A levonorgestrel-releasing intrauterine system for the treatment of dysmenorrhea associated with endometriosis: a pilot study

Levonorgestrel-releasing intrauterine system (Mirena) and Depot medroxyprogesterone acetate (Depoprovera) as long-term maintenance therapy for patients with moderate and severe endometriosis: a randomised controlled trial

BACKGROUND

Progestogen therapy has been found to be useful in controlling endometriosis. For patients after conservative surgery, long-term medical maintenance therapy should be sought to prevent recurrence and control symptoms. Levonorgestrel-releasing intrauterine system (LNG-IUS) may be a useful form of prolonged progestogen therapy for endometriosis.

AIMS

To evaluate and compare the efficacy and safety of LNG-IUS to depot medroxyprogesterone acetate (MPA) for patients with moderate or severe endometriosis following conservative surgery, in terms of symptoms control, recurrence prevention and patients' acceptance.

METHODS

A total of 30 patients after conservative surgery for endometriosis underwent randomisation. Of these patients, 15 received LNG-IUS and 15 had three-monthly depot MPA for three years. Their symptom control, recurrence, compliance and change in bone mineral density (BMD) were compared. The data were analysed using student's t-test and chi-square test.

RESULTS

Symptoms and recurrence were controlled by both therapies. The compliance was better in LNG-IUS Group with 13 patients staying on their therapy versus seven patients in Depot MPA Group. LNG-IUS users had a significantly better change in BMD (+0.023, +0.071 g/cm(2)) than Depot MPA users (-0.030, -0.017 g/cm(2)) in both hip and lumbar regions.

CONCLUSIONS

Levonorgestrel-releasing intrauterine system was effective in symptom control and prevention of recurrence. LNG-IUS users showed a better compliance. After three years, bone gain was noted with LNG-IUS, but bone loss with depot MPA.

Non-contraceptive applications of the levonorgestrel intrauterine system

Intrauterine progestins have many important current and potential gynecologic applications. This article describes the evidence for use of intrauterine progestin for common gynecologic conditions beyond its important role in contraception. The pharmacology of and selection criteria for use of the levonorgestrel intrauterine device is discussed, and the evidence for use of intrauterine progestin delivery for menorrhagia, endometriosis management, uterine fibroids, adenomyosis and endometrial hyperplasia is reviewed.

Intrauterine progestins, progesterone antagonists, and receptor modulators: a review of gynecologic applications

Intrauterine progestins, progesterone receptor modulators, and antagonists have many important current and potential gynecologic applications. This article will describe the evidence for use of intrauterine progestin for common gynecologic conditions beyond its important role in contraception. We will review the evidence for use of intrauterine progestin delivery for menorrhagia, endometriosis management, adenomyosis treatment, uterine fibroids, endometrial hyperplasia, and its concurrent use in women on hormone replacement therapy or tamoxifen.

Endometriosis: current therapies and new pharmacological developments

Endometriosis is a chronic inflammatory condition that is responsive to management with steroids. The establishment of a steady hormonal environment and inhibition of ovulation can temporarily suppress ectopic implants and reduce inflammation as well as associated pain symptoms. In terms of pharmacological management, the currently available agents are not curative, and treatment often needs to be continued for years or until pregnancy is desired. Similar efficacy has been observed from the various therapies that have been investigated for endometriosis. Accordingly, combined oral contraceptives and progestins, based on their favourable safety profile, tolerability and cost, should be considered as first-line options, as an alternative to surgery and for post-operative adjuvant use. In situations where progestins and oral contraceptives prove ineffective, are poorly tolerated or are contraindicated, gonadotrophin-releasing hormone analogues, danazol or gestrinone may be used. Future therapeutic options for managing endometriosis must compare favourably against existing agents before they can be considered for inclusion into current practice. Finally, as reproductive prognosis is not ameliorated by medical treatment, it is not indicated for women seeking conception.

