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Impact of combined endometrial resection or ablation and levonorgestrel intrauterine device on postoperative bleeding pattern. Arch Gynecol Obstet 2023; 307:493-499. [PMID: 36129518 DOI: 10.1007/s00404-022-06790-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/07/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE The aim of this study was to describe the rate of amenorrhea in women treated with transcervical endometrial resection (TCER) or radiofrequency endometrial ablation combined with levonorgestrel intrauterine contraceptive device (LNG-IUD) six months post-operatively. METHODS The study was performed as a prospective cohort study. All patients were included at four gynecological centers in Region of Southern Denmark. In total, 162 women referred due to menorrhagia, metrorrhagia or menometrorrhagia and offered TCER or radiofrequency endometrial ablation in combination with or without LNG-IUD included during November 2018 to June 2021 at the women's own discretion and without any cost (covered by the hospital). Data were analyzed using a multivariate regression model. RESULTS In total, 58 women were offered TCER and 31 (53.4%) combined treatment with TCER + LNG-IUD. Among 104 women who received radiofrequency endometrial ablation, 46 (44.2%) underwent combined treatment with LNG-IUD. The incidence of amenorrhea was 26% among women who underwent treatment with TCRE and 52% when treated with TCER + LNG-IUD (adjusted OR 5.16; 95% CI 1.35-19.6; P < 0.016). Radiofrequency endometrial ablation was followed by a 41% incidence of amenorrhea, and when radiofrequency endometrial ablation was combined with LNG-IUD, the incidence of amenorrhea was 63% (adjusted OR 2.15; 95% CI 0.86-5.37; P < 0.1). We observed no statistically significant differences when comparing the groups across. CONCLUSION Our study suggests that the combination of TCER or radiofrequency endometrial ablation with LNG-IUD was superior to TCER. However, the combined treatment of radiofrequency endometrial ablation with LNG-IUD did not reach statistical significance. Further studies are needed to evaluate the effects of different ablation techniques on the amenorrhea rate.
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Oderkerk TJ, Beelen P, Geomini PMAJ, Herman MC, Leemans JC, Duijnhoven RG, Bosmans JE, Pannekoek JN, Clark TJ, Mol BWJ, Bongers MY. Endometrial ablation plus levonorgestrel releasing intrauterine system versus endometrial ablation alone in women with heavy menstrual bleeding: study protocol of a multicentre randomised controlled trial; MIRA2 trial. BMC Womens Health 2022; 22:257. [PMID: 35761328 PMCID: PMC9235075 DOI: 10.1186/s12905-022-01843-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/17/2022] [Indexed: 11/13/2022] Open
Abstract
Background It is estimated that between 12 to 25% of women who undergo an endometrial ablation for heavy menstrual bleeding (HMB) are dissatisfied after two years because of recurrent menstrual bleeding and/or cyclical pelvic pain, with around 15% of these women ultimately having a hysterectomy. The insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) immediately after endometrial ablation may inactivate residual untreated endometrium and/or inhibit the regeneration of endometrial tissue. Furthermore, the LNG-IUS may prevent agglutination of the uterine walls preventing intrauterine adhesion formation associated with endometrial ablation. In these ways, insertion of an LNG-IUS immediately after endometrial ablation might prevent subsequent hysterectomies because of persisting uterine bleeding and cyclical pelvic pain or pain that arises de novo. Hence, we evaluate if the combination of endometrial ablation and an LNG-IUS is superior to endometrial ablation alone in terms of reducing subsequent rates of hysterectomy at two years following the initial ablative procedure. Methods/design We perform a multicentre randomised controlled trial in 35 hospitals in the Netherlands. Women with heavy menstrual bleeding, who opt for treatment with endometrial ablation and without contraindication for an LNG-IUS are eligible. After informed consent, participants are randomly allocated to either endometrial ablation plus LNG-IUS or endometrial ablation alone. The primary outcome is the hysterectomy rate at 24 months following endometrial ablation. Secondary outcomes include women’s satisfaction, reinterventions, complications, side effects, menstrual bleeding patterns, quality of life, societal costs. Discussion The results of this study will help clinicians inform women with HMB who opt for treatment with endometrial ablation about whether concomitant use of the LNG-IUS is beneficial for reducing the need for hysterectomy due to ongoing bleeding and/or pain symptoms. Trial registration Dutch Trial registration: NL7817. Registered 20 June 2019, https://www.trialregister.nl/trial/7817. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-022-01843-6.
