Use of a levonorgestrel-releasing intrauterine device in the treatment of rectovaginal endometriosis

Levonorgestrel-Releasing Intrauterine System for the Treatment of Endometriosis: Biological and Clinical Evidence

Endometriosis-associated symptomatology can be safely and effectively treated with intrauterine-released progestin, which is associated with fewer adverse effects than other therapeutic options and may be used on a long-term basis. We have herein reviewed the current literature in relation to the biological and clinical rationale for the use of an intrauterine system releasing 20 μg/day of levonorgestrel for the treatment of pelvic pain symptoms associated with endometriosis. Levonorgestrel induces endometrial glandular atrophy and decidual transformation of the stroma, reduces endometrial cell proliferation and increases apoptotic activity. After the first year of use, a 70–90% reduction in menstrual blood loss is observed. The levonorgestrel-releasing intrauterine system has proven effective in relieving pelvic pain symptoms caused by peritoneal and rectovaginal endometriosis and in reducing the risk of recurrence of dysmenorrhea after conservative surgery. Thus, the intrauterine delivery of a potent progestin may constitute an innovative, effective, safe and convenient alternative for local delivery of a potent progestin in the long-term therapy of symptomatic endometriosis.

Complications and their management in endometriosis surgery

Endometriosis is a common chronic disease mostly seen in young women. Endometriosis surgery may be considered as rather challenging in gynecology. In this article, we tried to emphasize on basic concepts of endometriosis surgery, the best surgical method that should be applied and the complications and the management of the complications.

Measures used to assess chronic pelvic pain in randomized controlled clinical trials: a systematic review

RATIONALE

Many types of pain assessment are available to researchers carrying out clinical trials in chronic pelvic pain (CPP), ranging from a single-item scale to multidimensional inventories.

AIM

Our objective was to investigate which assessments of pain are more commonly used in clinical trials on CPP.

METHOD

We have reviewed articles published between 1991 and 2014. A total of 74 studies out of 1299 original research articles reviewed met the selection criteria by containing at least one method of pain assessment. The selected studies were classified according to the dimensions of pain evaluated, the type of scale and the descriptors used.

RESULTS

The instruments most frequently used were single-item VAS and Biberoglu and Behrman pain score, while multidimensional inventories were used in few studies. The results of clinical studies in CPP are more frequently based on one-dimensional measurements. Valuable results from clinical studies in CPP might have been omitted because of incomplete outcome measurements.

CONCLUSION

We believe the authors of clinical studies should report their results in a comprehensive way including in the outcomes of the measurement of one-dimensional and multidimensional pain characteristics.

How to Manage Bowel Endometriosis: The ETIC Approach

A panel of experts in the field of endometriosis expressed their opinions on management options in a 35-year-old patient desiring pregnancy with a history of previous surgery for endometrioma and bowel obstruction symptoms. Many questions that this paradigmatic patient may pose to the clinician are addressed, and various clinical scenarios are discussed. A decision algorithm derived from this discussion is proposed as well.

Current strategies for endometriosis management

Endometriosis is a common gynecologic disorder that persists throughout the reproductive years. Although endometriosis is a surgical diagnosis, medical management with ovarian suppression remains the mainstay of long-term management with superimposed surgical intervention when needed. The goal of surgery should be excision or ablation of all visible disease to minimize risk of recurrence and need for repeat surgeries. When infertility is the presenting symptom, surgical therapy in addition to assisted reproductive technology can improve chances of conception; however, the treatment approach depends on stage of disease and other patient characteristics that affect fecundity.

National German Guideline (S2k): Guideline for the Diagnosis and Treatment of Endometriosis: Long Version - AWMF Registry No. 015-045

In this guideline, recommendations and standards for optimum diagnosis and treatment of endometriosis are presented. They are based on the analysis of the available scientific evidence as published in prospective randomized and retrospective studies as well as in systematic reviews. The guideline working group consisted of experts from Austria, Germany, Switzerland, and the Czech Republic.