Mirena (Levonorgestrel intrauterine system): a successful novel drug delivery option in contraception

This manuscript serves as a review of Mirena, the levonorgestrel intrauterine system (LNG IUS) as a very successful drug delivery system. The LNG IUS has a very high contraceptive efficacy rate, and low rates of patient discontinuation. In addition to its contraceptive benefits, most users experience a decrease in menstrual bleeding over the 5 years of use. LNG IUS has also been used for management of menorrhagia, dysmenorrhea, adenomyosis, and endometrial hyperplasia in some cases. The LNG IUS provides long term efficacy, high rates of compliance, rapid return to fertility, and minimal adverse effects during use.

Modern management of abnormal uterine bleeding: the levonorgestrel intra-uterine system

Since its launch, more than 9 million women worldwide have used the levonorgestrel intra-uterine system (IUS) for contraception, as a treatment for heavy menstrual bleeding and as the progestogen component of hormone-replacement therapy. For women in their reproductive years, the IUS has become one of the most acceptable medical treatments for menorrhagia, reducing referrals to specialists and decreasing the need for operative gynaecological surgery. This article will outline the development of the IUS, highlighting the most important recent areas of research covering its use to control menstrual blood loss and pain.

Long-term use of the levonorgestrel-releasing intrauterine system

Since its launch in Finland in 1990, the levonorgestrel-releasing intrauterine system (LNG IUS) has become available in more than 100 countries throughout the world, with most countries also having the approval for the treatment of idiopathic menorrhagia and protection from endometrial hyperplasia during estrogen replacement therapy. After its introduction in Finland and Scandinavian countries, the LNG IUS has been available in most European countries since the mid to late 1990s and in the United States since 2001. Studies on the repeat use of the LNG IUS with second and third consecutive IUSs have shown high continuation rates and low rates of adverse effects. During repeat use of the LNG IUS, the bleeding pattern changes toward an increasing amenorrhea rate. With regard to the menorrhagia indication, the 5-year follow-up results of a randomized comparative trial of the LNG IUS and hysterectomy have shown equal satisfaction and improvement in health-related quality of life with both treatments. Although a proportion of women assigned to the LNG IUS group eventually underwent hysterectomy, the continuation rate of the LNG IUS for menorrhagia is clearly superior to that of conventional medical therapy (e.g., oral progestins). Use of the LNG IUS in combination with estrogen therapy in women undergoing menopausal transition seems to be well tolerated and associated with a favorable bleeding pattern.

Use of the levonorgestrel-releasing intrauterine system in women with endometriosis, chronic pelvic pain and dysmenorrhea

OBJECTIVES

This report is a review of the medical literature on the use of the levonorgestrel-releasing intrauterine system (LNG-IUS) in women with endometriosis, adenomyosis, cyclic pelvic pain and dysmenorrhea.

MATERIAL AND METHODS

A review was carried out using the MEDLINE and EMBASE databases to evaluate the use of LNG-IUS in women with endometriosis and adenomyosis.

RESULTS

Nine studies were identified, only two of which were randomized clinical trials. One compared the insertion of LNG-IUS after surgery with expectant conduct and the other compared the use of the device with a GnRH analogue (GnRH-a). All studies reported an improvement in pelvic pain and dysmenorrhea, and a reduction in menstrual bleeding. One study found an improvement in the staging of the disease at 6 months of use, and the studies that evaluated the use of LNG-IUS in women with adenomyosis reported a reduction in uterine volume. Furthermore, the only study in which women were followed up for 3 years after insertion found improvement in pelvic pain at 12 months of use. However, there was no improvement after that period.

CONCLUSIONS

The use of LNG-IUS is an alternative for the medical treatment of women suffering from endometriosis, adenomyosis, chronic pelvic pain or dysmenorrhea, but experience is limited and long-term studies are necessary to reach definitive conclusions. However, for women who do not wish to become pregnant, this device offers the possibility of at least 5 years of treatment following one single intervention.

