Efficacy of the levonorgestrel intrauterine system in treating menorrhagia: Actualities and ambiguities

Abstract

Objective. To review the literature on usage of the levonorgestrel intrauterine system (LNG IUS) An observational study and isolated reports of women with adenomyosis report significant symptomatic relief in these women. Conclusion. Available data refute the notion that uterine enlargement is a contraindication to insertion of the LNG IUS, but there appear to be reasons for a cautious approach when dealing with pathological uteri. IntroductionThe levonorgestrel intrauterine system (LNG IUS: Mirena ® , Schering, UK) is a highly effective contraceptive 1 and is extremely helpful in treating menorrhagia 2 among other confirmed or highly suggestive non-contraceptive benefits. 3 Randomised trials have confirmed its superior efficacy when compared with conventional medical treatment for menorrhagia 4 and its comparability with hysteroscopic surgical ablation of the endometrium. 5 Its advantages over endometrial ablation are: relative simplicity as well as reversibility, contraceptive effect 6 and the relief of pelvic pain. 7 The latter is frequently of even greater importance to the woman herself and is seldom relieved by, for example, transcervical resection of the endometrium (TCRE). 8 Recently published studies suggest the potential of the IUS to reduce hysterectomy waiting lists, 9,10 and it is generally accepted as a first option in women with heavy periods who also require contraception.Available information on the LNG IUS as a treatment for menorrhagia is mainly derived from studies of carefully selected women with dysfunctional uterine bleeding in research settings. However, in routine clinical practice, heavy menstrual loss is often due to underlying uterine pathology, most commonly fibroids and adenomyosis. It is therefore important to consider the possible effect of these conditions on the efficacy of the device and with this in mind, the available literature was reviewed. Effect of uterine fibroidsUterine myomas (fibroids) are benign tumours, which primarily contain smooth muscle, but may have varying densities of fibrous elements. Postmortem studies suggest that up to 50% of all women have fibroids 11 and that these are commonly associated with heavy menstrual loss. 12 This means practitioners who use the LNG IUS will undoubtedly encounter fibroids on a regular basis. Significant enlargement or distortion of uterine cavities, as well as excessive bleeding secondary to fibroids, can potentially affect the positioning of the device and hence efficacy.In addressing this issue, one also has to consider the possible effect of the released progestogen (levonorgestrel) on existing fibroids. This is a controversial subject as in vitro 13 and some clinical studies 14 have suggested a stimulatory effect in certain circumstances of some progestogens on uterine fibroids. Long-term contraceptive studies, however, have demonstrated protection from the complications of fibroids in association with use of depotmedroxyprogesterone acetate (DMPA) 15 and the LNG IUS 7 . Intramuscular DMPA causes moderately high sy...

Effect of menstrual cycle and hormonal treatment on ki-67 and bcl-2 expression and adenomyosis

“…The observations that the local release of levonorgestrel in the uterine cavity can cause regression of adenomyosis is further evidence that these lesions can respond to high intrauterine doses of progestins by reducing proliferation and augmenting apoptosis in a similar way to that occurring in the eutopic endometrium [6,14,15]. This is in agreement with our findings that the presence of Mirena in the uterine cavity decreases proliferation and bcl-2 expression in adenomyosis more efficiently than oral contraceptive pills, which were able effectively to reduce proliferation but not bcl-2 expression.…”

Ulipristal acetate: a novel pharmacological approach for the treatment of uterine fibroids

“…The use of a levonorgestrel intrauterine device (LNG-IUS) has been associated with a reduction in menstrual blood loss in women with uterine myomas, but its effect on the size of uterine myoma is still debated 8. LNG-IUS is contraindicated in the case of fibroid-associated severe distortion of the uterine cavity (LNG-IUS SmPC), because of the high expulsion rate 8–10…”

Abnormal uterine bleeding in midlife: The role of levonorgestrel intrauterine system

“…There is some evidence that expulsion rates may be increased in the presence of submucous fibroids. [17] Recently, Kriplani et al . reported that use of the LNG-IUS appears to lead to a significant reduction in the uterine volume of women with menorrhagia, as well as reducing the MBL in women with uterine leiomyomas.…”