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FSRH Guideline (March 2023) Intrauterine contraception. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:1-142. [PMID: 37188461 DOI: 10.1136/bmjsrh-2023-iuc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
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Bianchi P, Guo SW, Habiba M, Benagiano G. Utility of the Levonorgestrel-Releasing Intrauterine System in the Treatment of Abnormal Uterine Bleeding and Dysmenorrhea: A Narrative Review. J Clin Med 2022; 11:jcm11195836. [PMID: 36233703 PMCID: PMC9570961 DOI: 10.3390/jcm11195836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/28/2022] [Accepted: 09/28/2022] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION We undertook a literature review of the use of levonorgestrel-releasing intrauterine devices when utilized for heavy menstrual bleeding and/or dysmenorrhea. METHODS A narrative review of articles in the Scopus and Medline databases was conducted. RESULTS A number of options exist for the management of both abnormal uterine bleeding (AUB) and dysmenorrhea, and evidence is accumulating that the insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) represents a useful option for their long-term treatment. The idea of using a progestogen released in utero was initially conceived to achieve long-term contraception, but it was quickly found that these systems could be utilized for a number of therapeutic applications. The first device to be made commercially available, Progestasert, was withdrawn from the market because, in the event of contraceptive failure, it caused a disproportionate percentage of extrauterine pregnancies. On the other hand, the LNG-IUS continues to be successfully utilized in its various variants, releasing 20, 13, or 8 μg/day. These devices have a respective duration of action of 7 (possibly 8), 5, and 3 years, and there exist versions of frameless systems affixed to the myometrium of the uterine fundus. In the present review, following a brief description of the major causes of AUB and dysmenorrhea, the molecular bases for the use of the LNG-IUS are summarized. This is followed by a compendium of its use in AUB and dysmenorrhea, concluding that the insertion of the system improves the quality of life, reduces menstrual blood loss better than other medical therapies, and decreases the extent of dysmenorrhea and pelvic pain. In addition, there is no evidence of a significant difference in these outcomes when the use of the LNG-IUS was compared with improvements offered by endometrial ablation or hysterectomy. Possibly, the most important mechanism of action of the system consists of its ability to induce amenorrhea, which effectively eliminates heavy bleeding and dysmenorrhea. However, no method is ideal for every woman, and, in the case of the LNG-IUS, younger age and severe dysmenorrhea seem to be associated with a higher risk of discontinuation. CONCLUSION The higher-dose LNG-IUS is a useful tool for HMB and dysmenorrhea in women of all ages. The low cost and ease of use make the LNG-IUS an attractive option, especially when contraception is also desired.
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Affiliation(s)
- Paola Bianchi
- Department of Medico-Surgical Sciences and Translational Medicine, Sant’Andrea Hospital, Sapienza, University of Rome, 00161 Rome, Italy
- Correspondence:
| | - Sun-Wei Guo
- Shanghai OB/GYN Hospital, Fudan University, Shanghai 200011, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai 200011, China
| | - Marwan Habiba
- Department of Health Sciences, University Hospitals of Leicester, University of Leicester, Leicester LE1 7RH, UK
| | - Giuseppe Benagiano
- Faculty of Medicine and Dentistry, Sapienza, University of Rome, 00161 Rome, Italy
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Huguelet PS, Laurin JL, Thornhill D, Moyer G. Use of the Levonorgestrel Intrauterine System to Treat Heavy Menstrual Bleeding in Adolescents and Young Adults with Inherited Bleeding Disorders and Ehlers-Danlos Syndrome. J Pediatr Adolesc Gynecol 2022; 35:147-152.e1. [PMID: 34775059 DOI: 10.1016/j.jpag.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 10/05/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE To report on the rate of amenorrhea among adolescents and young adults with a bleeding diathesis after insertion of the 52-mg levonorgestrel intrauterine system (LNG-IUS) DESIGN: Retrospective chart review SETTING: Tertiary care, multidisciplinary Gynecology-Hematology clinic or Adolescent Gynecology clinic PARTICIPANTS: The cohort included 35 females aged 12-25 years presenting from January 2010 to January 2020 with heavy menstrual bleeding, 23 with an inherited blood disorder, and 12 with Ehlers-Danlos syndrome INTERVENTIONS: The 52-mg LNG-IUS MAIN OUTCOME MEASURES: Primary outcome was bleeding profile after LNG-IUS insertion. Secondary outcomes included rates of amenorrhea, intrauterine device (IUD) expulsion, IUD discontinuation, and unplanned pregnancy. RESULTS Mean age at menarche was 