Endometriosis: the way forward

Endometriosis, a common cause of morbidity, affects 10% of women of reproductive age. In this review we focus on the new developments in pathogenesis, diagnosis and treatment options, reviewing the literature published about this enigmatic disorder over the past three years. More specifically, new theories of the pathogenesis of the syndrome of Sampson and Cullen are discussed. The new era of genomics may characterize endometriosis and transform clinical management of the disease. Literature suggesting that endometriosis may have an environmental origin is reviewed. New approaches to medical therapy of endometriosis have been developed, including the levonorgestrel-releasing intrauterine device, aromatase inhibitors, immunomodulatory drugs, angiogenesis inhibitors, selective estrogen and progesterone receptor modulators, and statins. Subfertility is another well-known result of endometriosis and often complex decisions must be made regarding management of the endometriosis patient who wishes to conceive. Laparoscopic surgery and assisted reproduction--with or without gonadotropin-releasing hormone-agonist treatment--are reviewed. Finally we speculate about new developments in the field of endometriosis in the coming three years.

Medicated intrauterine systems for treatment of endometriosis-associated pain

Medicated intrauterine systems (IUSs) are intrauterine devices that act by means of the local release of a medication. The levonorgestrel (LNG)-IUS is a T-shaped device that releases the progestogen LNG directly into the uterine cavity. The LNG-IUS can be used with noncontraceptive, therapeutic intent for idiopathic menorrhagia, hormonal replacement therapy in conjunction with oral or transdermal estrogens, and endometriosis or adenomyosis-associated pain. For this last indication, however, the use of the LNG-IUS is still under clinical investigation.

The role of the levonorgestrel-releasing intrauterine device in the management of symptomatic endometriosis

PURPOSE OF REVIEW

The aim of this article is to evaluate the biological rationale for the use of an intrauterine device releasing 20 mug/day of levonorgestrel in women with endometriosis, and to assess its efficacy in relieving pelvic pain symptoms.

RECENT FINDINGS

Levonorgestrel induces endometrial glandular atrophy and extensive decidual transformation of the stroma, downregulates endometrial cell proliferation, increases apoptotic activity, and has antiinflammatory and immunomodulatory effects. Up to 85% of patients wearing the device have anovulatory cycles during the first 3 months of use, but the proportion falls to below 35% by 12 months. After the first year of use, a 70-90% reduction in monthly blood loss is observed; few women report intermenstrual bleeding and about 20-30% amenorrhea. This is advantageous in patients experiencing dysmenorrhea. Although it is maintained that the hormonal activity of the levonorgestrel intrauterine device is local, a systemic effect secondary to uterine absorption of levonorgestrel is probable. The levonorgestrel intrauterine device 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.

SUMMARY

Intrauterine administration of levonorgestrel with direct distribution to pelvic tissues would imply a local concentration greater than plasma levels. This could result in a superior effectiveness with limited adverse effects and increased patient compliance during long-term treatment. Further trials are needed, however, to verify whether the good results observed are maintained during an entire 5-year period, to confirm the efficacy on dyspareunia and dyschezia, and to compare the effects of the levonorgestrel intrauterine device with those of other treatment options.

The levonorgestrel-releasing intrauterine device reduces CA-125 serum levels in patients with endometriosis

This study compared the long-term effects of the levonorgestrel-releasing intrauterine device with those of GnRH agonist administration on serum levels of CA-125 in patients with endometriosis. The levonorgestrel-releasing intrauterine device was found to be as efficient as GnRH agonist in reducing CA-125 serum levels.

Medical management of endometriosis

Current approved medical therapies for endometriosis rely on drugs that suppress ovarian steroids and induce a hypoestrogenic state, which determines the atrophy of the ectopic endometrium. Gonadotropin-releasing hormone analogs such as danazol, progestogens and estrogen-progestin combinations have all proven effective in relieving pain and reducing the extent of endometriotic implants. However, symptoms often recur after discontinuation of therapy and hypoestrogenism-related side effects limit the long-term use of most medications. Recently, knowledge of the pathogenesis of endometriosis, particularly at the molecular level, has grown substantially, providing a rational basis for the development of new drugs with precise targets that may be safely administered over the long term.

