Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding

Levonorgestrel-releasing intrauterine device insertion ameliorates leiomyoma-dependent menorrhagia among women of reproductive age without a significant regression in the uterine and leiomyoma volumes

Levonorgestrel- (LNG) releasing intrauterine device (IUD) insertion revealed significant reduction in visual bleeding scores and spotting with an increase in amenorrhea and uterine pulsatility index scores. LNG-IUD can be considered as a simple and effective alternative to surgical treatment in the management of leiomyoma-dependent menorrhagia of reproductive-age women.

The levonorgestrel intrauterine system is an effective treatment in women with abnormal uterine bleeding and anticoagulant therapy

OBJECTIVE

To evaluate the efficacy of levonorgestrel intrauterine systems (LNG-IUS) in obese women with AUB on anticoagulant therapy.

DESIGN

Prospective observational case series (Canadian Task Force Classification II-3).

SETTING

University affiliated teaching hospital.

PATIENTS

Premenopausal women on Warfarin therapy.

INTERVENTIONS

From January 2002 through January 2007, 10 women were identified from the senior author's clinical practice (G.A.V.). After clinical assessment, including Papanicolaou smear, endometrial biopsy, and pelvic sonography, the LNG-IUS was placed to treat their AUB.

MEASUREMENTS AND MAIN RESULTS

The median and range of age, parity, and body mass index were 45 years (34-49), 1 (0-4), and 38 kg/m(2) (26-52), respectively. All women were receiving warfarin therapy (4-12.5 mg/d) for previous venous thromboembolism. Some patients had additional comorbid conditions and were at high risk for traditional medical or surgical therapies. After placement of the LNG-IUS, all women reported menstrual reduction at 3 and 6 months. By 12 months, 1 woman with large fibroids expelled the LNG-IUS and was treated with transfemoral uterine artery embolization. Two women had amenorrhea, and 7 had hypomenorrhea. At 2 to 5 years, 1 woman expelled the LNG-IUS and hysterectomy indicated extensive adenomyosis in a 195-g uterus, and 1 woman had hysteroscopic endometrial ablation, 4 were menopausal, 2 had amenorrhea, and 1 had hypomenorrhea. In the 5 women with uterine fibroids measuring 4.2 to 147 cm(3), the fibroids were reduced in volume by approximately 75% in 2, were no longer detectable in 1, were subsequently shown to be adenomyoma in 1, and required uterine artery embolization in 1.

CONCLUSION

In properly assessed and selected obese, premenopausal women with AUB receiving warfarin therapy and at high risk for traditional therapies, the LNG-IUS was an effective treatment in 70% of patients.

The levonorgestrel-releasing intrauterine system: Safety, efficacy, and patient acceptability

The levonorgestrel-releasing intrauterine system (LNG-IUS) is a safe, effective and acceptable form of contraception used by over 150 million women worldwide. It also has a variety of noncontraceptive benefits including treatment for menorrhagia, endometriosis, and endometrial hyperplasia. The LNG-IUS has also been used in combination with estrogen for hormone replacement therapy and as an alternative to hysterectomy. Overall, the system is very well tolerated and patient satisfaction is quite high when proper education regarding possible side effects is provided. However, despite all of the obvious benefits of the LNG-IUS, utilization rates remain quite low in the developed countries, especially in the United States. This is thought to be largely secondary to the persistent negative impressions from the Dalkon Shield intrauterine experience in the 1970s. This history continues to negatively influence the opinions of both patients and health care providers with regards to intrauterine devices. Providers should resolve to educate themselves and their patients on the current indications and uses for this device, as it, and intrauterine contraception in general, remains a largely underutilized approach to a variety of women’s health issues.

The effect of levonorgestrel intrauterine system on uterine myomas: a 1-year follow-up study

STUDY OBJECTIVE

To assess whether levonorgestrel intrauterine system is an effective means of therapy in menorrhagia associated with myomas.

DESIGN

Prospective before and after study (Canadian Task Force classification II-1).

