Levonorgestrel-releasing Intrauterine System Insertion Research Articles

Double-blind, randomized, placebo-controlled study on the effect of misoprostol on ease of consecutive insertion of the levonorgestrel-releasing intrauterine system

BackgroundMisoprostol has been studied intensively to produce cervical dilatation. To date, no studies have evaluated the effectiveness, safety or acceptability of this treatment for repeat intrauterine device insertions. Study DesignThis study was a randomized, double-blind, placebo-controlled trial on the consecutive use of the levonorgestrel-releasing intrauterine system (LNG-IUS). Women who had used their first LNG-IUS for 4 years and 3 to 9 months and opted for an immediate replacement with a second LNG-IUS received a single sublingual dose of 400 mcg misoprostol or placebo 3 h prior to the LNG-IUS insertion. ResultsThe proportion of easy insertions as judged by the investigator was 93% (40/43) in subjects randomized to misoprostol and 91% (42/46) in the placebo group (p=1.0 for the difference of proportions). No or mild pain at insertion was reported by 37% and 35% of subjects in the misoprostol and placebo groups, respectively. However, adverse events related to the study drug were more common in the misoprostol group. ConclusionSublingual misoprostol did not have a significant effect on the ease of insertion in subjects having a repeat insertion of the LNG-IUS.

The effectiveness of levonorgestrel releasing intrauterine system in the treatment of endometrial hyperplasia in Korean women

Levonorgestrel releasing intrauterine system (LNG-IUS) has been shown to treat patients with non-atypical & atypical endometrial hyperplasia (EH) successfully in many western studies. Our purpose was to examine the effectiveness of LNG-IUS in the treatment of Korean women with EH. We conducted a prospective observational study of 12 women diagnosed with EH and treated with LNG-IUS insertion between February 2007 and August 2009 at the Department of Gynecology of Gangnam CHA Hospital, CHA University School of Medicine. Baseline endometrial biopsies were done before insertion of LNG-IUS, and outpatient follow-up endometrial biopsies were undertaken at 3-month intervals after insertion of LNG-IUS. We investigated the regression rate and the time to regression. Four patients had simple hyperplasia without atypia, 7 patients complex hyperplasia without atypia, and just 1 patient complex atypical hyperplasia. Complete regression of EH was achieved in all cases (100%, 12/12), with the significant proportion (66%, 8/12) achieving it within 3 months. The mean duration to regression was 4.5 months. All cases had regression within 9 months. In the case of complex atypical hyperplasia, the regression was attained at the 9th month after insertion of LNG-IUS. The mean follow-up duration was 12 months (range, 3 to 27 months). As long as LNG-IUS was maintained, the EH did not recur. LNG-IUS appears to be as highly effective in treating Korean women with EH.

Randomized placebo-controlled trial of CDB-2914 in new users of a levonorgestrel-releasing intrauterine system shows only short-lived amelioration of unscheduled bleeding.

The levonorgestrel-releasing intrauterine system (LNG-IUS) is a highly effective contraceptive. However, during early months of use unscheduled vaginal bleeding is common, sometimes leading to discontinuation. This study aimed to determine whether intermittent administration of progesterone receptor modulator CDB-2914 would suppress unscheduled bleeding during the first 4 months after insertion of the LNG-IUS. CDB-2914 150 mg, in divided doses, or placebo tablets, were administered over three consecutive days starting on Days 21, 49 and 77 after LNG-IUS insertion, in a double-blind randomized controlled trial of women aged 19-49 years, newly starting use of LNG-IUS. Daily bleeding diaries were completed for 6 months, and summarized across blocks as percentage days bleeding/spotting (BS%). Of 69 women randomized to receive CDB-2914, and 67 placebo, 61 and 55, respectively, completed the trial. BS% decreased with time in both arms, but showed a much steeper treatment-phase gradient in the placebo arm (P < 0.0001), so that a benefit of CDB-2914 in the 28 days after first treatment (-11% points, 95% CI -19 to -2), converted to a disadvantage by 64 days after the third treatment (+10% points, 95% CI 1-18). The effect of CDB-2914 on BS% was initially beneficial but then by third treatment was disadvantageous. Nevertheless, only 3% (4/136) of all women discontinued LNG-IUS. These findings give insight into possible mechanisms and suggest future research directions. ISRCTN Trial no. ISRCTN58283041; EudraCT no. 2006-006511-72.