Vitamin D binding protein in endometriosis

OBJECTIVE

Two-dimensional gel electrophoresis is a powerful method for identifying post-translationally modified molecules in biological fluids. We examined the presence and expression of vitamin D binding protein (DBP) in the peritoneal fluid (PF) and plasma (PL) of women with endometriosis.

METHODS

PL and PF samples were obtained from 36 women with untreated mild endometriosis (revised classification of the American Fertility Society [rAFS] stage I-II), 52 women with untreated severe endometriosis (rAFS stage III-IV), 17 women with endometriosis treated with the oral contraceptive (OC), and 40 controls (infertility, n = 23; tubal sterilization, n = 12; pelvic pain, n = 5). PF and PL samples were analyzed by quantitative, high-resolution 2-dimensional gel electrophoresis.

RESULTS

The expression of one DBP isoform (DBPE) in the PF of patients with untreated endometriosis was significantly lower than in the control group (P <.05). The levels of PF DBPE in patients with endometriosis using OC were significantly higher than in women with untreated endometriosis (P <.05). No significant difference was observed in PL DBPE expression between women with and without endometriosis, while it was significantly increased in patients with endometriosis using OC (P <.05). DBP expression was not correlated with the stage of endometriosis (rAFS classification) or the phase of the menstrual cycle.

CONCLUSION

The decreased level of DBPE in the PF but not in PL of women with untreated endometriosis suggests that this molecule may be relevant in the pathogenesis of this disease.

Primary Dysmenorrhea Consensus Guideline

METHODS

Members of this consensus group were selected based on individual expertise to represent a range of practical and academic experience both in terms of location in Canada and type of practice, as well as subspecialty expertise along with general gynaecology backgrounds. The consensus group reviewed all available evidence through the English and French medical literature and available data from a survey of Canadian women. Recommendations were established as consensus statements. The final document was reviewed and approved by the Executive and Council of the SOGC.

RESULTS

This document provides a summary of up-to-date evidence regarding the diagnosis, investigations, and medical and surgical management of dysmenorrhea. The resulting recommendations may be adapted by individual health care workers when serving women who suffer from this condition.

CONCLUSIONS

Dysmenorrhea is an extremely common and sometimes debilitating condition for women of reproductive age. A multidisciplinary approach involving a combination of lifestyle, medications, and allied health services should be used to limit the impact of this condition on activities of daily living. In some circumstances, surgery is required to offer the desired relief.

OUTCOMES

This guideline discusses the various options in managing dysmenorrhea. Patient information materials may be derived from these guidelines in order to educate women in terms of their options and possible risks and benefits of various treatment strategies. Women who find an acceptable management strategy for this condition may benefit from an improved quality of life.

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.

The levonorgestrel-releasing intrauterine system in modern gynaecology

The levonorgestrel-releasing intrauterine system was initially developed for contraception but is now widely used for a variety of gynaecological conditions. Compliance can sometimes be hampered by troublesome side effects (principally breakthrough bleeding) but appropriate counselling can reduce unnecessary discontinuation.