New trends of progestins treatment of endometriosis

The management of endometriosis with OC or progestins is generally safe, effective and well-tolerated and should constitute the first line of medical treatment in symptomatic patients who do not want to have children. Progestins, synthetic progestational agents, have been used in the management of symptomatic endometriosis both as primary therapy and as an adjunct to surgical time. A variety of oral agents have been employed in this regard and investigators have demonstrated differing degrees of benefit. The lack of a standardized instrument to evaluate painful symptoms makes comparative analysis more difficult. Concern about efficacy and side effect has pushed the research on the development of new well-tolerated drugs and to develop new administration routes to minimize general side effects. Aim of the present review is to present the results of clinical studies on new trends of progestins in the treatment of endometriosis.

Systematic review of endometriosis pain assessment: how to choose a scale?

BACKGROUND

Numerous studies concerning endometriosis and pain have been reported. However, there is no consensus on the best method to evaluate pain in endometriosis and many scales have been used. Moreover, there are only a few descriptions of minimal clinically important differences after treatment (MCID) to evaluate variations in pain. In our study, we aim to identify pain scales used in endometriosis pain treatment, to address their strong and weak points and to define which would be the ideal scale to help clinicians and researchers to evaluate endometriosis-related pain.

METHODS

A search of the MEDLINE and EMBASE databases was carried out for publications in English, French or Portuguese from 1980 to December 2012, for the words: endometriosis, treatment, pain. Studies were selected if they studied an endometriosis treatment and a pain scale was specified. A quantitative and a qualitative analysis of each scale was performed to define strong and weak points of each scale (systematic registration number: CRD42013005336).

RESULTS

A total of 736 publications were identified. After excluding duplications and applying inclusion criteria 258 studies remained. We found that the visual analog scale (VAS) is the most frequently used scale. Both VAS and the numerical rating scale (NRS) show a good balance between strong and weak points in comparison with others such as the Biberoglu and Behrman scale. Concerning MCID, only VAS, NRS and Brief Pain Inventory scales have reported MCID and, among these, only VAS MCID has been studied in endometriosis patients (VAS MCID = 10 mm). Adding the Clinical Global Impression score (CGI) to the pain scale allows calculation of the MCID.

CONCLUSIONS

When using pain scales their strengths and weaknesses must be known and included in the analysis. VAS is the most frequently used pain scale and, together with NRS, seems the best adapted for endometriosis pain measurement. The use of VAS or NRS for each type of typical pain related to endometriosis (dysmenorrhea, deep dyspareunia and non-menstrual chronic pelvic pain), combined with the CGI and a quality-of-life scale will provide both clinicians and researchers with tools to evaluate treatment response.

Medical treatments for endometriosis-associated pelvic pain

The main sequelae of endometriosis are represented by infertility and chronic pelvic pain. Chronic pelvic pain causes disability and distress with a very high economic impact. In the last decades, an impressive amount of pharmacological agents have been tested for the treatment of endometriosis-associated pelvic pain. However, only a few of these have been introduced into clinical practice. Following the results of the controlled studies available, to date, the first-line treatment for endometriosis associated pain is still represented by oral contraceptives used continuously. Progestins represent an acceptable alternative. In women with rectovaginal lesions or colorectal endometriosis, norethisterone acetate at low dosage should be preferred. GnRH analogues may be used as second-line treatment, but significant side effects should be taken into account. Nonsteroidal anti-inflammatory drugs are widely used, but there is inconclusive evidence for their efficacy in relieving endometriosis-associated pelvic pain. Other agents such as GnRH antagonist, aromatase inhibitors, immunomodulators, selective progesterone receptor modulators, and histone deacetylase inhibitors seem to be very promising, but there is not enough evidence to support their introduction into routine clinical practice. Some other agents, such as peroxisome proliferator activated receptors-γ ligands, antiangiogenic agents, and melatonin have been proven to be efficacious in animal studies, but they have not yet been tested in clinical studies.

Treatment of pelvic pain associated with endometriosis: a committee opinion

Pain associated with endometriosis may involve many mechanisms and requires careful evaluation to confirm the diagnosis and exclude other potential causes. Both medical and surgical treatments for pain related to endometriosis are effective, and choice of treatment must be individualized. This document replaces the document by the same name last published in 2008 (Fertil Steril 2008;90:S260-9).

Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United States

Three intrauterine devices (IUDs), one copper and two containing the progestin levonorgestrel, are available for use in the United States. IUDs offer higher rates of contraceptive efficacy than nonlong-acting methods, and several studies have demonstrated higher satisfaction rates and continuation rates of any birth control method. This efficacy is not affected by age or parity. The safety of IUDs is well studied, and the risks of pelvic inflammatory disease, perforation, expulsion, and ectopic pregnancy are all of very low incidence. Noncontraceptive benefits include decreased menstrual blood loss, improved dysmenorrhea, improved pelvic pain associated with endometriosis, and protection of the endometrium from hyperplasia. The use of IUDs is accepted in patients with multiple medical problems who may have contraindications to other birth control methods. Yet despite well-published data, concerns and misperceptions still persist, especially among younger populations and nulliparous women. Medical governing bodies advocate for use of IUDs in these populations, as safety and efficacy is unchanged, and IUDs have been shown to decrease unintended pregnancies. Dispersion of accurate information among patients and practitioners is needed to further increase the acceptability and use of IUDs.

Dyspareunia and quality of sex life after surgical excision of endometriosis: a systematic review

Dyspareunia, a common symptom of endometriosis, severely affects quality of sex life in affected women. The objective of the present work was to review the effect of surgical resection of endometriosis on pain intensity and quality of sex life. MEDLINE and EMBASE databases were searched for papers investigating the outcome after surgical endometriosis resection on dyspareunia and quality of sex life measured via VAS/NAS respectively via standardised measuring instruments. Data did not permit a meaningful meta-analysis. Out of 64 papers, three studies fulfilled the predefined inclusion criteria involving 128 patients with endometriosis and dyspareunia preoperatively. All included studies showed a significant postoperative reduction (p<0.05) of dyspareunia after a follow-up period of 12 up to 60 months. Sex life also improved significantly (p<0.05), and predominantly evaluated parameters like quality of life and mental health. Intra- and postoperative complications were described in two out of three studies. Surgical excision of deep infiltrating endometriosis is feasible and improves dyspareunia and quality of sex life significantly.

Robotic surgery for deep endometriosis: a paradigm shift

BACKGROUND

Minimally invasive surgery represents the gold standard for the management of deep infiltrating endometriosis (DIE). This study aimed to evaluate the feasibility of robotic surgery for the management of DIE.

METHODS

A 5-year retrospective cohort study was made of robotic procedures including: segmental bowel resections, removal of nodules from the rectovaginal septum (RVS) with or without rectal shaving and partial bladder resection.

RESULTS

Overall, 19 bowel resections, 23 removals of RVS nodules and five bladder resections were performed, alone or in combination. Associated posterior vaginal resections were performed in 12 cases. Neither intra-operative complications, nor conversion to laparotomy occurred. One anastomotic leakage was recorded.

CONCLUSION

This series of robotic procedures for DIE represents the largest currently available and it helps to promote robotics as a safe and attractive alternative to accomplish a comprehensive surgical treatment of DIE, especially when bowel or bladder resections are needed.

Use of the levonorgestrel intrauterine system in adolescents with endometriosis

STUDY OBJECTIVE

The purpose of this study was to evaluate our adolescent patient population who had received a levonorgestrel intrauterine system (LNG-IUS) at or after the time of endometriosis diagnosis, and determine efficacy of the LNG-IUS in regards to pain and bleeding on follow-up exam.

DESIGN

Retrospective cohort study.

SETTING

Pediatric Adolescent Gynecology Clinic and Children's Hospital in a metropolitan area.

PARTICIPANTS

Adolescent patients age 14-22 with pathology-proven endometriosis who had the LNG-IUS placed during the course of their treatment for this disease. Patients were divided into LNG-IUS placement at the time of surgical diagnosis versus placement some time after diagnosis.

