/2022]
Abstract
We performed a literature review of reports comparing a levonorgestrel-releasing intrauterine device (LNG-IUD) with transcervical polyp resection (TCRP) as a treatment for heavy menstrual bleeding (HMB). Our second objective was to investigate the effectiveness of LNG-IUD and TCRP in reducing menstrual bleeding and the patient satisfaction with each technique. No previously reported studies have compared TCRP and LNG-IUD as treatment for HMB in premenopausal women with an endometrial polyp. Likewise, no studies are available on LNG-IUD as a treatment for HMB in the presence of an endometrial polyp. Several studies have found the LNG-IUD to be an effective treatment option for HMB, with high patient satisfaction rates. Evidence of the effectiveness of TCRP as treatment of HMB is scarce. Patient satisfaction is reported relatively good, although persistent or recurrent symptoms appear to be frequent. We conclude that no evidence is available on LNG-IUD as treatment for HMB in women with an endometrial polyp. We hypothesize that LNG-IUD could be a good alternative to TCRP for treating HMB in premenopausal women with a polyp; however, further evidence is needed, and a randomized controlled trial should be performed.
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Affiliation(s)
- Myrthe M van Dijk
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - Nehalennia van Hanegem
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands; Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, University of Maastricht, Maastricht, The Netherlands
| | - Maria E de Lange
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Anne Timmermans
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Lethaby A, Hussain M, Rishworth JR, Rees MC. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev 2015:CD002126. [PMID: 25924648 DOI: 10.1002/14651858.cd002126.pub3] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) is an important cause of ill health in women and it accounts for 12% of all gynaecology referrals in the UK. Heavy menstrual bleeding is clinically defined as greater than or equal to 80 mL of blood loss per menstrual cycle. However, women may complain of excessive bleeding when their blood loss is less than 80 mL. Hysterectomy is often used to treat women with this complaint but medical therapy may be a successful alternative.The intrauterine device was originally developed as a contraceptive but the addition of progestogens to these devices resulted in a large reduction in menstrual blood loss. Case studies of two types of progesterone or progestogen-releasing systems, Progestasert and Mirena, reported reductions of up to 90% and improvements in dysmenorrhoea (pain or cramps during menstruation). Insertion, however, may be regarded as invasive by some women, which affects its acceptability as a treatment. Frequent intermenstrual bleeding and spotting is also likely during the first few months after commencing treatment. OBJECTIVES To determine the effectiveness, acceptability and safety of progesterone or progestogen-releasing intrauterine devices in achieving a reduction in heavy menstrual bleeding. SEARCH METHODS All randomised controlled trials of progesterone or progestogen-releasing intrauterine devices for the treatment of heavy menstrual bleeding were obtained by electronic searches of The Cochrane Library, the specialised register of MDSG, MEDLINE (1966 to January 2015), EMBASE (1980 to January 2015), CINAHL (inception to December 2014) and PsycINFO (inception to January 2015). Additional searches were undertaken for grey literature and for unpublished trials in trial registers. Companies producing progestogen-releasing intrauterine devices and experts in the field were contacted for information on published and unpublished trials. SELECTION CRITERIA Randomised controlled trials in women of reproductive age treated with progesterone or progestogen-releasing intrauterine devices versus no treatment, placebo, or other medical or surgical therapy for heavy menstrual bleeding within primary care, family planning or specialist clinic settings were eligible for inclusion. Women with postmenopausal bleeding, intermenstrual or irregular bleeding, or pathological causes of heavy menstrual bleeding were excluded. DATA COLLECTION AND ANALYSIS Potential trials were independently assessed by at least two review authors. The review authors extracted the data independently and data were pooled where appropriate. Risk ratios (RRs) were estimated from the data for dichotomous outcomes and mean differences (MD) for continuous outcomes. The primary outcomes were reduction in menstrual blood loss and satisfaction; in addition, rate of adverse effects, changes in quality of life, failure of treatment and withdrawal from treatment were also assessed. MAIN RESULTS We included 21 RCTs (2082 women). The included trials mostly assessed the levonorgestrel-releasing intrauterine device (LNG IUS) (no conclusions could be reached from one small study assessing Progestasert which was discontinued in 2001) and so conclusions are based only on LNG IUS. Comparisons were made with placebo, oral medical treatment, endometrial destruction techniques and hysterectomy. Ratings for the overall quality of the evidence for each comparison ranged from very low to high. Limitations in the evidence included inadequate reporting of study methods and inconsistency.Seven studies compared the LNG IUS with