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Affiliation(s)
- Tamara J Oderkerk
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Postbox 7777, 5500 MB, Veldhoven, The Netherlands. .,Research School Grow, Maastricht University, Maastricht, The Netherlands.
| | - Pleun Beelen
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Postbox 7777, 5500 MB, Veldhoven, The Netherlands
| | - Peggy M A J Geomini
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Postbox 7777, 5500 MB, Veldhoven, The Netherlands
| | - Malou C Herman
- Department of Obstetrics and Gynaecology, Jeroen Bosch Ziekenhuis, 's-Hertogenbosch, The Netherlands
| | - Jaklien C Leemans
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Postbox 7777, 5500 MB, Veldhoven, The Netherlands
| | - Ruben G Duijnhoven
- Clinical Trials Unit of the Netherlands Society of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Judith E Bosmans
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Justine N Pannekoek
- Clinical Trials Unit of the Netherlands Society of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Thomas J Clark
- University Department of Medicine and Obstetrics & Gynaecology, Birmingham Women's Hospital, Birmingham, UK
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash Medical Centre Clayton, Melbourne, Australia
| | - Marlies Y Bongers
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Postbox 7777, 5500 MB, Veldhoven, The Netherlands.,Research School Grow, Maastricht University, Maastricht, The Netherlands
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Oderkerk TJ, van de Kar MMA, van der Zanden CHM, Geomini PMAJ, Herman MC, Bongers MY. The combined use of endometrial ablation or resection and levonorgestrel-releasing intrauterine system in women with heavy menstrual bleeding: A systematic review. Acta Obstet Gynecol Scand 2021; 100:1779-1787. [PMID: 34165779 DOI: 10.1111/aogs.14219] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/23/2021] [Accepted: 06/21/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Despite endometrial ablation/resection being a very successful treatment for women with heavy menstrual bleeding, re-intervention with additional surgery is needed in 12%-25% of cases. Introducing a levonorgestrel-intrauterine system (LNG-IUS) immediately after ablation could preserve the integrity of the uterine cavity and suppress the regenerated or non-ablated endometrial tissue. Therefore, this combined treatment can perhaps lower the re-intervention rate. The aim of this systematic review was to assess the impact of the combined treatment. MATERIAL AND METHODS The MEDLINE, EMBASE, and Cochrane library were systematically searched. No language restrictions were applied. All types of studies were included reporting on the results of endometrial ablation or resection combined with immediate insertion of LNG-IUS for treatment of heavy menstrual bleeding. The primary outcome was the number of hysterectomies after the ablation procedure. Secondary outcomes included re-intervention rates, removals of LNG-IUS, bleeding pattern, patient satisfaction, adverse effects, and complications. Our protocol was registered in PROSPERO, an international prospective register of systematic reviews under registration number CRD42020151384. RESULTS Six studies with a retrospective design and one case series with a follow-up duration varying from 6 to 55 months were included. In total, 427 women were treated with the combined treatment. The studies described a lower hysterectomy and re-intervention rate after combined treatment compared with treatment with endometrial ablation/resection alone. Hysterectomy rate varied from 0% to 11% after combined treatment compared with 9.4% to 24% after endometrial ablation/resection alone. Bleeding patterns and patient satisfaction appeared to be in favor of the combined treatment group. No intra- or post-operative complications or complications in the removal of LNG-IUS were described. The most reported adverse effects after combined treatment were weight gain, mood changes, and headaches. An additional 11 studies with only an abstract available substantiated these findings. All the included studies had poor methodological quality. CONCLUSIONS Based on the available literature, inserting an LNG-IUS immediately after endometrial ablation/resection seems to lower the hysterectomy and re-intervention rates compared with ablation/resection alone. However, as only limited observational studies of low methodological quality are available, high-quality research is necessary to confirm the findings of this systematic review.
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Affiliation(s)
- Tamara J Oderkerk
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, the Netherlands.,Department of Obstetrics and Gynecology, Grow-School of Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
| | - Majorie M A van de Kar
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, the Netherlands
| | | | - Peggy M A J Geomini
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, the Netherlands
| | - Malou C Herman
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, the Netherlands
| | - Marlies Y Bongers
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, the Netherlands.,Department of Obstetrics and Gynecology, Grow-School of Oncology and Developmental Biology, Maastricht University, Maastricht, the Netherlands
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