MAIN OUTCOME MEASURES

Pain and bleeding were assessed by follow-up exam. Pain was classified at each follow-up visit as either none, minimal, moderate, or severe. Bleeding was classified as none, irregular spotting, irregular bleeding, or daily bleeding.

RESULTS

The majority of patients (67%) required additional hormonal therapy for pain and bleeding suppression. Time to bleeding suppression and pain suppression was sooner in the group with interval time between surgical diagnosis and LNG-IUS placement, compared to LNG-IUS placement at the time of surgery (2.4 months vs 5.3 months until bleeding suppression, and 3.8 months vs 4.8 months until pain suppression), although statistical significance was not achieved.

CONCLUSIONS

The LNG-IUS is an option for treatment of endometriosis in adolescents. As pain is the main problem associated with endometriosis, LNG-IUS placement is beneficial at the time of surgery when it is diagnosed. A prospective study is needed for further assessment of outcomes.

Use of levonorgestrel intrauterine system for medical indications in adolescents

The levonorgestrel intrauterine system (LNG-IUS) is an underused contraceptive method in adolescent populations. In addition to being a highly effective, reversible, long-acting contraception, the LNG-IUS has many noncontraceptive health benefits including reduced menstrual bleeding, decreased dysmenorrhea and pelvic pain related to endometriosis, and menstruation suppression in teens with physical or developmental disabilities. The LNG-IUS can also provide endometrial protection in teens with chronic anovulation, and may be used to treat endometrial hyperplasia and cancer. This review examines the evidence supporting the use of the LNG-IUS in adolescents for these noncontraceptive benefits.

Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery

BACKGROUND

Various options exist for treating endometriosis, including surgical, medical, such as ovarian suppression, or a combination of these strategies. Surgical treatment of endometriosis aims to remove visible areas of endometriosis. The aim of medical therapy is to inhibit growth of endometriotic implants by induction of a hypo-estrogenic state. Treatment with a hormone-releasing intrauterine device, using levonorgestrel (LNG-IUD), has also been suggested.

OBJECTIVES

To determine whether postoperative LNG-IUD insertion in women with endometriosis improves pain and reduces recurrence of symptoms compared with no postoperative treatment, postoperative insertion of a placebo, or postoperative therapy.

SEARCH METHODS

The following databases were searched from inception to June 2012: Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, CINAHL, and the World Health Organization (WHO) International Clinical Trials Registry Platform. EMBASE was searched from 2010 to June 2012. The citation lists of relevant publications, review articles, abstracts of scientific meetings, and included studies were also searched.

SELECTION CRITERIA

Trials were included if they compared women undergoing surgical treatment for endometriosis with uterine preservation and then randomised within three months to LNG-IUD insertion versus no postoperative treatment, placebo (inert IUD), or other treatment. Diagnostic laparoscopy alone was not considered suitable treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion and extracted data to allow for an intention-to-treat analysis. For dichotomous data, the risk ratio (RR) and 95% confidence interval (CI) were calculated using the Mantel-Haenszel random-effects method. For continuous data, the mean difference (MD) and 95% CI were calculated using the inverse variance random-effects method.

MAIN RESULTS

Three randomised controlled trials were included. In two trials, there was a statistically significant reduction in the recurrence of painful periods in the LNG-IUD group compared with expectant management (RR 0.22, 95% CI 0.08 to 0.60, 95 women, I(2) = 0%, moderate strength of evidence). The proportion of women who were satisfied with their treatment was also higher in the LNG-IUD group but did not reach statistical significance (RR 1.21, 95% CI 0.80 to 1.82, 95 women, I(2) = 0%). The number of women reporting a change in menstruation was significantly higher in the LNG-IUD group (RR 37.80, 95% CI 5.40 to 264.60, 95 women, I(2) = 0%) but the number of women not completing the allocated treatment did not differ between groups (RR 0.66, 95% CI 0.08 to 5.25, I(2) = 43%).In one trial, women receiving LNG-IUD noted lower pain scores compared with women receiving gonadotrophin-releasing hormone agonists (MD -0.16, 95% CI -2.02 to 1.70, 40 women) but this did not reach statistical significance.

