Effect of myoma size on failure of thermal balloon ablation or levonorgestrel releasing intrauterine system treatment in women with menorrhagia

Comparative study of the levonorgestrel intrauterine system and laparoscopic hysterectomy for the treatment of heavy menstrual bleeding in enlarged uteri

OBJECTIVE

The levonorgestrel intrauterine system treatment prevents 67.7% of surgeries in patients with heavy menstrual bleeding and enlarged uteri. To evaluate the effectiveness of the levonorgestrel intrauterine system in the treatment of patients with heavy menstrual bleeding and an enlarged uterus and to compare satisfaction and its complications with hysterectomy.

METHODS

This was a comparative cross-sectional observational study of women with heavy menstrual bleeding and an enlarged uterus. Sixty-two women were treated and followed up for four years. Insertion of the levonorgestrel intrauterine system was performed in Group 1, and laparoscopic hysterectomy was performed in Group 2.

RESULTS

In Group 1 (n=31), 21 patients (67.7%) showed improvement in the bleeding pattern, and 11 patients (35.5%) had amenorrhea. Five patients (16.1%) remained with heavy bleeding and were considered to have experienced treatment failure. There were seven expulsions (22.6%); in five patients, bleeding remained heavy, but in two patients the bleeding returned to that of normal menstruation. No relationship was found between treatment failure and greater hysterometries (p=0.40) or greater uterine volumes (p=0.50), whereas expulsion was greater in uteri with smaller hysterometries (p=0.04). There were 13 (21%) complications, seven (53.8%) in the group that underwent insertion of the levonorgestrel intrauterine system (all were device expulsions), and six (46.2%) in the surgical group, which were the most severe ones (p=0.76). Regarding satisfaction, 12 patients (38.7%) were dissatisfied with the levonorgestrel intrauterine system and one (3.23%) was dissatisfied with the surgical treatment (p=0.00).

CONCLUSION

Treatment with the levonorgestrel intrauterine system in patients with heavy menstrual bleeding and an enlarged uterus was effective, and when compared with laparoscopic hysterectomy, it had a lower rate of satisfaction and the same rate of complications, although less severe.

Predictive factors for failure of the levonorgestrel releasing intrauterine system in women with heavy menstrual bleeding

Background

This study was conducted to identify factors that are associated with failure of treatment using the levonorgestrel releasing intrauterine system (LNG-IUS) in women with heavy menstrual bleeding.

Methods

For this study, data of a cohort of women treated with an LNG-IUS was used. Women who suffered from heavy menstrual bleeding, aged 34 years and older, without intracavitary pathology and without a future child wish, were recruited in hospitals and general practices in the Netherlands. Eight potential prognostic baseline variables (age, body mass index, caesarean section, vaginal delivery, previous treatment, anticoagulant use, dysmenorrhea, and pictorial blood assessment score) were analyzed using univariable and multivariable regression models to estimate the risk of failure. The main outcome measure was discontinuation of the LNG-IUS within 24 months of follow up, defined as removal of the LNG-IUS or receiving an additional intervention.

Results

A total of 209 women received the LNG-IUS, 201 women were included in the analyses. 93 women (46%) discontinued LNG-IUS treatment within 24 months. Multivariable analysis showed younger age (age below 45) (adjusted RR 1.51, 95% CI 1.10–2.09, p = .012) and severe dysmenorrhea (adjusted RR 1.36, 95% CI 1.01–1.82, p = .041) to be associated with a higher risk of discontinuation.

Conclusions

High discontinuation rates are found in women who receive an LNG-IUS to treat heavy menstrual bleeding. A younger age and severe dysmenorrhea are found to be risk factors for discontinuation of LNG-IUS treatment. These results are relevant for counselling women with heavy menstrual bleeding.

Randomized controlled trial of thermal balloon ablation versus vaginal hysterectomy for leiomyoma-induced heavy menstrual bleeding

OBJECTIVE

To compare the efficacy of thermal balloon ablation (TBA) with that of vaginal hysterectomy in the treatment of leiomyoma-induced heavy menstrual bleeding (HMB).

METHODS

An open-label randomized controlled trial was conducted between November 1, 2012, and October 31, 2014, in a tertiary care hospital in Delhi, India. Eligible women with HMB (aged ≥40 years, uterus size ≤14 weeks of pregnancy, leiomyoma ≤5 cm, uterocervical length ≤12 cm) were randomly assigned (1:1) to undergo TBA or vaginal hysterectomy using computer-generated random number tables. The primary outcome was the number of women in the TBA group with HMB 6 months after surgery. Analyses were by intention to treat.

RESULTS

Each group contained 20 women. No women in the TBA group had HMB at 6 months. Nineteen women were amenorrheic by 6 months and one was hypomenorrheic.

CONCLUSION

TBA can replace vaginal hysterectomy in some perimenopausal women with uterine leiomyomas. Clinical Trials Registry India: CTRI/2016/07/007119.

Levonorgestrel intrauterine system versus thermal balloon ablation for the treatment of heavy menstrual bleeding: A meta-analysis of randomized controlled trials

At present, there have been no standard research outcomes as to whether the levonorgestrel intrauterine system (LNG-IUS) or thermal balloon ablation (TBA) is superior for the treatment of patients suffering from heavy menstrual bleeding (HMB). Therefore, in the present study, a meta-analysis of randomized controlled trials (RCTs) was conducted in order to compare the effectiveness and affordability of the LNG-IUS with TBA in the treatment of HMB. A literature search of the following electronic databases was conducted: PubMed, EMBASE, the Cochrane Library, Google Scholar, the Chinese Scientific Journals Database, and the China National Knowledge Infrastructure; and a statistical analysis was performed using RevMan 5.2 software. Seven RCTs involving 467 patients (235 LNG-IUS, 232 TBA) met the inclusion criteria for the present study. As assessed by pictorial blood loss assessment chart (PBAC) scores, the LNG-IUS significantly reduced menstrual bleeding after 24 months [standardized mean difference (SMD), −0.86; 95% confidence interval (CI), −1.22 to −0.50; P<0.00001]. Furthermore, the total treatment cost of the LNG-IUS was lower than that of TBA (SMD, −2.35; 95% CI, −2.98 to −1.72; P<0.00001). However, at the 24 month follow-up, side effects such as amenorrhea occurred more frequently in patients treated with the LNG-IUS, as compared with TBA (relative risk, 2.49; 95% CI, 1.46–4.25; P=0.0008). No significant differences in hemoglobin levels and quality of life were demonstrated between the two treatment groups. The results of the present meta-analysis suggest that the LNG-IUS may be more effective and affordable than TBA as a long-term treatment (24 months) for HMB. However, following 12–24 months of treatment, side effects such as amenorrhea may be more frequent in patients treated with the LNG-IUS. When considering short-term treatment for HMB, controversy remains regarding the two methods and further studies are required to precisely evaluate the outcomes.