oral medical therapy: either norethisterone acetate (NET) administered over most of the menstrual cycle, medroxyprogesterone acetate (MPA) (administered for 10 days), the oral contraceptive pill, mefenamic acid or usual medical treatment where participants could choose the oral treatment that was most suitable. The LNG IUS was more effective at reducing HMB as measured by the alkaline haematin method (MD 66.91 mL, 95% CI 42.61 to 91.20; two studies, 170 women; I(2) = 81%, low quality evidence) or by Pictorial Bleeding Assessment Chart (PBAC) scores (MD 55.05, 95% CI 27.83 to 82.28; three studies, 335 women; I(2) = 79%, low quality evidence), improving quality of life and a greater number of women continued with their treatment at two years when compared with oral treatment. Although substantial heterogeneity was identified for the bleeding outcomes, the direction of effect consistently favoured the LNG IUS. There was insufficient evidence to reach conclusions on satisfaction. Minor adverse effects (such as pelvic pain, breast tenderness and ovarian cysts) were more common with the LNG IUS.Ten studies compared the LNG IUS with endometrial destruction techniques: three with transcervical resection, one with rollerball ablation and six with thermal balloon ablation. Evidence was inconsistent and very low quality with respect to reduction in bleeding outcomes and satisfaction was comparable between treatments (low and moderate quality evidence). Improvements in quality of life were experienced with both types of treatment. Minor adverse events were more common with the LNG IUS overall, but it appeared more cost effective compared to thermal ablation within a two-year time frame in one study.Three studies compared the LNG IUS with hysterectomy. The LNG IUS was not as successful at reducing HMB as hysterectomy (high quality evidence). The women in these studies reported improved quality of life, regardless of treatment. In spite of the high rate of surgical treatment in those having LNG IUS within 10 years, the LNG IUS was more cost effective than hysterectomy. AUTHORS' CONCLUSIONS The levonorgestrel-releasing intrauterine device (LNG IUS) is more effective than oral medication as a treatment for heavy menstrual bleeding (HMB). It is associated with a greater reduction in HMB, improved quality of life and appears to be more acceptable long term but is associated with more minor adverse effects than oral therapy.When compared to endometrial ablation, it is not clear whether the LNG IUS offers any benefits with regard to reduced HMB and satisfaction rates and quality of life measures were similar. Some minor adverse effects were more common with the LNG IUS but it appeared to be more cost effective than endometrial ablation techniques.The LNG IUS was less effective than hysterectomy in reducing HMB. Both treatments improved quality of life but the LNG IUS appeared more cost effective than hysterectomy for up to 10 years after treatment.
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Affiliation(s)
- Anne Lethaby
- Department of Obstetrics and Gynaecology, University of Auckland, Private Bag 92019, Auckland, New Zealand, 1142
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Therapy of heavy menstrual bleeding in Korea: Subanalysis and results from a multinational clinical trial in the Asian region investigating the levonorgestrel-releasing intrauterine system versus conventional therapy. Obstet Gynecol Sci 2015; 58:162-70. [PMID: 25798431 PMCID: PMC4366870 DOI: 10.5468/ogs.2015.58.2.162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 08/19/2014] [Accepted: 09/22/2014] [Indexed: 11/08/2022] Open
Abstract
Objective To compare real-life clinical outcomes with the levonorgestrel-releasing intrauterine system (LNG-IUS) and conventional medical therapies (CMTs), including combined oral contraceptives and oral progestins in the treatment of idiopathic heavy menstrual bleeding (HMB) in South Korea. Methods This prospective, observational cohort study recruited a total of 647 women aged 18 to 45 years, diagnosed with HMB from 8 countries in Asia, including 209 women from South Korea (LNG-IUS, 169; CMTs, 40), who were followed up to one year. The primary outcome was cumulative continuation rate (still treated with LNG-IUS and CMTs) at 12 months. Secondary outcomes included bleeding pattern, assessment of the treatment efficacy by treating physician and safety profile. Results The continuation rate at 12 months was significantly higher with the LNG-IUS than CMTs (85.1% vs. 48.5%, respectively; P<0.0001). The 51.5% of CMTs patients discontinued treatment and 18.8% of LNG-IUS patients discontinued treatment. The most common reasons for discontinuation for CMTs were switching to another treatment and personal reasons. When compared to CMTs, the LNG-IUS offered better reduction in subjectively assessed menstrual blood loss and the number of bleeding days, tolerability and with better efficacy in HMB, as assessed by physician's final evaluation. Conclusion This study provides novel information on the real-life treatment patterns of HMB in South Korea. The efficacy of CMTs was inferior compared to the LNG-IUS in the clinical outcomes measured in this study. Due to the better compliance with LNG-IUS, the cumulative continuation rate is higher than CMTs. We conclude that the LNG-IUS should be used as the first-line treatment for HMB in Korean women, in line with international guidelines.