AUTHORS' CONCLUSIONS

There is limited but consistent evidence showing that postoperative LNG-IUD use reduces the recurrence of painful periods in women with endometriosis. Further well-designed RCTs are needed to confirm these findings.

An update on the pharmacological management of endometriosis

INTRODUCTION

Endometriosis is a common disease that causes pain symptoms and/or infertility in women in their reproductive years. The disease is characterised by the presence of endometrium-like tissue - glands and stroma - outside the uterine cavity. Different treatment options exist for endometriosis including medical and surgical treatments or a combination of the two approaches. The most commonly used medications are non-steroidal anti-inflammatory drugs, GnRH agonists, androgen derivatives such as danazol, combined oral contraceptive pills, progestogens and more recently the levonorgestrel intrauterine system.

AREAS COVERED

The authors review current medical treatments used for symptomatic endometriosis and also discuss new treatment approaches. The authors conducted a literature search for randomised controlled trials related to medical treatments of endometriosis in humans, searched the Cochrane library for reviews and also searched for registered trials that have not yet been published on ClinicalTrials.gov.

EXPERT OPINION

The medical treatment of endometriosis is effective at treating pain and preventing recurrence of disease after surgery. Remarkably, the oral contraceptive pill taken continuously is as effective as GnRH-a, while causing far less side-effects. Conversely, no treatment currently exists for enhancing fecundity in women whose infertility is associated with endometriosis. As all existing therapies of endometriosis are contraceptive, great efforts should be targeted at researching novel products that reduce the disease expression without shuttering ovulation.

Long-term regression of experimental endometriosis in a rat model treated with local application of levonorgestrel-loaded biodegradable microspheres

BACKGROUND

A previous study demonstrated that local application of levonorgestrel-loaded polylactic acid microspheres (LNG microspheres) resulted in significant regression of endometriotic cysts in a rabbit model for 6 months without disturbing the metabolic parameters or ovarian function. In order to investigate the feasibility of local application of LNG microspheres as a long-term maintenance treatment for endometriosis, the suppressive effect of a single intra-cystic injection of LNG microspheres was studied for 1 year in a rat model.

METHODS AND RESULTS

Twenty four rats with experimental endometriotic cysts were randomized to be treated with a single intra-cystic injection of LNG microspheres (n = 8); 6-month GnRH agonist (GnRHa, n = 8) or control (n = 8). Intra-cystic injection of LNG microspheres and GnRHa treatment caused comparable regression and atrophy in endometriotic cysts in the first 6 months. Compared with the control, the wet weight of the endometriotic cysts was significantly lower in both groups at Month 6 but by Month 12 only remained low in the LNG microspheres group (P < 0.01). The immunostaining of estrogen receptors (ERs) in both the epithelium and stroma and progesterone receptors (PRs) in the stroma was significantly weakened in the LNG microspheres group at Month 6 and was not fully restored at Month 12 (P < 0.01). Metabolic parameters and estrous cycle were not disturbed by local application of LNG microspheres.

CONCLUSIONS

In a rat endometriosis model, the suppressive effect of a single intra-cystic injection of LNG microspheres was comparable to that of GnRHa, and was maintained for 1 year. The down-regulation of ERs and PRs might serve as possible mechanism of long-term effectiveness.

[Medical treatment of endometriosis: an obligation rather than a mere option!]

The aim of this article is to argue the usefulness of the systematic administration of medical treatment in women managed for endometriosis, either alone or associated with the surgery. The authors dispute seven frequent objections against the medical treatment: the lack of curative effect, the lack of primary prevention and the risk of delaying the diagnostic, the contraceptive effect in women wishing to conceive, the adverse effects, the risk of occurrence of new lesions following the arrest of the treatment, the lack of proof favourable to the efficient prevention of recurrences and the cost of the treatment. The authors conclude that to date the therapeutic amenorrhea represents an indispensable tool in the management of the endometriosis, in women both benefiting or not from surgical procedures.