11.6 years, with mean age at insertion of 16.9 (range 11-23). Most participants were white (n = 26, 74.3%). Von Willebrand disease was present in 16 patients (45.7%) and Ehlers-Danlos syndrome in 12 (34.3%). Most (91.4%) had tried at least 1 hormonal regimen prior to LNG-IUS. Most participants (81.8%) reported improvement in bleeding, with 60.6% reporting spotting or amenorrhea. LNG-IUS expulsion occurred in 3 participants (9.1%) within the first 21 days, despite hemostatic agents at time of insertion. Mean continuation was 5.08 years (95% CI, 4.24-5.92), with 79% likelihood that participants kept their IUD in place for at least 2.5 years, and some up to 6 years. CONCLUSION The 52-mg LNG-IUS is an effective treatment option for adolescents and young adults with heavy menstrual bleeding and a bleeding diathesis, with high rates of amenorrhea. Rates of IUD expulsion appeared higher during the first 30 days, but long-term continuation remained high.
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Affiliation(s)
- Patricia S Huguelet
- Section of Pediatric and Adolescent Gynecology, Children's Hospital Colorado, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - J L Laurin
- Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - D Thornhill
- Department of Pediatrics, Division of Hematology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - G Moyer
- Department of Internal Medicine, Division of Hematology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Lee JK, Zimrin AB, Sufrin C. Society of Family Planning clinical recommendations: Management of individuals with bleeding or thrombotic disorders undergoing abortion. Contraception 2021; 104:119-127. [PMID: 33766610 DOI: 10.1016/j.contraception.2021.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 02/06/2023]
Abstract
Individuals who have bleeding disorders, thrombophilias, a history of venous thromboembolism (VTE), or who are taking anticoagulation medication for other reasons may present for abortion. Clinicians should be aware of risk factors and histories concerning for excessive bleeding and thrombotic disorders around the time of abortion. This document will focus on how to approach abortion planning in these individuals. For first-trimester abortion, procedural abortion (sometimes called surgical abortion) is generally preferred over medical management for individuals with bleeding disorders or who are on anticoagulation. First-trimester procedural abortion in an individual on anticoagulation can generally be done without interruption of anticoagulation. The decision to interrupt anticoagulation for a second-trimester procedure should be individualized. Individuals at high risk for VTE can be offered anticoagulation post-procedure. Individuals with bleeding disorders or who are anticoagulated can safely be offered progestin intrauterine devices. Future research is needed to better assess quantitative blood loss and complications rates with abortion in these populations.
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Affiliation(s)
- Jessica K Lee
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Ann B Zimrin
- University of Maryland Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Carolyn Sufrin
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, United States
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Djambas Khayat C, Gouider E, von Mackensen S, Abdul Kadir R. Heavy menstrual bleeding in women with inherited bleeding disorders. Haemophilia 2021; 26 Suppl 3:16-19. [PMID: 32356352 DOI: 10.1111/hae.13888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 11/27/2022]
Abstract
Heavy menstrual bleeding (HMB) is the commonest bleeding symptom among women with inherited bleeding disorders (IBD). Since HMB starts at the very onset of menarche and continues throughout the reproductive life, the health related quality of life of these women is affected and they are at an increased risk of developing iron-deficiency anemia. Because of the entrenched stigma and taboos, women and girls are often reluctant to discuss the problem of HMB within their families and do not seek medical advice. Increased awareness and multidisciplinary management approach for the management of these women are essential in ensuring an optimal outcome. It is important to take a careful history and undertake a thorough gynecological assessment to exclude other underlying/concomitant causes of HMB. Iron supplementation is essential. Strategies for decreasing menstrual blood flow are similar to those used for HMB in general with the addition of desmopressin and replacement therapy and the exclusion of non-steroidal anti-inflammatory drugs. Tranexamic acid and/or hormonal intervention are usually recommended as first-line therapy. Treatment choice should be individualized taking into account whether the woman wishes to preserve her fertility, if she requires contraception, the type of IBD, the severity of bleeding, and her social and religious background as well as acceptability and availability of the treatment options.