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Qiu J, Cheng J, Wang Q, Hua J. Levonorgestrel-releasing intrauterine system versus medical therapy for menorrhagia: a systematic review and meta-analysis. Med Sci Monit 2014; 20:1700-13. [PMID: 25245843 PMCID: PMC4181308 DOI: 10.12659/msm.892126] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background The aim of this study was to compare the effects of the levonorgestrel-releasing intrauterine system (LNG-IUS) with conventional medical treatment in reducing heavy menstrual bleeding. Material/Methods Relevant studies were identified by a search of MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and clinical trials registries (from inception to April 2014). Randomized controlled trials comparing the LNG-IUS with conventional medical treatment (mefenamic acid, tranexamic acid, norethindrone, medroxyprogesterone acetate injection, or combined oral contraceptive pills) in patients with menorrhagia were included. Results Eight randomized controlled trials that included 1170 women (LNG-IUS, n=562; conventional medical treatment, n=608) met inclusion criteria. The LNG-IUS was superior to conventional medical treatment in reducing menstrual blood loss (as measured by the alkaline hematin method or estimated by pictorial bleeding assessment chart scores). More women were satisfied with the LNG-IUS than with the use of conventional medical treatment (odds ratio [OR] 5.19, 95% confidence interval [CI] 2.73–9.86). Compared with conventional medical treatment, the LNG-IUS was associated with a lower rate of discontinuation (14.6% vs. 28.9%, OR 0.39, 95% CI 0.20–0.74) and fewer treatment failures (9.2% vs. 31.0%, OR 0.18, 95% CI 0.10–0.34). Furthermore, quality of life assessment favored LNG-IUS over conventional medical treatment, although use of various measurements limited our ability to pool the data for more powerful evidence. Serious adverse events were statistically comparable between treatments. Conclusions The LNG-IUS was the more effective first choice for management of menorrhagia compared with conventional medical treatment. Long-term, randomized trials are required to further investigate patient-based outcomes and evaluate the cost-effectiveness of the LNG-IUS and other medical treatments.
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Affiliation(s)
- Jin Qiu
- Department of Obstetrics and Gynecology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Jiajing Cheng
- Department of Obstetrics and Gynecology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Qingying Wang
- Department of Obstetrics and Gynecology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Jie Hua
- Department of Obstetrics and Gynecology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
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What to do when she's bleeding through: the recognition, evaluation, and management of abnormal uterine bleeding in adolescents. Curr Opin Pediatr 2014; 26:413-9. [PMID: 25007322 DOI: 10.1097/mop.0000000000000121] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This article reviews the current understanding and management of abnormal uterine bleeding (AUB) in adolescents. The readers will learn a practical approach to the evaluation and treatment of mild-to-severe uterine bleeding. RECENT FINDINGS In 2011, a new classification system was proposed to standardize the terminology used to describe AUB. This system is based on the pattern and etiology of bleeding and has been adopted by other organizations. The term dysfunctional uterine bleeding has been replaced by AUB. The negative effect of AUB on adolescents' quality of life is now well established. The levonorgestrel-releasing intrauterine system is considered a first-line treatment for heavy menstrual bleeding and should be considered, especially in those adolescents who may also need contraception. SUMMARY AUB is a common adolescent complaint that can vary from mild to life-threatening if not recognized and treated promptly. This article reviews the appropriate assessment and management of AUB and proposes a practical algorithm that can be used in an office or hospital setting.
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Hale GE, Robertson DM, Burger HG. The perimenopausal woman: endocrinology and management. J Steroid Biochem Mol Biol 2014; 142:121-31. [PMID: 24134950 DOI: 10.1016/j.jsbmb.2013.08.015] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Revised: 08/08/2013] [Accepted: 08/19/2013] [Indexed: 11/26/2022]
Abstract
This review focuses on the endocrine and physiological features of the transition to menopause, known as the menopausal transition or the perimenopause. The updated 2011 Stages of Reproductive Aging workshop (STRAW) system is presented with a discussion of the new subdivisions within stages -3 (late reproductive age) and +1 (postmenopause) and incorporation of FSH and other biomarkers in the supportive criteria. Ovarian follicle reserve and ovarian follicle dynamics are also discussed in terms of the changes that occur with reproductive aging, and the dramatic effect these changes have on the hypothalamic-pituitary-gonadal feedback system. Topics include the disruption of normal ovulatory function and related hormone secretion patterns, abnormal uterine bleeding, and the changes that occur in bone and the cardiovascular system. The review concludes with a discussion of management strategies. This article is part of a Special Issue entitled 'Menopause'.