Letrozole and norethisterone acetate versus letrozole and triptorelin in the treatment of endometriosis related pain symptoms: a randomized controlled trial

BACKGROUND

When aromatase inhibitors are used to treat premenopausal women with endometriosis, additional drugs should be used to effectively down-regulate gonadal estrogen biosynthesis. This randomized prospective open-label study compared the efficacy in treating pain symptoms and the tolerability of letrozole combined with either norethisterone acetate or triptorelin.

METHODS

Women with pain symptoms caused by rectovaginal endometriosis were treated with letrozole (2.5 mg/day) and were randomized to also receive either oral norethisterone acetate (2.5 mg/day; group N) or intramuscular injection of triptorelin (11.25 mg every 3 months; group T). The scheduled length of treatment was 6 months. A visual analogue scale and a multidimensional categorical rating scale were used to assess the severity of pain symptoms. The volume of the endometriotic nodules was estimated by ultrasonography using virtual organ computer-aided analysis. Adverse effects of treatment were recorded.

RESULTS

A total of 35 women were randomized between the two treatment protocols. Significantly more patients in group N rated their treatment as satisfactory or very satisfactory (64.7%) as compared to group T (22.2%; p=0.028). The intensity of both non-menstrual pelvic pain and deep dyspareunia significantly decreased during treatment in both study groups, though no statistically meaningful difference between the two groups was apparent. Reduction in the volume of endometriotic nodules was significantly greater in group T than in group N. Interruption of treatment due to adverse effects significantly differed between the groups, with 8 women in group T (44.4%) and 1 woman in group N (5.9%) interrupting treatment (p=0.018). Similarly, 14 women included in group T (77.8%) and 6 women included in group N (35.3%) experienced adverse effects of treatment (p=0.018). During treatment, mineral bone density significantly decreased in group T but not in group N.

CONCLUSIONS

Aromatase inhibitors reduce the intensity of endometriosis-related pain symptoms. Combining letrozole with oral norethisterone acetate was associated with a lower incidence of adverse effects and a lower discontinuation rate than combining letrozole with triptorelin.

Use of aromatase inhibitors to treat endometriosis-related pain symptoms: a systematic review

This systematic review aims to assess the efficacy of aromatase inhibitors (AIs) in treating pain symptoms caused by endometriosis. A comprehensive literature search was conducted to identify all the published studies evaluating the efficacy of type II nonsteroidal aromatase inhibitors (anastrozole and letrozole) in treating endometriosis-related pain symptoms. The MEDLINE, EMBASE, PubMed, and SCOPUS databases and the Cochrane System Reviews were searched up to October 2010. This review comprises of the results of 10 publications fitting the inclusion criteria; these studies included a total of 251 women. Five studies were prospective non-comparative, four were randomized controlled trials (RCTs) and one was a prospective patient preference trial. Seven studies examined the efficacy of AIs in improving endometriosis-related pain symptoms, whilst three RCTs investigated the use of AIs as post-operative therapy in preventing the recurrence of pain symptoms after surgery for endometriosis. All the observational studies demonstrated that AIs combined with either progestogens or oral contraceptive pill reduce the severity of pain symptoms and improve quality of life. One patient preference study demonstrated that letrozole combined with norethisterone acetate is more effective in reducing pain and deep dyspareunia than norethisterone acetate alone. However, letrozole causes a higher incidence of adverse effects and does not improve patients' satisfaction or influence recurrence of symptoms after discontinuation of treatment. A RCT showed that combining letrozole with norethisterone acetate causes a lower incidence of adverse effects and lower discontinuation rate than combining letrozole with triptorelin. Two RCTs demonstrated that, after surgical treatment of endometriosis, the administration of AIs combined with gonadotropin releasing hormone analogue for 6 months reduces the risk of endometriosis recurrence when compared with gonadotropin releasing hormone analogue alone. In conclusion, AIs effectively reduce the severity of endometriosis-related pain symptoms. Since endometriosis is a chronic disease, future investigations should clarify whether the long-term administration of AIs is superior to currently available endocrine therapies in terms of improvement of pain, adverse effects and patient satisfaction.