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Affiliation(s)
| | - Emna Gouider
- Aziza Othmana Hospital, University Manar 2, Tunis, Tunisia
| | - Sylvia von Mackensen
- Department of Medical Psychology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Rezan Abdul Kadir
- Royal Free NHS foundation Trust and institute of women's Health, UCL, London, UK
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Management of Refractory Menstrual Bleeding in an Adolescent with Glanzmann Thrombasthenia: A Case Report and Review. Case Rep Obstet Gynecol 2020; 2020:8848763. [PMID: 33062357 PMCID: PMC7545426 DOI: 10.1155/2020/8848763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 11/17/2022] Open
Abstract
Glanzmann Thrombasthenia is a rare bleeding disorder causing life-threatening bleeding at menarche in the adolescent female. Bleeding often necessitates admission and multiple blood transfusions. Due to the rarity of the disease, management of acute bleeding in new-onset menarche poses a particular challenge. A 12-year-old menarchial female had persistent vaginal bleeding despite multiple treatment modalities including aminocaproic acid, recombinant factor VIIa, intravenous estrogen, and gonadotropin receptor hormone agonists. Although the standard treatment of bleeding in patients with GT is primarily rFVIIa, new-onset menstrual bleeding in conjunction with an immature hypothalamic-pituitary-ovarian axis often requires expanding treatment to include multiple drug modalities. In our case, a two-step approach was necessary. The first is targeting the cessation of the first menses. The second is optimizing ongoing management of long-term control of heavy menstrual bleeding to achieve amenorrhea, prevent further hospital admissions, and avoid recurrent transfusions.
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Takamura M, Koga K, Harada M, Hirota Y, Fujii T, Osuga Y. A case of hemorrhagic shock occurred during dienogest therapy for uterine adenomyosis. J Obstet Gynaecol Res 2020; 46:2696-2700. [PMID: 33090620 DOI: 10.1111/jog.14519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/06/2020] [Accepted: 09/21/2020] [Indexed: 11/30/2022]
Abstract
We present a case of hemorrhagic shock occurred during dienogest therapy for uterine adenomyosis which necessitated an emergency hysterectomy. The patient was a 45-year-old woman with adenomyosis. Magnetic resonance imaging showed type I adenomyosis measuring 10 cm. She had a history of intimal thrombectomy of pulmonary embolism and had been receiving warfarin and aspirin until the onset of the hemorrhagic shock. Following 6-month of gonadotropin-releasing hormone analogue, dienogest was commenced. Nine months after switching to dienogest, the patient experienced a persistent abnormal uterine bleeding for 2 weeks, eventually causing a massive bleeding and was transferred to our emergency room. A diagnosis of hemorrhagic shock with a severe anemia (hemoglobin 3.6 g/dL) was made. Despite blood transfusion and warfarin antagonization, continuous bleeding ≥150 g/h was not controlled. Emergent hysterectomy was opted and enabled hemostasis. Although the number of patients with adenomyosis who can avoid surgery by dienogest is increasing, care must be taken during dienogest therapy, especially in patients with anticoagulants and after gonadotropin-releasing hormone analogue treatment. To prevent such a critical event, careful management including patient education should be carried out.