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Affiliation(s)
- Georgina E Hale
- University of Sydney, Department of Medicine, NSW, Australia.
| | | | - Henry G Burger
- University of Sydney, Department of Medicine, NSW, Australia
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Xu L, Lee BS, Asif S, Kraemer P, Inki P. Satisfaction and health-related quality of life in women with heavy menstrual bleeding; results from a non-interventional trial of the levonorgestrel-releasing intrauterine system or conventional medical therapy. Int J Womens Health 2014; 6:547-54. [PMID: 24920936 PMCID: PMC4043813 DOI: 10.2147/ijwh.s57470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the patient satisfaction and health related quality of life (HRQoL) for levonorgestrel-releasing intrauterine system (LNG-IUS) versus conventional medical treatments ([CMTs] combined oral contraceptives, oral progestins, and antifibrinolytics, alone or in combination) in Asian women with heavy menstrual bleeding (HMB). Patients and methods A total of 647 patients diagnosed with HMB were recruited to this non-interventional study from the eight participating countries in Asia. Patient satisfaction was recorded at the last visit (at 12 months or premature discontinuation). At each visit (at 3, 6, and 12 months), patients completed the menorrhagia multi-attribute scale (MMAS) to assess HRQoL. Results A total of 83.5% of patients on the LNG-IUS were “very satisfied” or at least “satisfied” with the therapeutic effect of HMB treatment, compared with 59.2% of patients with CMTs (P<0.05). The mean (± standard deviation) MMAS score increased from 41.4±24.5 to 87.7±21.4 in the LNG-IUS arm, and from 44.1±24.9 to 73.1±25.3 in the CMTs arm. This increase was significantly higher in patients on the LNG-IUS, as compared with those on CMTs (P<0.05). The improvement in HRQoL in both treatment groups correlated with the body mass index of the patient, with larger improvement obtained in women with a higher body mass index. Conclusion The majority of women using the LNG-IUS or CMTs for HMB were satisfied with their treatment, and both treatment modalities were associated with significant improvements in HRQoL over time. The improvement was greater with the LNG-IUS, compared with CMTs.
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Affiliation(s)
- Ling Xu
- Department of Gynecology and Obstetrics, Peking Union Medical College Hospital, Beijing, People's Republic of China
| | - Byung Seok Lee
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Shaheena Asif
- Department of Gynaecology and Obstetrics, Surgimed Hospital, Lahore, Pakistan
| | - Peter Kraemer
- Global Medical Affairs Excellence and Operations, Berlin, Germany
| | - Pirjo Inki
- Global Medical Affairs Women's Healthcare, Bayer HealthCare, Berlin, Germany
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Long ME, Faubion SS, MacLaughlin KL, Pruthi S, Casey PM. Contraception and hormonal management in the perimenopause. J Womens Health (Larchmt) 2014; 24:3-10. [PMID: 24773233 DOI: 10.1089/jwh.2013.4544] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
This literature review focuses on contraception in perimenopausal women. As women age, their fecundity decreases but does not disappear until menopause. After age 40, 75% of pregnancies are unplanned and may result in profound physical and emotional impact. Clinical evaluation must be relied on to diagnose menopause, since hormonal levels fluctuate widely. Until menopause is confirmed, some potential for pregnancy remains; at age 45, women's sterility rate is 55%. Older gravidas experience higher rates of diabetes, hypertension, and death. Many safe and effective contraceptive options are available to perimenopausal women. In addition to preventing an unplanned and higher-risk pregnancy, perimenopausal contraception may improve abnormal uterine bleeding, hot flashes, and menstrual migraines. Long-acting reversible contraceptives, including the levonorgestrel intrauterine system (LNG-IUS), the etonogestrel subdermal implant (ESI), and the copper intrauterine device (Cu-IUD), provide high efficacy without estrogen. LNG-IUS markedly decreases menorrhagia commonly seen in perimenopause. Both ESI and LNG-IUS provide endometrial protection for women using estrogen for vasomotor symptoms. Women without cardiovascular risk factors can safely use combined hormonal contraception. The CDC's Medical Eligibility Criteria for Contraceptive Use informs choices for women with comorbidities. No medical contraindications exist for levonorgestrel emergency-contraceptive pills, though obesity does decrease efficacy. In contrast, the Cu-IUD provides reliable emergency and ongoing contraception regardless of body mass index (BMI).