ESHRE guideline for the diagnosis and treatment of endometriosis

The objective was to develop recommendations for the diagnosis and treatment of endometriosis and its associated symptoms. A working group was convened comprised of practising gynaecologists and experts in evidence-based medicine from Europe, as well as an endometriosis self-help group representative. After reviewing existing evidence-based guidelines and systematic reviews, the expert panel met on three occasions for a day during which the guideline was developed and refined. Recommendations based solely on the clinical experience of the panel were avoided as much as possible. The entire ESHRE Special Interest Group for Endometriosis and Endometrium was given the opportunity to comment on the draft guideline, after which it was available for comment on the ESHRE website for 3 months. The working group then ratified the guideline by unanimous or near-unanimous voting; finally, it was approved by the ESHRE Executive Committee. The guideline will be updated regularly, and will be made available at http://www.endometriosis.org/guidelines.html with hyperlinks to the supporting evidence, and the relevant references and abstracts. For women presenting with symptoms suggestive of endometriosis, a definitive diagnosis of most forms of endometriosis requires visual inspection of the pelvis at laparoscopy as the 'gold standard' investigation. However, pain symptoms suggestive of the disease can be treated without a definitive diagnosis using a therapeutic trial of a hormonal drug to reduce menstrual flow. In women with laparoscopically confirmed disease, suppression of ovarian function for 6 months reduces endometriosis-associated pain; all hormonal drugs studied are equally effective although their side-effects and cost profiles differ. Ablation of endometriotic lesions reduces endometriosis-associated pain and the smallest effect is seen in patients with minimal disease; there is no evidence that also performing laparoscopic uterine nerve ablation (LUNA) is necessary. In minimal-mild endometriosis, suppression of ovarian function to improve fertility is not effective, but ablation of endometriotic lesions plus adhesiolysis is effective compared to diagnostic laparoscopy alone. There is insufficient evidence available to determine whether surgical excision of moderate-severe endometriosis enhances pregnancy rates. IVF is appropriate treatment especially if there are coexisting causes of infertility and/or other treatments have failed, but IVF pregnancy rates are lower in women with endometriosis than in those with tubal infertility. The management of severe/deeply infiltrating endometriosis is complex and referral to a centre with the necessary expertise is strongly recommended. Patient self-help groups can provide invaluable counselling, support and advice.

Serum and peritoneal fluid levels of levonorgestrel in women with endometriosis who were treated with an intrauterine contraceptive device containing levonorgestrel

OBJECTIVE

To determine and compare levels of levonorgestrel (Lng) in serum and peritoneal fluid (PF) of patients on the Lng intrauterine system Mirena (Schering Health, Berlin, Germany) for endometriosis and to relate these to symptoms.

DESIGN

Prospective clinical trial.

SETTING

Gynecology unit of a teaching hospital.

PATIENT(S)

Women with minimal to moderate endometriosis at diagnostic laparoscopy.

INTERVENTION(S)

Mirena was inserted at diagnostic laparoscopy and blood and PF collected for Lng levels. Levonorgestrel was again quantified in serum at 1, 3, and 6 months and PF at 6 months.

MAIN OUTCOME MEASURE(S)

Serum and PF Lng levels during 6 months, differences in levels before and 6 months after Mirena insertion, and the relationship between these levels and symptoms of endometriosis.

RESULT(S)

There was significant improvement in symptoms after 6 months on Mirena. The mean (SD) serum Lng levels were 459.2 (100.2), 368.2 (51.8), and 357.3 (53.0) pg/mL at 1, 3, and 6 months, respectively. The PF levels at 6 months were approximately two-thirds the serum levels in patients showing improvement in symptoms.

CONCLUSION(S)

Mirena delivers significant amounts of Lng into the PF and serum. The relationship between Lng levels in these compartments is linear.

Randomized clinical trial of a levonorgestrel-releasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis

BACKGROUND

The objective of this multicentre randomized, controlled clinical trial was to compare the efficacy of a levonorgestrel-releasing intrauterine system (LNG-IUS) and a depot-GnRH-analogue in the control of endometriosis-related pain over a period of six months.