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Affiliation(s)
- Masashi Takamura
- Department of Obstetrics and Gynecology, Saitama Medical University, Saitama, Japan
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
| | - Kaori Koga
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
| | - Miyuki Harada
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
| | - Yasushi Hirota
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
| | - Tomoyuki Fujii
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
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Brull EP, Fernandes A, Monteiro I, Bahamondes L, Juliato CRT. Safety and bleeding patterns of the levonorgestrel 52-mg intrauterine system among women with thrombosis or coagulopathy. Int J Gynaecol Obstet 2020; 151:355-361. [PMID: 32966599 DOI: 10.1002/ijgo.13378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/10/2020] [Accepted: 09/14/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess the safety of the levonorgestrel 52-mg intrauterine system (LNG-IUS) in women with a history of thrombosis or coagulopathy and to evaluate bleeding patterns. METHODS A retrospective chart review was conducted of 117 women attending a clinic between 2007 and 2019. Their sociodemographic characteristics, hematologic status, reasons for using LNG-IUS, duration of use, use of oral anticoagulants, complications, and bleeding patterns were analyzed. RESULTS Ninety-nine women had a history of thrombosis (71.7% in use of oral anticoagulants) and 18 had coagulopathies. No bleeding or any other complications occurred during placement of the LNG-IUS. Around two-thirds of the women reported amenorrhea or oligomenorrhea at 12, 24, and 54 months of follow-up, with no difference between the groups using the IUS for contraception or to treat heavy menstrual bleeding (HMB) (P=0.07), those with a history of thrombosis or coagulopathy (P=0.53), and users or non-users of oral anticoagulants (P=0.59). CONCLUSION The LNG-IUS is safe for women with hematologic disorders. It was associated with amenorrhea or oligomenorrhea in a large proportion of users up to 54 months of follow-up regardless of use of oral anticoagulants, reason for use of LNG-IUS (contraception or HMB), or history of coagulopathy or thrombosis.
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Affiliation(s)
- Eliza P Brull
- Family Planning Clinic, Department of Obstetrics and Gynecology, University of Campinas Medical School, Campinas, SP, Brazil
| | - Arlete Fernandes
- Family Planning Clinic, Department of Obstetrics and Gynecology, University of Campinas Medical School, Campinas, SP, Brazil
| | - Ilza Monteiro
- Family Planning Clinic, Department of Obstetrics and Gynecology, University of Campinas Medical School, Campinas, SP, Brazil
| | - Luis Bahamondes
- Family Planning Clinic, Department of Obstetrics and Gynecology, University of Campinas Medical School, Campinas, SP, Brazil
| | - Cassia R T Juliato
- Family Planning Clinic, Department of Obstetrics and Gynecology, University of Campinas Medical School, Campinas, SP, Brazil
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Abstract
Long-acting reversible contraceptives are the most effective methods to prevent pregnancy and also offer noncontraceptive benefits such as reducing menstrual blood flow and dysmenorrhea. The safety and efficacy of long-acting reversible contraception are well established for adolescents, but the rate of use remains low for this population. The pediatrician can play a key role in increasing access to long-acting reversible contraception for adolescents by providing accurate patient-centered contraception counseling and by understanding and addressing the barriers to use.
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Affiliation(s)
- Seema Menon
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Alaqzam TS, Stanley AC, Simpson PM, Flood VH, Menon S. Treatment Modalities in Adolescents Who Present with Heavy Menstrual Bleeding. J Pediatr Adolesc Gynecol 2018. [PMID: 29524595 DOI: 10.1016/j.jpag.2018.02.130] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE On this study we sought to determine the relationship of bleeding disorders to iron deficiency anemia. Additionally, this study was undertaken to examine all current treatment modalities used in a menorrhagia clinic with respect to heavy menstrual bleeding management to identify the most effective options for menstrual management in the setting of an underlying bleeding disorder. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We performed a retrospective chart review of adolescents younger than 21 years with heavy menstrual bleeding attending a multidisciplinary hematology-adolescent gynecology clinic. Information including demographic characteristics, bleeding diathesis, hematologic parameters, treatment, and the diagnosis was extracted from each chart. Subjects were grouped into 2 categories on the basis of the diagnosis of a bleeding disorder. Hemoglobin level, iron deficiency anemia, and need for transfusion were compared between a bleeding disorder and no bleeding disorder group. Subjects were grouped into categories depending on hormonal modality and treatment success of the groups were compared. RESULTS Seventy-three subjects were tested for a bleeding disorder. Of the subjects who completed testing, 34 (46%) were diagnosed with a bleeding disorder. Thirty-nine subjects (54%) had heavy menstrual bleeding because of other causes. There was no significant difference in hemoglobin between those with and without a bleeding disorder. Iron deficiency anemia was significantly higher in subjects without a bleeding disorder. In a comparison of hormone therapy success, the levonorgestrel intrauterine device (89%, 8 out of 9 subjects) had the highest rate of menstrual suppression followed by norethindrone acetate 5-10 mg/d (83%, 5 out of 6 subjects), and the transdermal patch (80%, 4 out of 5 subjects). All subjects using tranexamic acid as well as hormonal therapy had 100% achievement of menstrual suppression. CONCLUSION A high frequency of bleeding disorders was found in those tested. Subjects with a bleeding disorder were less likely to present with severe anemia requiring blood transfusion and less likely to have iron deficiency anemia. Although combined oral contraceptives were commonly used clinically for menstrual suppression, they were not found to be the most effective option.