SETTING

Teaching and research hospital, a tertiary center.

PATIENTS

In all, 21 premenopausal women attending our gynecology clinic because of menorrhagia associated with uterine myomas were enrolled into the study.

INTERVENTIONS

Levonorgestrel-releasing intrauterine system use in uterine myomas.

MEASUREMENTS AND MAIN RESULTS

Patients with myomas greater than 4 cm were excluded. Clinical assessment tools of menstrual bleeding were measured both before (pretreatment) and 1 year after the insertion (posttreatment). A p value less than or equal to .05 was considered statistically significant for menstrual blood loss as a primary outcome and Bonferroni correction was done for secondary outcomes as 0.01. The mean age of the patients was 47.05+/-4.9 years. At 1-year follow-up, 5 women had had a hysterectomy. Four patients were amenorrheic. The duration of menstruation and the mean endometrial thickness were decreased 1 year after insertion; these decreases were not statistically significant (p=.034 and p=.204, respectively). While the mean number of pads used daily during menstruation decreased (p=.011), the hemoglobin level was increased (p=.001). A reduction in mean uterine volume and increase in ferritin levels were observed, but these changes did not reach statistical significance (p = .050 and p = .036, respectively).

CONCLUSION

The use of the levonorgestrel intrauterine system seems to be effective in reducing menorrhagia associated with myomas with improvement in hemoglobin levels.

Non-contraceptive benefits and risks of contraception

Contraception is primarily used to prevent pregnancy. However, a user should be aware of both the possible non-contraceptive benefits she/he may experience and any potential risks to her/his health. These issues should be discussed as fully as possible, using current, evidence-based information prior to commencing a method. Some methods may be prescribed solely for their non-contraceptive benefits for a woman who does not require it for contraception. Potential risks to a woman's health may make certain methods unacceptable if concurrent medical problems or lifestyle issues exist. This chapter discusses the main non-contraceptive benefits and risks for each contraceptive method in turn.

Use of the Levonorgestrel-IUS in the treatment of menorrhagia: assessment of quality of life in Turkish users

OBJECTIVE

The aim of the present study was to measure the treatment of menorrhagia and health-related quality of life (QoL) in Levonorgestrel-releasing intrauterine system (LNG-IUS) in Turkish women.

MATERIALS AND METHODS

We recruited 66 premenopausal women, aged 26-55 years, who had sought care in the previous year for menorrhagia. All patients were asked to complete a visual analog scale (VAS) form regarding pelvic pain, sexual life (libido) and general feeling of health. Patients filled the VAS form before LNG-IUS insertion and after 6 months.

RESULTS

After the 6-month visit, PBAC score was condirebly decreased (p < 0.001). Six (10%) of the 60 patients PBAC score was higher than 75. VAS score for pelvic pain decreased from baseline to 6-month follow-up (4.32-3.55), and the libido and general feeling of health increased (4.27-4.95 and 3.47-6.87, respectively).

CONCLUSION

The LNG-IUS device in the trearment of menorrhagia has cost effective, less side effects and increse in the QoL.

Therapeutic amenorrhea in patients at risk for thrombocytopenia

To examine the need for and evaluate the method of menses suppression in women at risk for thrombocytopenia. A systematic review of the published literature in MEDLINE using the search terms thrombocytopenia, menorrhagia, therapeutic amenorrhea, progestin intrauterine device, combination oral contraceptive--extended and cyclic, gonadotropin releasing hormone agonist, danazol, and progestins. There are an increased number of reproductive age women at risk for thrombocytopenia who would benefit from menses suppression. A number of effective medical regimens are available. In patients who fail medical therapy, endometrial ablation appears to be effective in women with thrombocytopenia. As a result of the increased number of women at risk for thrombocytopenia, there is a need for therapeutic amenorrhea. The type of regimen selected depends upon the patients need for contraception and the ability to tolerate estrogen-containing medications. For women who fail medical therapy, there are surgical options, which are associated with less morbidity than hysterectomy.