METHODS

Eighty-two women, 18 to 40 years of age (mean 30 years), with endometriosis, dysmenorrhoea and/or CPP, were randomized using a computer-generated system of sealed envelopes into either LNG-IUS (n = 39) or GnRH analogue (n = 43) treatment groups at three university centres. Daily scores of endometriosis-associated CPP were evaluated using the Visual Analogue Scale (VAS), daily bleeding score was calculated from bleeding calendars, and improvement in quality of life was evaluated using the Psychological General Well-Being Index Questionnaire (PGWBI). The pain score diary was based on the VAS in which women recorded the occurrence and intensity of pain on a daily basis. A monthly score was calculated from the result of the sum of the daily scores divided by the number of days in each observation period.

RESULTS

CPP decreased significantly from the first month throughout the six months of therapy with both forms of treatment and there was no difference between the groups (P > 0.999). In both treatment groups, women with stage III and IV endometriosis showed a more rapid improvement in the VAS pain score than women with stage I and II of the disease (P < 0.002). LNG-IUS users had a higher bleeding score than GnRH-analogue users at all time points of observation with 34% and 71% of patients in the LNG-IUS and GnRH-analogue groups, respectively, reporting no bleeding during the first treatment month, and 70% and 98% reporting no bleeding during the sixth month. No difference was observed between groups with reference to improvement in quality of life.

CONCLUSIONS

Both, the LNG-IUS and the GnRH-analogue were effective in the treatment of CPP-associated endometriosis, although no differences were observed between the two treatments. Among the additional advantages of the LNG-IUS is the fact that it does not provoke hypoestrogenism and that it requires only one medical intervention for its introduction every 5 years. This device could therefore become the treatment of choice for CPP-associated endometriosis in women who do not wish to conceive.

The efficacy, side-effects and continuation rates in women with symptomatic endometriosis undergoing treatment with an intra-uterine administered progestogen (levonorgestrel): a 3 year follow-up

BACKGROUND

Side-effects and choice of drugs influence compliance during treatment for endometriosis. Progestogen administered by a device with a 5-year lifespan, has been shown to be an effective medical alternative with several advantages. The aims of this study were to investigate its efficacy, continuation rates and side-effects in women with endometriosis over a 3-year period.

METHODS

Thirty-four women with laparoscopically confirmed minimal to moderate symptomatic endometriosis offered insertion of an intrauterine device at diagnostic laparoscopy were followed up at 1, 3 and 6 months, and then every 6 months for 3 years. A symptom diary for side-effects, documentation of symptoms on a visual analogue scale (VAS), a verbal rating scale (VRS) and quantified menstrual loss using the pictorial blood loss chart was used to assess response to treatment.

RESULTS

The continuation rates were respectively 85%, 68%, 62% and 56% at, 6, 12, 24 and 36 months. Discontinuation rates were highest at <12 months, and most of these were for irregular and intolerable bleeding and persistent pain. An improvement in symptoms was observed throughout the 36 months. The greatest changes in pain assessed by either the VAS or VRS were between the pretreatment scores and those after 12 months (7.7 +/- 1.3 versus 3.5 +/- 1.8 for VAS, P < 0.001; and 25 +/- 13.8 versus 14 +/- 9.4 for VRS, P < 0.002). The monthly quantified blood loss fell from 204 (196) pretreatment to 60 (50) at 12 months (P < 0.001) and then to 70 (30) after 36 months. The most common side-effects were bleeding irregularities (14.7%), one-sided abdominal pain (11.8%) and weight gain (8.8%).

CONCLUSIONS

Intrauterine progestogen is effective in symptom control throughout the 3 years on the device, and discontinuation is greatest between 3 and 6 months. For those patients with improvement in symptoms, it is an acceptable long-term alternative.

Human endometriotic xenografts in immunodeficient RAG-2/gamma(c)KO mice

OBJECTIVE

The purpose of this study was to create a novel animal model for studies of endometriosis.

STUDY DESIGN

To facilitate the study of the transplantation of endometriosis into immunodeficient RAG-2/gamma(c)KO mice, endometriosis biopsy specimens were collected from 19 women by laparoscopic surgery and grafted subcutaneously into the mice, which were treated subsequently with estradiol and progesterone to create 28-day artificial cycles. The grafts were collected during the first, second, and fourth cycles and were evaluated histologically for evidence of bleeding and immunocytochemically for estrogen receptor and progesterone receptor.