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Affiliation(s)
- Tasneem S Alaqzam
- Division of Adolescent Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Angela C Stanley
- Division of Adolescent Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pippa M Simpson
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Veronica H Flood
- Division of Hematology and Oncology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Seema Menon
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Adeyemi-Fowode OA, Santos XM, Dietrich JE, Srivaths L. Levonorgestrel-Releasing Intrauterine Device Use in Female Adolescents with Heavy Menstrual Bleeding and Bleeding Disorders: Single Institution Review. J Pediatr Adolesc Gynecol 2017; 30:479-483. [PMID: 27108228 DOI: 10.1016/j.jpag.2016.04.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 03/07/2016] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
Abstract
STUDY OBJECTIVE To identify complications and efficacy of the levonorgestrel-releasing intrauterine device (LNgIUD) in adolescents with heavy menstrual bleeding (HMB) and bleeding disorders (BD). DESIGN, SETTING, AND PARTICIPANTS A retrospective chart review of 13 postmenarchal adolescent girls with HMB/BD who underwent placement of an LNgIUD. INTERVENTIONS Placement of an LNgIUD. MAIN OUTCOME MEASURES Primary outcome was to identify complications from placement of an LNgIUD. Secondary outcome was to evaluate the efficacy of the LNgIUD in adolescents with BD. RESULTS Thirteen patients met study criteria. The mean age of diagnosis of HMB was 14.08 ± 1.75 years. BD or bleeding risk factor diagnoses included low von Willebrand (VW) activity in 5, type I VW disease in 5, type IIM VW disease in 1, low VW activity and factor 7 deficiency in 1, and acquired VW disease and factor 7 deficiency in 1. Before LNgIUD placement, other hormonal therapy (n = 13) and hemostatic therapy (antifibrinolytic agents, desmopressin acetate; n = 8) yielded poor control of HMB. The LNgIUD was placed using anesthesia with periprocedure hemostatic therapy with no complications. All patients reported significant improvement in HMB after LNgIUD placement and 60% achieved amenorrhea, with mean time to improvement of 94 ± 69 days. Mean hemoglobin and ferritin levels increased after LNgIUD placement compared with before LNgIUD placement values (P = .02, P = .0085, respectively). Use of supplemental hormonal and hemostatic agents decreased (n = 4) after LNgIUD placement. None required LNgIUD removal; 1 spontaneously expelled the LNgIUD with subsequent replacement. CONCLUSION Study results indicated the LNgIUD is an effective therapeutic option in postmenarchal adolescents with HMB due to BD/bleeding risk factor with minimal complications, high compliance rate, improvement in HMB and anemia, and no periprocedural bleeding with hemostatic management.
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Affiliation(s)
- Oluyemisi A Adeyemi-Fowode
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas.