Use of the levonorgestrel-releasing intrauterine system, quality of life and sexuality. Experience in an Italian family planning center

BACKGROUND

The levonorgestrel-releasing intrauterine system (LNG-IUS) was first marketed in 1990 in Finland. Since then, it has been approved in approximately 120 countries throughout the world, with almost 50 million women-years of cumulative experience to date. Its high contraceptive effectiveness and favorable bleeding profile, leading to significant reduction of menstrual bleeding both in women with idiopathic menorrhagia and in those with normal menstrual bleedings, have been the key to the success of the system. At the same time, women need to be provided adequate preinsertion counseling about changes in menstrual bleeding to be expected. In the Italian context, it is important to highlight during counseling that amenorrhea is not harmful but can lead to health benefits such as an increase in iron blood stores and blood hemoglobin concentration.

STUDY DESIGN

To evaluate contraceptive efficacy, compliance and the effect of changes in menstrual cyclicity on quality of life and sexuality of the LNG-IUS (Mirena®), 156 women attending the Family Planning Clinic to request contraception were enrolled in the study and inserted with the device.

RESULTS

Menstrual blood flow decreased in all users, in terms of both quantity and duration; although spotting was present in 93.7% of the women, it disappeared within 6 months in the majority of cases. Amenorrhea occurred in 29.5% of all women, with onset within the first six cycles postinsertion. Data from the EuroQuality of Life-5D and Female Sexual Function Index questionnaires showed improvement in the quality of life, with a decrease in intercourse-related pain and an improvement in sexual desire.

CONCLUSIONS

Although in Italy intrauterine contraception is poorly accepted, once started on LNG-IUS, women found that the device represents a safe and effective contraceptive modality, with valuable noncontraceptive benefits, especially in the presence of heavy or prolonged bleeding.

Surgical management of deep infiltrating endometriosis of the rectum: pleading for a symptom-guided approach

Two surgical approaches are usually employed in the treatment of deep infiltrating endometriosis of the rectum (DIER): colorectal resection removing the rectal segment affected by the disease, and nodule excision either without opening the rectum (shaving) or by removing the nodule along with the surrounding rectal wall (full thickness or disc excision). Although the present available data are from retrospective series reported by surgeons who generally perform only one technique, there is no evidence to support the risk of recurrences as a valid argument in favour of colorectal resection over rectal nodule excision. The advantage of a lower morbidity associated with nodule excision is not necessarily at the cost of an increased rate of pain recurrences, especially in women benefiting from post-operative medical treatment. The symptom-guided surgical approach in DIER primarily focuses on the relief of digestive symptoms and pelvic pains, rather than on mandatory 'carcinologic' resection of lesions. In addition, the risk of new post-operative unpleasant symptoms as a result of a compulsory and systematic excision of all endometriotic foci may be avoided. In a majority of cases, pelvic anatomy and digestive function can be restored by shaving or disc excision, as well as by colorectal resection; thus digestive complaints can be resolved even when the rectum is conserved. The most accurate evaluation of the results of DIER surgery should be provided by post-operative evolution in digestive function. Even though quality of life is improved for the majority of patients managed by colorectal resection, the question is whether or not a greater health improvement can be achieved by performing nodule excision, which avoids various post-operative and functional digestive complications. In addition, continuous medical treatment leads to a decrease in endometriotic nodules and prevents post-operative pain recurrences. Instead of choosing between medical and surgical management in the treatment of DIER, it is most likely that the two therapies should be associated.

Hormonal contraceptives and endometriosis/adenomyosis

Over the past 50 years hormonal contraceptives have gradually developed to be cost-effective medical treatment modalities for primary and secondary therapy of endometriosis/adenomyosis. This is particularly true for the various estrogen/progestogen combinations as monophasic - particularly progestogen-dominant - preparations in cyclic, long-cyclic and continuous treatment forms. An alternative is the progestogen-only therapy used continuously. Therapeutic effects have been shown for peritoneal, ovarian and deep-infiltrating endometriosis as well as for adenomyosis. An individualized, medical long-term treatment concept to control endometriosis/adenomyosis-related symptoms, endometriosis/adenomyosis development and minimizing the recurrence rate needs to be further studied in women, who do not desire to become pregnant.