RESULTS

Biopsy specimens that contained endometrium-like glands were well accepted (>90% success). These grafts maintained glandular morphologic condition, estrogen receptor, and progesterone receptor; bled after progesterone withdrawal; and formed chocolate cysts. However, biopsy specimens that lacked glands or that consisted of peritoneal adhesions and stroma were accepted poorly <5% success) and failed to show evidence of estrogen receptor, progesterone receptor, or cyclic bleeding.

CONCLUSION

Human endometriosis transplanted into RAG-2/gamma(c)KO mice can provide a model for endometriotic bleeding.

Recent developments in hormone delivery systems

Women who want safe, effective contraception have many more options than they did only a few years ago. Each option must be weighed carefully according to the needs and lifestyle of each particular woman. One method that provides long-term convenience with a side-effect profile that is comparable to that of oral contraceptives is the once-a-month injectable contraceptive containing 25 mg medroxyprogesterone acetate and 5 mg estradiol cypionate. Another option is the levonorgestrel-releasing intrauterine contraceptive system that offers pregnancy prevention for 5 years. Finally, hormonal implants that release low doses of progestins have been used for more than 30 years by a total of 10 million women, and easier-to-use implants will soon be available.

Benefit-Risk Assessment of the Levonorgestrel Intrauterine System in Contraception

The levonorgestrel-releasing intrauterine system (IUS) is a long-acting, fully reversible method of contraception. It is one of the most effective forms of contraception available, and combines the advantages of both hormonal and intrauterine contraception. The levonorgestrel-releasing IUS also gives the users many non-contraceptive benefits: the amount of menstrual bleeding and the number of days of menstrual bleeding are reduced, which makes it suitable for the treatment of menorrhagia (heavy menstrual blood loss). Dysmenorrhoea (painful menstruation) and premenstrual symptoms are also relieved. In addition, the levonorgestrel-releasing IUS provides protection for the endometrium during hormone replacement therapy. The local release of levonorgestrel into the uterine cavity results in a strong uniform suppression of the endometrial epithelium as the epithelium becomes insensitive to estradiol released from the ovaries. This accounts for the reduction in menstrual blood loss. All possible patterns of bleeding are seen among users of the levonorgestrel-releasing IUS; however, most of the women who experience total amenorrhoea continue to ovulate. The first months of use are often characterised by irregular, scanty bleeding, which in most cases resolves spontaneously. The menstrual pattern and fertility return to normal soon after the levonorgestrel-releasing IUS is removed. The contraceptive efficacy is high with 5-year failure rates of 0.5-1.1 per 100 users. The absolute number of ectopic pregnancies is low, as is the rate per 1000 users. The levonorgestrel-releasing IUS is equally effective in all age groups and the bodyweight of the user is not associated with failure of the method. In Western cultures continuance rates among users of the levonorgestrel-releasing IUS are comparable with those of other long-term methods of contraception. Premature removal of the device is most often associated with heavy menstrual bleeding and pain, as with other long-term methods of contraception, and is most common in the youngest age group. When adequately counselled about the benign nature of oligo- or amenorrhoea, most women are very willing to accept life without menstruation. The risk of premature removal can be markedly diminished with good pre-insertion counselling, which also markedly increases user satisfaction. User satisfaction is strongly associated with the information given at the time of the levonorgestrel-releasing IUS insertion. Thus, the benefits of the levonorgestrel-releasing IUS make it a very suitable method of contraception for most women.

Comparison of a levonorgestrel-releasing intrauterine device versus expectant management after conservative surgery for symptomatic endometriosis: a pilot study

OBJECTIVE

To determine whether the frequency and severity of dysmenorrhea are reduced in women with symptomatic endometriosis in whom a levonorgestrel-releasing intrauterine device (Lng-IUD) is inserted after operative laparoscopy compared with those treated with surgery only.