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Affiliation(s)
- Margaret E Long
- 1 Division of Gynecology, Mayo Clinic , Rochester, Minnesota
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Youm J, Lee HJ, Kim SK, Kim H, Jee BC. Factors affecting the spontaneous expulsion of the levonorgestrel-releasing intrauterine system. Int J Gynaecol Obstet 2014; 126:165-9. [DOI: 10.1016/j.ijgo.2014.02.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 02/06/2014] [Accepted: 04/08/2014] [Indexed: 11/16/2022]
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28
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Zhao S, Deng J, Wang Y, Bi S, Wang X, Qin W, Huang Z, Li L, Mi X, Han L, Chang Q, Li J. Experience and levels of satisfaction with the levonorgestrel-releasing intrauterine system in China: a prospective multicenter survey. Patient Prefer Adherence 2014; 8:1449-55. [PMID: 25364235 PMCID: PMC4211859 DOI: 10.2147/ppa.s68299] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Although surveys conducted in Western countries have shown that the levonorgestrel-releasing intrauterine system (LNG-IUS; Mirena(®)) is well accepted by European women, its acceptance by Chinese women is not yet clearly known. The purpose of this study was to analyze the experiences and levels of satisfaction with Mirena among Chinese women living in 12 different cities. METHODS In total, 1,021 women who attended 21 medical centers for insertion of Mirena were invited to complete a questionnaire regarding their contraceptive decision at baseline (preinsertion), and two further questionnaires on their experience and satisfaction with Mirena at 3-6 months and 1 year after insertion. RESULTS At baseline, 36% of women self-reported heavy or very heavy menstrual bleeding, while 41% reported normal bleeding. The majority of women (98%) were satisfied with the preinsertion counseling, during which contraceptive reliability was identified as the most important reason for considering Mirena. Continuation rates for Mirena were 99% at 3-6 months and 93% at 12 months after insertion, and most women (92% and 93%, respectively) had less bleeding at these times. The percentage of women who rated Mirena as better than their previous contraceptive method was 63%. Overall, around 90% of respondents were very satisfied or rather satisfied with Mirena, and 64% stated that they would recommend it to their friends. CONCLUSION These data suggest that continuation and satisfaction rates with Mirena were very high, and that the device is well accepted by Chinese women.
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Affiliation(s)
- Shuping Zhao
- The Affiliated Hospital of the Medical College Qingdao University, Qingdao, People’s Republic of China
| | - Jihong Deng
- Kunming Maternal and Child Health Hospital, Kunming, People’s Republic of China
| | - Yan Wang
- Hubei Maternity and Child Health Hospital, Wuhan, People’s Republic of China
| | - Shiliang Bi
- West China Second University Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Xiaoye Wang
- Peking University Third Hospital, Beijing, People’s Republic of China
| | - Wen Qin
- Changzhou Maternity and Child Health Hospital, Affiliated to Nanjing Medical University, Jiangsu, People’s Republic of China
| | - Zirong Huang
- The Affiliated Women’s Hospital of Fudan University, Shanghai, People’s Republic of China
| | - Li Li
- Guangzhou Women and Children’s Medical Center, Guangzhou, People’s Republic of China
| | - Xin Mi
- Maternity and Child Health Care Hospital, Shunyi District, Beijing, People’s Republic of China
| | - Liping Han
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou City, Henan, People’s Republic of China
| | - Qing Chang
- Southwest Hospital, Chongqing City, Chongqing, People’s Republic of China
| | - Jian Li
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, People’s Republic of China
- Correspondence: Jian Li, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, 251 Yaojia Yuan Road, Beijing, People’s Republic of China, Tel +86 10 5227 5418, Fax +86 10 5227 5418, Email
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Abstract
Inherited platelet function disorders are of variable severity and unknown frequency and may be difficult to diagnose. Nevertheless, they are increasingly recognized as an important cause of bleeding in pediatrics, particularly in adolescent girls with menorrhagia, where they may be more common than von Willebrand disease. This article reviews the presentation of these disorders, summarizes the most common types of platelet function disorders, discusses the challenges in diagnostic testing, and details treatment and supportive care options.
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Affiliation(s)
- Dana C Matthews
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA; Cancer and Blood Disorders Center, Seattle Children's Hospital MS MB.8.501, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA.