Management of abnormal uterine bleeding and the pathology of endometrial hyperplasia

There are no screening tests for endometrial carcinoma, and patients typically present with abnormal uterine bleeding. This article discusses the pathophysiology and clinical work-up of abnormal uterine bleeding, and risk factors for endometrial carcinoma. Atypical complex hyperplasia and the more recently defined endometrial intraepithelial neoplasia are well recognized as precancers. Evolving knowledge of their genetic alterations provides the opportunity to develop molecular markers, so that endometrial diseases may be diagnosed at the precancerous or early invasive stage. Emerging molecular markers also provide the opportunity to develop clinically useful screening tests for the most common malignancy of the female genital tract.

Review of the safety, efficacy and patient acceptability of the levonorgestrel-releasing intrauterine system

The levonorgestrel-containing intrauterine system is an extremely effective, reversible and safe form of long-term yet reversible birth control. In view of its efficacy, it is a safer alternative to permanent contraceptive methods such as sterilization. It is especially useful in situations where use of estrogen-containing contraceptives is contraindicated. While menstrual disturbances are a common side effect, proper counseling improves compliance. In addition to its contraceptive effect, the levonorgestrel intrauterine system offers potential therapeutic benefits in other clinical contexts, including menorrhagia, symptomatic fibroids, endometriosis, and endometrial protection.

Current issues in the management of endometrial cancer

Endometrial cancer (EC) remains the most common gynecologic malignancy in the United States. It is expected to become more common as the prevalence of obesity, one of the most common risk factors for EC, increases worldwide. The 2 main histologic subcategories of EC, endometrioid and nonendometrioid EC, show unique molecular aberrations and are responsible for markedly disparate clinical behaviors. The primary treatment of EC is surgery, ie, hysterectomy, removal of the adnexa, and pelvic and para-aortic lymphadenectomy, either via laparotomy or endoscopic techniques. Adjuvant therapy is necessary for patients at high risk of recurrence and consists of vaginal brachytherapy, teletherapy, systemic chemotherapy, or some combination thereof. Multi-institutional trials are in progress in this country and in Europe to better define optimal adjuvant treatment for subsets of patients, as well as the role of surgical staging in reducing both overuse and underuse of radiation therapy. Hormonal therapy is an option for some young women with EC who wish to preserve fertility. This review summarizes the diagnosis and management of EC and discusses current controversies and upcoming investigations pertaining to EC staging and adjuvant treatment.

Current treatment options for abnormal uterine bleeding: an evidence-based approach

Heavy menstrual bleeding is the predominant complaint in women with abnormal uterine bleeding. Treatment options are drug therapy, and first- and second-generation endometrial resection. Many women will subsequently have a hysterectomy. Uterine fibroids are the most common solid pelvic tumours in women, and although many fibroids seem to cause no symptoms, they can have serious adverse effects and impact on quality of life. As women postpone having children, gynaecologists will have to manage fibroids and polyps in a conservative manner. The past decade has witnessed the development of highly sophisticated diagnostic and therapeutic technology for women suffering from menorrhagia, fibroids and polyps, including minimally invasive uterine therapy. The tools currently at our disposal permit greater management flexibility, which must be tailored to the individual clinical situation. This chapter reviews the evidence-based approach and minimally invasive therapy.

Future research into abnormal uterine bleeding

Abnormal uterine bleeding in terms of menstrual disorders and postmenopausal bleeding are common clinical problems in both primary and secondary care. Advances in diagnostic and therapeutic technologies have offered opportunities to improve the outcomes of women suffering with these complaints. Future research should concentrate on a robust approach to the assessment of these health technologies, including the use of outcome assessments of importance to patients such as effects on health-related quality of life and taking account of patient preferences. In addition, economic evaluations need to be conducted alongside clinical research to facilitate a rational basis on which to allocate resources and upon which to base clinical decisions. Specific areas highlighted for research in this review include the role of diagnostic technologies incorporating the clinical context within which diagnostic work-up takes place. The clinical application of progesterone antagonists and selective progesterone receptor modulators is a developing area with potential for the treatment of menorrhagia. The place of minimally invasive therapies for the treatment of menstrual dysfunction and fibroid-associated menorrhagia needs more examination, as does the place of outpatient 'ambulatory' settings to provide convenient, effective 'see and treat' targeted services in both primary and secondary care.