DESIGN

Open-label, parallel-group, randomized, controlled trial.

SETTING

A tertiary care and referral center for patients with endometriosis.

PATIENTS(S)

Parous women with moderate or severe dysmenorrhea undergoing first-line operative laparoscopy for symptomatic endometriosis.

INTERVENTION(S)

Randomization to immediate Lng-IUD insertion or expectant management after laparoscopic treatment of endometriotic lesions. Proportions of women with recurrence of moderate or severe dysmenorrhea in the two study groups 1 year after surgery and overall degree of satisfaction with treatment. Moderate or severe dysmenorrhea recurred in 2 of 20 (10%) subjects in the postoperative Lng-IUD group and 9/20 (45%) in the surgery-only group. Thus, a medicated device inserted postoperatively will prevent the recurrence of moderate or severe dysmenorrhea in one out of three patients 1 year after surgery. A total of 15/20 (75%) women in the Lng-IUD group and 10/20 (50%) in the expectant management group were satisfied or very satisfied with the treatment received.

CONCLUSION(S)

Insertion of an Lng-IUD after laparoscopic surgery for symptomatic endometriosis significantly reduced the medium-term risk of recurrence of moderate or severe dysmenorrhea.

The efficacy of non-contraceptive uses for hormonal contraceptives

In addition to providing safe and effective contraception, both the combined oral contraceptive pill (COCP) and selected long-acting progestogen-only contraceptives have significant health benefits. The COCP may reduce menstrual blood loss, dysmenorrhoea and premenstrual syndrome; unequivocally reduces the later incidence of endometrial and ovarian cancer; appears to help protect future fertility, probably by reducing the risk of acute pelvic inflammatory disease, endometriosis and uterine fibroids. The quality of evidence for individual non-contraceptive health benefits of the COCP is very variable.

Medical management of endometriosis-associated pain

In the coming years, basic science research into the mechanisms of endometriosis development and persistence almost certainly will open new avenues for treatment. A wide armamentarium of medical therapies already exists, however. The efficacy of most of these methods in reducing endometriosis-associated pain is well established. The choice of which to use depends largely on patient preference after an appropriate discussion of risks, side effects, and cost. Typically, oral contraceptives and NSAIDs are first-line therapy because of their low cost and mild side effects (Box 6). Because of its greater potential for suppressing endometrial development, consideration should be given to prescribing a low-dose monophasic oral contraceptive continuously. If adequate relief is not obtained or if side effects prove intolerable, consideration should be given to the use of progestins (oral, intramuscular, or IUD) or a GnRH agonist with immediate add-back therapy. Progestins are less expensive, but GnRH agonists with add-back may be better tolerated. If none of these medications proves beneficial or if side effects are too pronounced, then repeat surgery is warranted. The surgery may have analgesic value and serves to reconfirm the diagnosis. Finally, if endometriosis is identified at the time of surgery, then consideration should be given to prescribing medical therapy postoperatively.

Intrauterine devices

The aim of this chapter is to review the worldwide use of intrauterine devices (IUDs) for contraception and the long-term contraceptive efficacy and safety of copper-bearing IUDs. The TCu380A and Multiload Cu375 have a very low failure rate (0.2-0.5%) over 10 years. The main concerns of the use of IUDs are risk of pelvic inflammatory diseases and increased menstrual blood loss and irregular bleeding. Factors associated with an increase in risk of pelvic inflammatory diseases are discussed. Preventive measures can be taken with careful screening of eligible IUD users, technical training and adequate service facilities for provision of IUDs. Levonorgestrel-releasing IUDs have the benefit of reducing menstrual blood loss in addition to high contraceptive efficacy. The copper IUD is the most effective method for emergency contraception. It can prevent over 95% of unwanted pregnancies within 5 days of unprotected intercourse.