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30
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Kaunitz AM. The levonorgestrel intrauterine system: effective non-surgical treatment for heavy menstrual bleeding. EVIDENCE-BASED MEDICINE 2013; 18:e57. [PMID: 23635841 DOI: 10.1136/eb-2013-101275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, , Jacksonville, Florida, USA
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31
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Khafizova L, Minas V, Alam MA. Induction of abortion following radiofrequency ablation of the endometrium: A case report and search for evidence-based practice. EUR J CONTRACEP REPR 2013; 19:66-70. [PMID: 24266730 DOI: 10.3109/13625187.2013.856407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Pregnancy following endometrial ablation is a rare event that carries significant risks to the mother. The majority of women elect to terminate such pregnancies. This brings into question which of the available methods should best be employed and what kinds of problems to anticipate. CASE We present a case of a pregnancy following radiofrequency endometrial ablation that was terminated surgically and review the relevant English literature. CONCLUSIONS Medical or surgical abortion can be considered as primary methods of terminating a first trimester intrauterine pregnancy following endometrial ablation. The choice will depend on patient preference but also on the available expertise. Cervical stenosis and/or intrauterine adhesions may limit the effectiveness of these methods. In such cases methotrexate is an alternative option, whereas hysterotomy or hysterectomy should be considered as final options. Counselling patients at the time of endometrial ablation regarding the need for contraception, even after prolonged periods of amenorrhoea is of paramount importance. Laparoscopic or hysteroscopic sterilisation can be offered together with endometrial ablation.
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Affiliation(s)
- Lilia Khafizova
- * Department of Orthopaedics, Aintree University Hospital , Liverpool, Merseyside
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Magon N, Chauhan M, Goel P, Malik S, Kapur K, Kriplani A, Dhaliwal L, Pandit SN. Levonorgestrel intrauterine system: Current role in management of heavy menstrual bleeding. J Midlife Health 2013; 4:8-15. [PMID: 23833527 PMCID: PMC3702077 DOI: 10.4103/0976-7800.109627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A review of literature was conducted to report on the effectiveness of levonorgestrel intrauterine system (LNG-IUS) in women with heavy menstrual bleeding (HMB). The relevant data were obtained by computerized searches of PubMed up to December 2012 and other references available with the authors. Information was obtained from references listed. Studies and case reports were excluded if they did not specifically provide information about LNG-IUS usage in women with HMB. After perusal, each relevant publication was summarized and appraised in terms of whether it contained information relevant to the stated objective. Available data shows that LNG-IUS therapy is effective and safe, providing significant reduction of menstrual bleeding in patients with HMB. LNG-IUS is a good strategy to reduce the number of hysterectomies in women with HMB.
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Affiliation(s)
- Navneet Magon
- Department of Obstetrics and Gynecology, Air Force Hospital, Kanpur, India
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33
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Shawki O, Wahba A, Magon N. Abnormal uterine bleeding in midlife: The role of levonorgestrel intrauterine system. J Midlife Health 2013; 4:36-9. [PMID: 23833532 PMCID: PMC3702063 DOI: 10.4103/0976-7800.109634] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Abnormal uterine bleeding is a common gynecological complaint affecting 10-30% of women in midlife and constitute about one-third of all outpatient gynecological visits. It adversely affects the quality of woman's life and can lead to psychological, social, medical, and sexual problems and thus necessitating appropriate and adequate management. Different treatment modalities for such problems are available, yet the levonorgestrel intrauterine system (LNG-IUS) has recently provided a good treatment option effective in treating such complaints and at the same time, having a reliable contraceptive effect which is desired by such age group. For women in their reproductive years, the LNG-IUS has become one of the most acceptable medical treatments for menorrhagia, reducing referrals to specialists, and decreasing the recourse to operative treatments. It is easy to insert, has a sustained effect, cost-effective, and well tolerated besides providing reliable contraception.
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Affiliation(s)
- Osama Shawki
- Department of Obstetrics and Gynecology, Cairo University Hospital, Egypt
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34
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Hoaglin DC, Filonenko A, Glickman ME, Wasiak R, Gidwani R. Use of mixed-treatment-comparison methods in estimating efficacy of treatments for heavy menstrual bleeding. Eur J Med Res 2013; 18:17. [PMID: 23786677 PMCID: PMC3698104 DOI: 10.1186/2047-783x-18-17] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 05/23/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A variety of pharmacological and surgical treatments have been developed for heavy menstrual bleeding (HMB), which can have negative physical, social, psychological, and economic consequences. We conducted a systematic literature review and mixed-treatment-comparison (MTC) meta-analysis of available data from randomized controlled trials (RCTs) to derive estimates of efficacy for 8 classes of treatments for HMB, to inform health-economic analysis and future studies. METHODS A systematic review identified RCTs that reported data on menstrual blood loss (MBL) at baseline and one or more follow-up times. Eight treatment classes were considered: COCs, danazol, endometrial ablation, LNG-IUS, placebo, progestogens given for less than 2 weeks out of 4 during the menstrual cycle, progestogens given for close to 3 weeks out of 4, and TXA. The primary measure of efficacy was the proportion of women who achieved MBL < 80 mL per cycle (month), as measured by the alkaline hematin method. A score less than 100 on an established pictorial blood-loss assessment chart (PBAC) was considered an acceptable substitute for MBL < 80 mL. Estimates of efficacy by treatment class and time were obtained from a Bayesian MTC model. The model also included effects for treatment class, study, and the combination of treatment class and study and an adjustment for baseline mean MBL. Several methodological challenges complicated the analysis. Some trials reported various summary statistics for MBL or PBAC, requiring estimation (with less precision) of % MBL < 80 mL or % PBAC < 100. Also, reported follow-up times varied substantially. RESULTS The evidence network involved 34 RCTs, with follow-up times from 1 to 36 months. Efficacy at 3 months of follow-up (estimated as the posterior median) ranged from 87.5% for the levonorgestrel-releasing intrauterine system (LNG-IUS) to 14.2% for progestogens administered for less than 2 weeks out of 4 in the menstrual cycle. The 95% credible intervals for most estimates were quite wide, mainly because of the limited evidence for many combinations of treatment class and follow-up time and the uncertainty from estimating % MBL < 80 mL or % PBAC < 100 from summary statistics. CONCLUSIONS LNG-IUS and endometrial ablation are very efficacious in treating HMB. The study yielded useful insights on using MTC in sparse evidence networks. Diversity of outcome measures and follow-up times in the HMB literature presented considerable challenges. The Bayesian credible intervals reflected the various sources of uncertainty.