| | - Xiomara M Santos
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Jennifer E Dietrich
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Lakshmi Srivaths
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas; Texas Children's Cancer and Hematology Centers, Houston, Texas
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Bahamondes L, Valeria Bahamondes M, Shulman LP. Non-contraceptive benefits of hormonal and intrauterine reversible contraceptive methods. Hum Reprod Update 2015; 21:640-51. [DOI: 10.1093/humupd/dmv023] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 04/09/2015] [Indexed: 01/26/2023] Open
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Roos-Hesselink JW, Cornette J, Sliwa K, Pieper PG, Veldtman GR, Johnson MR. Contraception and cardiovascular disease. Eur Heart J 2015; 36:1728-34, 1734a-1734b. [DOI: 10.1093/eurheartj/ehv141] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 04/08/2015] [Indexed: 11/15/2022] Open
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Braga GC, Brito MB, Ferriani RA, Oliveira LC, Garcia AA, Pintão MC, Vieira CS. Oral anticoagulant therapy does not modify the bleeding pattern associated with the levonorgestrel-releasing intrauterine system in women with thrombophilia and/or a history of thrombosis. Contraception 2014; 89:48-53. [DOI: 10.1016/j.contraception.2013.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 06/24/2013] [Accepted: 06/30/2013] [Indexed: 10/26/2022]
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Callegari LS, Darney BG, Godfrey EM, Sementi O, Dunsmoor-Su R, Prager SW. Evidence-based selection of candidates for the levonorgestrel intrauterine device (IUD). J Am Board Fam Med 2014; 27:26-33. [PMID: 24390883 PMCID: PMC4049525 DOI: 10.3122/jabfm.2014.01.130142] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Recent evidence-based guidelines expanded the definition of appropriate candidates for the levonorgestrel-releasing intrauterine system (LNG-IUS). We investigated correlates of evidence-based selection of candidates for the LNG-IUS by physicians who offer insertion. METHODS We conducted a mixed-mode (online and mail) survey of practicing family physicians and obstetrician-gynecologists in Seattle. RESULTS A total of 269 physicians responded to the survey (44% response rate). Of the 217 respondents who inserted intrauterine devices, half or fewer routinely recommended the LNG-IUS to women who are nulliparous, younger than 20 years old, or have a history of sexually transmitted infections (STIs). In multivariable analyses, training/resident status was positively associated with recommending the LNG-IUS to women <20 years old (adjusted odds ratio [aOR], 3.6; 95% confidence interval [CI], 1.6-8.0) and women with history of STI (aOR, 3.7; 95% CI, 1.6-8.4). Perceived risk of infection or infertility was negatively associated with recommending the LNG-IUS to nulliparous women (aOR, 0.2; 95% CI, 0.1-0.5) and women with a history of STI (aOR, 0.3; 95% CI, 0.1-0.8). CONCLUSIONS Many family physicians and obstetrician-gynecologists who insert the LNG-IUS are overly restrictive in selecting candidates, although those who train residents are more likely to follow evidence-based guidelines. Interventions that address negative bias and perceptions of risks, in addition to improving knowledge, are needed to promote wider use of the LNG-IUS.
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Affiliation(s)
- Lisa S Callegari
- the Departments of Obstetrics and Gynecology and Family Medicine and the Departments of Epidemiology and Department of Health Services, School of Public Health, University of Washington, Seattle; the Departments of Medical Informatics and Clinical Epidemiology and Obstetrics and Gynecology, Oregon Health & Science University, Portland
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Cihangir U, Ebru A, Murat E, Levent Y. Mechanism of action of the levonorgestrel-releasing intrauterine system in the treatment of heavy menstrual bleeding. Int J Gynaecol Obstet 2013; 123:146-9. [DOI: 10.1016/j.ijgo.2013.05.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Revised: 05/14/2013] [Accepted: 07/25/2013] [Indexed: 11/30/2022]
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Pai M, Chan A, Barr R. How I manage heavy menstrual bleeding. Br J Haematol 2013; 162:721-9. [DOI: 10.1111/bjh.12447] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 05/17/2013] [Indexed: 12/12/2022]
Affiliation(s)
| | - Anthony Chan
- Department of Pediatrics; McMaster University; Hamilton; Canada
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Rimmer E, Jamieson MA, James P. Malposition and expulsion of the levonorgestrel intrauterine system among women with inherited bleeding disorders. Haemophilia 2013; 19:933-8. [PMID: 23711358 DOI: 10.1111/hae.12184] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2013] [Indexed: 11/30/2022]
Abstract
The levonorgestrel-releasing intrauterine system (LNG-IUS) is indicated for the management of menorrhagia and for contraception. The LNG-IUS is effective at reducing menstrual bleeding and improving haemoglobin among women with bleeding disorders. Expulsion rates for the LNG-IUS among normal women are reported to be approximately 5-10%. The aim of this study was to examine the malposition and expulsion rates of the LNG-IUS among women with inherited bleeding disorders. We conducted a retrospective study of women with an inherited bleeding disorder in Kingston, Canada treated with an LNG-IUS between May 2005 and June 2012. The primary outcome was a combined endpoint of expulsion and/or malposition. Predetermined secondary outcomes were patient satisfaction and changes in haemoglobin and ferritin levels. The median age of the women at the time of LNG-IUS insertion was 31 years (range 18-43, mean 32.1 years). The most common diagnosis was type 1 VWD (12/20, 60%). There were three LNG-IUS expulsions and two episodes of device malposition resulting in removal [5/20 (25.0%), 95% CI 11.2-46.9%]. An additional five women had their device removed prematurely. The overall proportion of devices resulting in discontinuation in this population was 10/20 (50.0%, 95% CI 29.9-70.1%). In this retrospective study, a significant proportion of women with an inherited bleeding disorder had an LGN-IUS removed due to poor patient satisfaction, malposition, or expulsion. Further studies into the causes of higher complication rates and interventions such as premedication or prolonged treatment with antifibrinolytic agents targeted at improving outcomes in this population are required.