Contraception in Canada: a review of method choices, characteristics, adherence and approaches to counselling

Contraception is a significant concern for Canadian women of child-bearing age, their partners and their health care providers. In this narrative review we provide information on current trends and recent changes in Canadians' choices of contraceptive methods. We review the characteristics of contraceptive methods available in Canada, with an emphasis on hormonal methods and newer options such as the transdermal contraceptive patch, the vaginal contraceptive ring and the levonorgestrel-releasing intrauterine system. We also discuss adherence to contraception as well as approaches to counselling to promote adherence and to reduce the risk of sexually transmitted infections in the context of contraception.

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

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

Surgery versus medical therapy for heavy menstrual bleeding

BACKGROUND

Heavy menstrual bleeding (HMB) significantly impairs the quality of life of many otherwise healthy women. Perception of HMB is subjective and management usually depends upon what symptoms are acceptable to the individual. Medical treatment options include oral medication and a hormone-releasing intrauterine system (LNG-IUS). Surgical options include conservative surgery (uterine resection or ablation) and hysterectomy.

OBJECTIVES

To compare the effectiveness, safety and acceptability of surgery versus medical therapy for HMB.

SEARCH STRATEGY

In September 2005 we searched the Cochrane Menstrual Disorders and Subfertility Group trials register Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2005), MEDLINE EMBASE, Current Contents, Biological Abstracts, PsycINFO, and CINAHL. We also searched reference lists of articles retrieved and contacted pharmaceutical companies and experts in the field.

SELECTION CRITERIA

Controlled randomised trials comparing conservative surgery or hysterectomy versus medical therapy (oral or intrauterine) for HMB DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trials for quality and extracted data .

MAIN RESULTS

The eight included trials randomised 821 women. In comparisons of oral medication versus surgery, 58% of women randomised to medical treatment had received surgery by two years. Compared to oral medication, endometrial resection was significantly more effective in controlling bleeding (at four months: OR 10.62, 95% CI 5.30 to 21.27) and significantly less likely to cause side effects (at four months: OR 0.15, 95% CI 0.07 to 0.31) and hysterectomy resulted in significantly greater improvements in mental health (at six months p = 0.04). In comparisons of LNG-IUS versus conservative surgery or hysterectomy, at one year there was no statistically significant difference in satisfaction rates or quality of life, though adverse effects were significantly less likely with conservative surgery (OR 0.24, 95% CI 0.11 to 0.49). Two trials found conservative surgery significantly more effective than LNG-IUS in controlling bleeding at one year (OR 3.99, 95% CI 1.53 to 10.38). Two other small trials with longer follow-up found no difference or favoured LNG-IUS - however in both these studies the data were skewed and fewer than two thirds of participants were analysed. Hysterectomy stopped all bleeding but caused serious complications for some women.

AUTHORS' CONCLUSIONS

Surgery, especially hysterectomy, reduces menstrual bleeding at one year more than medical treatments but LNG-IUS appears equally effective in improving quality of life. The evidence for longer term comparisons is weak and inconsistent. Oral medication suits a minority of women long term.

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

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

Hormonally impregnated intrauterine systems (IUSs) versus other forms of reversible contraceptives as effective methods of preventing pregnancy

BACKGROUND

In the 1970s a new approach to the delivery of hormonal contraception was researched and developed. It was suggested that the addition of a progestogen to a non-medicated contraceptive device improved its contraceptive action. An advantage of these hormonally impregnated intrauterine systems (IUS) is that they are relatively maintenance free, with users having to consciously discontinue using them to become pregnant rather than taking a proactive daily decision to avoid conception.