Levonorgestrel-releasing intrauterine system vs. endometrial thermal ablation for menorrhagia

To evaluate the efficacy of a Levonorgestrel-releasing Intrauterine System (LNG-IUS) in controlling menorrhagia in comparison with endometrial thermal rollerball ablation. Seventy-nine consecutive patients with menorrhagia underwent either LNG-IUS insertion (n=42) or hysteroscopical endometrial thermal rollerball ablation (n=37) in a prospective, observational, comparative study. Women reported duration of uterine bleeding in days prior to, and six and 12 months after each intervention. Prior to each intervention, endometrial, cervical or other pathological conditions of the genital tract were excluded. GnRH analogues for endometrial suppression were given for ten weeks before endometrial ablation but not prior to LNG-IUS insertion. There were no differences in duration of uterine bleeding before each intervention in the two groups. The duration of uterine bleeding was lower in the LNG-IUS group as compared with endometrial ablation at six (p<0.001) and 12 months (p<0.001) after each intervention. Furthermore, the effect on reduction of bleeding was stronger in the LNG-IUS group as compared with the endometrial ablation group at six (p<0.001) and 12 months (p<0.001). The LNG-IUS was more efficacious than endometrial thermal ablation in reducing duration of uterine bleeding at six and 12 months post-intervention.

The LNG-IUS study on adenomyosis: a 3-year follow-up study on the efficacy and side effects of the use of levonorgestrel intrauterine system for the treatment of dysmenorrhea associated with adenomyosis

Background The objective of this study was to evaluate the efficacy and side effects of the levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of moderate or severe dysmenorrhea associated with adenomyosis for a 3-year follow-up period. Study Design The LNG-IUS was inserted into 94 women who had moderate or severe dysmenorrhea associated with adenomyosis diagnosed by transvaginal sonography during Cycle Days 5–7. A visual analogue scale (VAS) of dysmenorrhea, uterine volume and serum CA125 levels were used to assess the efficacy of the treatment at baseline and 3, 6, 12, 24 and 36 months after the LNG-IUS insertion. Side effects were recorded at every follow-up visit. Results The VAS of dysmenorrhea dropped continuously and significantly from the baseline score of 77.9±14.7 to 11.8±17.9 after 36 months of the LNG-IUS insertion (p<.001). The uterine volume decreased significantly from 113.8±46.9 mL to 94.5±40.1 mL (p=.003) at 6 months and to 87.7±35.8 mL (p<.001) at 12 months and then rose slightly, but the variables at 24 and 36 months still decreased significantly in comparison with the baseline variable (p<.001). The serum CA125 levels reduced significantly starting from 6 months after device insertion (p<.001). The most common side effects were weight gain (28.7%), simple ovarian cyst formation (22.3%) and lower abdominal pain (12.8%). At 36 months, the overall satisfaction rate of the treatment was 72.5%. Conclusions The LNG-IUS appears to be an effective method in alleviating dysmenorrhea associated with adenomyosis during 3 years. It may be a valuable long-term alternative for the treatment of adenomyosis.

Use of the Levonorgestrel-IUS in the treatment of menorrhagia: assessment of quality of life in Turkish users

The aim of the present study was to measure the treatment of menorrhagia and health-related quality of life (QoL) in Levonorgestrel-releasing intrauterine system (LNG-IUS) in Turkish women. We recruited 66 premenopausal women, aged 26-55 years, who had sought care in the previous year for menorrhagia. All patients were asked to complete a visual analog scale (VAS) form regarding pelvic pain, sexual life (libido) and general feeling of health. Patients filled the VAS form before LNG-IUS insertion and after 6 months. After the 6-month visit, PBAC score was condirebly decreased (p < 0.001). Six (10%) of the 60 patients PBAC score was higher than 75. VAS score for pelvic pain decreased from baseline to 6-month follow-up (4.32-3.55), and the libido and general feeling of health increased (4.27-4.95 and 3.47-6.87, respectively). The LNG-IUS device in the trearment of menorrhagia has cost effective, less side effects and increse in the QoL.

Endometrioid Adenocarcinoma after Insertion of a Levonorgestrel-releasing Intrauterine System

The levonorgestrel-releasing intrauterine system (IUS) is now widely used and recommended as a reliable contraceptive and treatment for menorrhagia. It also potentially provides a simple alternative to treatment for women with stage-1, grade-1 endometrial cancers who are at high risk for surgery. This case describes a 39-year-old multiparous patient who visited the gynecology outpatient department at a district general hospital with a history of heavy, prolonged periods for 1 year. Hysteroscopy and biopsy specimen revealed benign nonsecretory endometrium and a levonorgestrel-releasing IUS was inserted. The patient visited again 4 years later with an 8-month history of prolonged bleeding. Endometrial biopsy specimen confirmed well-differentiated endometrioid adenocarcinoma. This is the first case report, to our knowledge, where hysteroscopy was performed before levonorgestrel-releasing IUS insertion with conclusive evidence of initial negative malignancy followed by development of endometrial cancer 4 years after insertion. This case raises the question of the safety of levonorgestrel-releasing IUS for the prevention and treatment of endometrial hyperplasia and carcinoma.