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Affiliation(s)
- David C Hoaglin
- Consulting Statistician, 73 Hickory Road, Sudbury, MA, 01776, USA
| | | | - Mark E Glickman
- Center for Health Quality, Outcomes & Economics Research, Boston University, Edith Nourse Rogers Memorial Hospital (152), Bldg 70, 200 Springs Road, Bedford, MA, 01730, USA
| | - Radek Wasiak
- United BioSource Corporation, 26-28 Hammersmith Grove, London, W6 7HA, UK
| | - Risha Gidwani
- VA Health Economics Resource Center, 795 Willow Road 152 MPD, Menlo Park, CA, 94025, USA
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35
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Affiliation(s)
- Rebecca H Allen
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI, USA. rhallen@wihri
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36
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Added health benefits of the levonorgestrel contraceptive intrauterine system and other hormonal contraceptive delivery systems. Contraception 2013; 87:273-9. [DOI: 10.1016/j.contraception.2012.08.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 08/29/2012] [Indexed: 11/22/2022]
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37
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Lee BS, Ling X, Asif S, Kraemer P, Hanisch JU, Inki P. Levonorgestrel-releasing intrauterine system versus conventional medical therapy for heavy menstrual bleeding in the Asia-Pacific region. Int J Gynaecol Obstet 2013; 121:24-30. [PMID: 23340271 DOI: 10.1016/j.ijgo.2012.10.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2012] [Revised: 10/22/2012] [Accepted: 12/19/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To compare clinical outcomes, including cumulative continuation rate (CCR), in the treatment of idiopathic heavy menstrual bleeding (HMB) with the levonorgestrel-releasing intrauterine system (LNG-IUS) and with conventional medical therapies (CMTs), including combined oral contraceptives, oral progestins, and antifibrinolytics, either alone or in combination, in the Asia-Pacific region. METHODS In a prospective observational cohort study conducted between September 2008 and December 2010, 647 women (LNG-IUS, n=483; CMTs, n=164), aged 18-45 years and diagnosed with HMB, were recruited from 8 countries and followed for up to 1 year. The primary outcome was the CCR at 12 months. Secondary outcomes included bleeding pattern, an assessment of treatment efficacy by the treating physician, and safety. RESULTS The CCR at 12 months was significantly higher for LNG-IUS than for CMTs (87.6% vs 56.3% P<0.05). Compared with CMTs, LNG-IUS offered a better reduction in both subjectively assessed menstrual blood loss and the number of bleeding days, and had better efficacy for HMB, as determined by the physician's final evaluation. CONCLUSION The present study provides information on the real-life patterns of treatment of HMB in the Asia-Pacific region. The efficacy of CMTs was inferior compared with LNG-IUS in the clinical outcomes measured. ClinicalTrials.gov:NCT00864136.
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Affiliation(s)
- Byung S Lee
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea.