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Affiliation(s)
- E Rimmer
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada; CancerCare Manitoba, Winnipeg, MB, Canada; Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
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Bayer LL, Hillard PJA. Use of levonorgestrel intrauterine system for medical indications in adolescents. J Adolesc Health 2013; 52:S54-8. [PMID: 23535058 DOI: 10.1016/j.jadohealth.2012.09.022] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 09/07/2012] [Accepted: 09/14/2012] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Lisa L Bayer
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon 97239, USA.
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Added health benefits of the levonorgestrel contraceptive intrauterine system and other hormonal contraceptive delivery systems. Contraception 2013; 87:273-9. [DOI: 10.1016/j.contraception.2012.08.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 08/29/2012] [Indexed: 11/22/2022]
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Kaunitz AM, Inki P. The levonorgestrel-releasing intrauterine system in heavy menstrual bleeding: a benefit-risk review. Drugs 2012; 72:193-215. [PMID: 22268392 DOI: 10.2165/11598960-000000000-00000] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Heavy menstrual bleeding (HMB) is a common problem in women of reproductive age and can cause irritation, inconvenience, self-consciousness and fear of social embarrassment. Our objective was to review and appraise literature identified from the MEDLINE and EMBASE databases to evaluate the clinical evidence and provide an update on the risks and benefits of using the levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of HMB. The LNG-IUS consistently reduces menstrual blood loss (MBL) in women with HMB, including those with underlying uterine pathology or bleeding disorders. The available data suggest that it reduces MBL to a greater extent than other medical therapies, including combined oral contraceptives, oral progestogens (both short- or long-cycle regimens), tranexamic acid and oral mefenamic acid. In addition, the LNG-IUS and endometrial ablation appear to reduce MBL to a similar extent. The adverse effects reported with the LNG-IUS in women with HMB are similar to those typically observed in women using the system for contraception. Uterine perforations were not reported in any of the studies reviewed, but expulsion rates may be higher than in the general population of LNG-IUS users. Overall, the LNG-IUS has a positive effect on most quality-of-life domains, at least comparable to those achieved with hysterectomy or endometrial ablation, and is consistently a cost-effective option across a variety of countries and settings. In conclusion, the LNG-IUS is an effective treatment option for women with HMB, including those with underlying organic pathology or bleeding disorders.
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Affiliation(s)
- Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, FL 32209, USA.
