Managing persistent ovarian follicles in premenopausal women fitted with the levonorgestrel-releasing intrauterine system

Abstract

Use of a progestin-releasing intrauterine device can be associated with development of persistent functional cysts. Specifically the levonorgestrel-releasing intrauterine system (LNG-IUS) may inhibit ovulation during the first few months and immediately affect the hypothalamic-pituitary-ovarian axis thereby altering follicular development and leading to the formation of ovarian cysts. The incidence of persistent ovarian follicles during LNG-IUS treatment has been reported in the range of 8%-31%. However these cysts are symptomless relatively small in size and seem to show a high rate (94%) of spontaneous resolution. The aim of the present study was to evaluate the optimal strategy to manage persistent ovarian follicles in premenopausal women fitted with the LNG-IUS through a retrospective case-series study. Institutional Review Board approval was not required and informed consent was not needed since data were collected retrospectively and did not include any personal identifying information. Patients included in the study were identified using the record charts and ultrasound findings of premenopausal women fitted with the LNG-IUS (Mirena; Bayer Italy) to manage abnormal uterine bleeding and chronic pelvic pain treated between February 12009 and December 31 2011 at the Department of Obstetrics and Gynecology University “Magna Graecia” of Catanzaro; the “Hospital Pugliese-Ciaccio” of Catanzaro; and the Oncology Center of Excellence “Tommaso Campanella” Catanzaro Italy. Among 185 women included in the study 75 (40.5%) women presented with a persistent ovarian follicle (>3 cm) at 6 months. The mean size of the follicles evaluated was 5.5 cm. However within 6 months spontaneous resolution of the persistent follicles was observed by ultrasound evaluation in all of the women. The present study provides further evidence that use of the LNG-IUS in premenopausal women can be associated with the development of persistent ovarian follicles. However the rate of spontaneous resolution appeared complete in all patients making surgical removal an unnecessary overtreatment. Considering the total rate of spontaneous resolution intense ultrasound monitoring aimed at identifying ovarian cysts is necessary in premenopausal women using the LNG-IUS. To reduce the risk of surgical overtreatment and avoid premature LNG-IUS removal and unnecessary estroprogestinic treatment when persistent ovarian follicles are detected during the course of a routine annual visit a 3-6-month ultrasound re-evaluation should be performed. These functional ovarian masses should be managed for 3-6 months with a wait-and-see approach. (full text) Copyright © 2013 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.