OBJECTIVES

To assess the contraceptive efficacy, tolerability and acceptability of hormonally impregnated intrauterine systems (IUSs) in comparison to other reversible contraceptive methods.

SEARCH STRATEGY

Literature was identified through database searches, reference lists and individuals/organisations working in the field. Searches covered the period from 1972 to November 2003.

SELECTION CRITERIA

All randomised controlled trials comparing IUSs with other forms of reversible contraceptives and reporting on pre-determined outcomes in women of reproductive years. The primary outcomes were pregnancy due to method/user failure and continuation rate.

DATA COLLECTION AND ANALYSIS

The quality assessment of studies and data extraction were completed independently by two blinded reviewers. A quality checklist was designed to identify general methodological and contraceptive specific factors which could bias results. Events per women months and single decrement life table rates were extracted where possible for pregnancy, continuation, adverse events and reasons for discontinuation. Events per total number of women at follow up were collected for hormonal side effects and menstrual disturbance. When appropriate, data were pooled at the same points of follow up to calculate rate ratios in order to determine the relative effectiveness of one method compared to another. For the single decrement life table rates, the rate differences were pooled to determine the absolute difference in effectiveness of one method compared to another. Interventions were only combined if the contraceptive methods were similar. Non-hormonal IUDs were divided into three categories for the purpose of comparison with IUSs: IUDs >250mm2 (i.e. CuT 380A IUD and CuT 380 Ag IUD), IUDs <=250mm2 (i.e. Nova-T, Multiload, CuT 200 and CuT 220 IUDs) and non-medicated IUDs.

MAIN RESULTS

Twenty-one RCTs comparing hormonally impregnated IUSs to a reversible contraceptive method met the inclusion criteria and it was possible to include eight of these in the meta-analyses, four comparing LNG-20 IUSs with non-hormonal IUDs, one comparing the LNG-20 IUS with Norplant-2 and three comparing Progestasert with non-hormonal IUDs. No significant difference was observed between the pregnancy rates for the LNG-20 users and those for the IUD >250mm2 users. However, women using the LNG-20 IUS were significantly less likely to become pregnant than those using the IUD <=250mm2. Women using the LNG-20 IUS were more likely to experience amenorrhoea and device expulsion than women using IUDs >250mm2. LNG-20 users were significantly more likely than all the IUD users to discontinue because of hormonal side effects and menstrual disturbance, which on further breakdown of the data was due to amenorrhoea. When the LNG-20 IUS was compared to Norplant-2, the LNG-20 users were significantly more likely to experience amenorrhoea and oligomenorrhoea, but significantly less likely to experience prolonged bleeding and spotting. No other significant differences were observed. Progestasert users were significantly less likely to become pregnant and less likely to continue on the method than non-medicated IUD users after one year, but no significant difference was noted for these two outcomes when Progestasert users were compared to IUD<=250mm2 users. The only other significant differences found in the meta-analyses were that Progestasert users were less likely to expel the device and more likely to discontinue the method because of menstrual bleeding and pain than users of IUDs <=250mm2. REVIEWERS' CONCLUSIONl the device and more likely to discontinue the method because of menstrual bleeding and pain than users of IUDs <=250mm2.

REVIEWERS' CONCLUSIONS

Current evidence suggests LNG-20 IUS users are no more or less likely to have unwanted pregnancies than IUD >250mm2 and Norplant-2 users. The LNG-20 IUS was more effective in preventing either intrauterine or extrauterine pregnancies than IUDs <=250mm2. The contraceptive effectiveness of Progestasert was significantly better than non-medicated IUDs, but no difference was observed when compared to IUDs<=250mm2. Continuation of LNG-20 IUS use was similar to continuation of the non-hormonal IUDs and Norplant-2. Amenorrhoea was the main reason for the discontinuation for the LNG-20 IUS and women should be informed of this prior to starting this method.