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Laurence V, Rousset-Jablonski C. Contraception and Cancer Treatment in Young Persons. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 732:41-60. [DOI: 10.1007/978-94-007-2492-1_4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Non-contraceptive health benefits of intrauterine hormonal systems. Contraception 2011; 82:396-403. [PMID: 20933112 DOI: 10.1016/j.contraception.2010.05.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 05/04/2010] [Indexed: 11/21/2022]
Abstract
Non-contraceptive health benefits are now recognized as an important aspect of the overall impact of all hormonal contraceptives. The levonorgestrel-releasing intrauterine systems (LNG IUS) are particularly effective at producing a number of health benefits for women using the LNG IUS as a contraceptive (reduced menstrual bleeding; reduced dysmenorrhea and the potential for prevention of a number of gynecological conditions in the longer term, such as iron-deficiency anemia, endometrial hyperplasia, uterine fibroids, acute episodes of pelvic inflammatory disease, endometriosis and perhaps others). The LNG IUS also has the potential to specifically treat a range of pre-existing gynecological conditions such as heavy menstrual bleeding due to a wide range of underlying causes, endometrial hyperplasia, uterine fibroids, adenomyosis, and endometriosis. These health benefits should be recognized as a key component in the decision-making process for individual women in choosing a specific type of hormonal or other contraceptive. Investment in research into the very substantial health benefits of hormonal contraceptives, such as the LNG IUS, has generally been ignored in comparison with the massive investment into understanding the often subtle or rare complications of hormonal contraceptive use. Both are important, but there is a real need to define more accurately those women who will benefit most from these health benefits.
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Vilos GA, Tureanu V, Garcia M, Abu-Rafea B. The levonorgestrel intrauterine system is an effective treatment in women with abnormal uterine bleeding and anticoagulant therapy. J Minim Invasive Gynecol 2009; 16:480-4. [PMID: 19573825 DOI: 10.1016/j.jmig.2009.04.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Revised: 04/28/2009] [Accepted: 04/30/2009] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- George A Vilos
- St. Joseph's Health Care, Department of Obstetrics and Gynecology, The University of Western Ontario, London, Ontario, Canada.
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Kilic S, Yuksel B, Doganay M, Bardakci H, Akinsu F, Uzunlar O, Mollamahutoglu L. The effect of levonorgestrel-releasing intrauterine device on menorrhagia in women taking anticoagulant medication after cardiac valve replacement. Contraception 2009; 80:152-7. [DOI: 10.1016/j.contraception.2009.02.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Revised: 02/06/2009] [Accepted: 02/09/2009] [Indexed: 11/16/2022]
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Kailasam C, Cahill D. Review of the safety, efficacy and patient acceptability of the levonorgestrel-releasing intrauterine system. Patient Prefer Adherence 2008; 2:293-302. [PMID: 19920976 PMCID: PMC2770406 DOI: 10.2147/ppa.s3464] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Chandra Kailasam
- Bristol Centre for Reproductive Medicine, Southmead Hospital, Bristol, UK
| | - David Cahill
- Dept of Obstetrics and Gynaecology, University of Bristol, St Michael’s Hospital, Bristol, UK
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Fraser IS. The promise and reality of the intrauterine route for hormone delivery for prevention and therapy of gynecological disease. Contraception 2007; 75:S112-7. [PMID: 17531600 DOI: 10.1016/j.contraception.2006.12.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Accepted: 12/16/2006] [Indexed: 10/23/2022]
Abstract
CONTEXT Progestins delivered by a variety of routes have been demonstrated, in addition to their high contraceptive effect, to have substantial benefits in the treatment of various gynecological disorders, and the intrauterine route has particular efficacy in treating endometrial and myometrial disorders. It should be possible to extend this to prevention of disease. THERAPY OF GYNECOLOGICAL DISEASE Those conditions for which there is most evidence of therapeutic benefit from intrauterine release of progestins include heavy menstrual bleeding (due to most causes), endometrial hyperplasia, endometriosis and adenomyosis. PREVENTION OF GYNECOLOGICAL DISEASE Reasonable evidence exists to support the findings that intrauterine levonorgestrel helps to prevent the development of uterine fibroids, endometriosis, endometrial hyperplasia, acute episodes of pelvic infection and a wide range of menstrual symptoms. There is also promise of prevention of endometrial carcinoma, endometrial polyps, infertility and perhaps adenomyosis. CONCLUSIONS There is a need for specific studies to further explore the prevention of these gynecological conditions which can cause major health disturbances and community distress.
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Affiliation(s)
- Ian S Fraser
- Department of Obstetrics and Gynaecology, Queen Elizabeth II Research Institute for Mothers and Infants, University of Sydney, NSW 2006, Australia.
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