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39
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Bleeding patterns with the levonorgestrel-releasing intrauterine system when used for heavy menstrual bleeding in women without structural pelvic pathology: a pooled analysis of randomized controlled studies. Contraception 2013; 87:107-12. [DOI: 10.1016/j.contraception.2012.08.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 08/13/2012] [Accepted: 08/20/2012] [Indexed: 11/19/2022]
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Abu Hashim H. Medical treatment of idiopathic heavy menstrual bleeding. What is new? An evidence based approach. Arch Gynecol Obstet 2012; 287:251-60. [PMID: 23117248 DOI: 10.1007/s00404-012-2605-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 10/18/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND Heavy menstrual bleeding (HMB) is an important health problem affecting up to 30 % of reproductive age women, interfering with their quality of life. Medical therapy, with the avoidance of unnecessary surgery, is an attractive option. PURPOSE To provide a comprehensive review of the current medical treatments available for idiopathic HMB and to focus on the newly introduced modalities. Furthermore, to provide a practical algorithm based on the best available evidence. METHODS A PubMed search was conducted looking for the different trials, reviews and various guidelines relating to medical treatment of idiopathic HMB. RESULTS The most effective medical treatment for idiopathic HMB is the levonorgestrel-releasing intrauterine system. It provides a reliable long-term effect. Importantly, there is a growing scientific evidence for new modalities entailing; modified-release formulation of tranexamic acid, the new four-phasic estradiol valerate/dienogest contraceptive pills and combined contraceptive vaginal ring. Also, vaginal danazol has been tried. CONCLUSION Maintenance of status quo, i.e., keeping first-line treatment of idiopathic HMB as medical treatment is an essential issue. Modified-release formulation of tranexamic acid, the new four-phasic contraceptive pills and contraceptive vaginal ring are recently added to the medical armamentarium for treatment of idiopathic HMB increasing its efficacy.
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Affiliation(s)
- Hatem Abu Hashim
- Department of Obstetrics and Gynecology, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt.
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41
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Levonorgestrel-releasing intrauterine system for heavy menstrual bleeding improves hemoglobin and ferritin levels. Contraception 2012; 86:452-7. [PMID: 22959906 DOI: 10.1016/j.contraception.2012.07.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 07/20/2012] [Accepted: 07/27/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND We compared the effects of the levonorgestrel-releasing intrauterine system (LNG-IUS) with cyclic oral medroxyprogesterone acetate (MPA) on hemoglobin and serum ferritin levels in women with heavy menstrual bleeding (HMB). STUDY DESIGN This was a multicenter, randomized study assessing the efficacy of the LNG-IUS and oral MPA (10 mg/day for 10 days) in women with confirmed HMB over 6 cycles of treatment. We previously reported that treatment with the LNG-IUS resulted in greater menstrual blood loss reduction than MPA. In this analysis, hemoglobin and serum ferritin levels were assessed at baseline, Cycle 3, and at Cycle 6, and the relative improvement on treatment was subjectively rated by investigators and women. RESULTS One hundred and sixty-five women were randomized (82 LNG-IUS/83 MPA). Increases in median hemoglobin levels from baseline to Cycle 6 (7.5% vs. 1.9%; p<.001) and median serum ferritin levels (68.8% vs. 14.3%; p<.001) were greater in the LNG-IUS group than in the oral MPA group. Baseline median hemoglobin and ferritin levels were 12.4 g/dL and 19.0 mcg/L with the LNG-IUS and 12.2 g/dL and 19.0 mcg/L with oral MPA, respectively. At Cycle 6, the corresponding medians were 13.4 g/dL and 34.0 mcg/L with the LNG-IUS and 12.6 g/dL and 21.0 mcg/L with oral MPA. At Cycle 6, the proportion of women who rated their bleeding as 'improved' was higher with the LNG-IUS than with oral MPA, both according to investigator assessment (93.6% vs. 61.0%) and self-assessment (93.6% vs. 67.1%). CONCLUSIONS Women treated with the LNG-IUS had greater increases in median hemoglobin and serum ferritin levels, and higher rates of subjective improvement than women treated with oral MPA.
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Concepts of contraception for adolescent and young adult women with chronic illness and disability. Dis Mon 2012; 58:258-320. [PMID: 22510362 DOI: 10.1016/j.disamonth.2012.02.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Sexual behavior is common in adolescents and young adults with or without chronic illness or disability, resulting in high levels of unplanned pregnancy and STDs. Individuals with chronic illness or disability should not receive suboptimal preventive health care. These individuals have a need for counseling regarding issues of sexuality and contraception. Sexually active adolescent and young adult women can be offered safe and effective contraception if they wish to avoid pregnancy. Women with chronic illnesses and disabilities who are sexually active should also be offered contraception based on their specific medical issues. Condoms are also recommended to reduce STD risks. Table 36 summarizes basic principles of contraception application for specific illnesses, which have been identified since the release of the combined OC in 1960. Clinicians should also consider the noncontraceptive benefits of this remarkable and life-changing technology that allows all reproductive age women to improve their lives, including those with chronic illnesses and disabilities.
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