Treatment of endometrial hyperplasia without atypia in peri- and postmenopausal women with a levonorgestrel intrauterine device

To assess the effectiveness of the Mirena levonorgestrel-releasing intrauterine system (LNG-IUS) in peri- and postmenopausal women with endometrial hyperplasia without atypia. All consecutive women with histologically documented endometrial hyperplasia without atypia recruited during a 1-year period participated in an open, prospective, single-center study. They were followed for at least 2 years after levonorgestrel-releasing intrauterine system insertion. The pattern of uterine bleeding was evaluated on a 4-point qualitative scale (1 = amenorrhea, 2 = scarce, 3 = normal, 4 = abundant). The study population consisted of 15 women with a mean (SD) age of 49 (2.7) years. Compared with baseline, bleeding decreased quantitatively from a mean score of 3 at baseline (normal bleeding) to 2 (scarce) at 3and 6 months, and 1 (amenorrhea) at 24 months. Endometrial biopsies performed at 12 months revealed atrophicendometrium in 14 women (93.3%) and secretory endometrium in 1 (6.7%) (P < 0.001). At 24 months, endometrial atrophy was documented in 100% of women. The levonorgestrel-releasing intrauterine system seems to be an effective and safe alternative in the treatment of peri- and postmenopausal women with (simple) endometrial hyperplasia without atypia.

Contraceptive effectiveness of levonorgestrel releasing intrauterine system

Background: This study evaluated the contraceptive effectiveness of progesterone releasing intrauterine contraceptive devices (IUCD) and compared it with the Copper T device. Methods: Seventy patients were selected in each group. Menstrual charts were maintained and data recorded at one, three, six months and one year after insertion of the device. Result: One year follow up was completed by 66 patients in the Levonorgestrel Releasing Intrauterine System (LNG-IUS) group and 62 in the Cu T group. They were age, parity and education level matched. The mean duration of menstrual flow for the LNGIUS group was 3.6 days and that for CuT group was 5.1 days (p>0.05). Insertion of LNG-IUS was found to be significantly difficult than the Cu T 380, with increased pain at insertion (p<0.05). There was no pregnancy in the LNG-IUS group and expulsion rates were low. The most significant difference was scanty periods and at times amenorrhoea in the LNG-IUS group. Termination rates for various reasons were almost equal in both groups. Conclusion: Both devices were effective, safe, well accepted and tolerated. LNG-IUS scores high in patients with preexisting menorrhagia or dysmenorrhoea while Cu T 380 has advantages of lower cost, ease of insertion and comparable efficacy.

Cytological evaluation and investigation of the vaginal flora of long-term users of the levonorgestrel-releasing intrauterine system (LNG-IUS)

Background The study was conducted to evaluate the cytopathological findings and vaginal flora in cervical smear samples from women using the levonorgestrel-releasing intrauterine system (LNG-IUS) for a period of up to 7 years. Study Design Postinsertion cytology examinations were conducted on 187 women who had an LNG-IUS inserted between April and September 1998 in the family planning clinic of the Universidade Estadual de Campinas. Results During the 7 years of follow-up, a high frequency of candidiasis was found from the fourth through the seventh year of use in comparison to the first year of use. No significant results were found with respect to cytopathological abnormalities or other microbiological alterations following insertion of the LNG-IUS. Conclusion Use of the LNG-IUS had no effect on cervical smears over the 7-year follow-up period; however, an increase occurred in the frequency of candidiasis.

Predictors of oligoamenorrhea at 1-year follow-up in premenopausal women using a levonorgestrel-releasing intrauterine system

Objective The study was conducted to identify predictors of oligoamenorrhea at 12 months in levonorgestrel-releasing intrauterine system (LNG-IUS) users. Design A 12-month observational study. Setting Gynecologic outpatient clinic in a large regional hospital in Flanders, Belgium. Population or Sample A total of 150 women who had made an informed decision to use a LNG-IUS either as a method of contraception or to manage menorrhagia. Methods All women were premenopausal and first-time users. The variables recorded prior to insertion on Days 1 to 5 of the menstrual cycle were age, parity, body mass index, indication for LNG-IUS use, prior contraceptive use, menstrual bleeding history, length of the uterine cavity, endometrial thickness, number of antral follicles, serum follicle-stimulating hormone, inhibin B and anti-Müllerian hormone. Menstrual bleeding pattern, patient satisfaction or wish to discontinue the method was noted at 3, 6 and 12 months of follow-up visits. Main Outcome Measures Menstrual bleeding pattern (amenorrhea, oligomenorrhea, menorrhagia) at 12 months was taken as the primary outcome measurement. Patient satisfaction was followed as a secondary outcome. Results Oligoamenorrhea was associated with a high patient satisfaction. A bleeding period less than 5 days, absence of severe uterine bleeding at baseline, LNG-IUS use for contraception and oligoamenorrhea at 3 months were predictors of a favorable outcome at 12 months in a univariate analysis. The absence of severe bleeding prior to LNG-IUS insertion was the only clinically useful predictor of favorable outcome in the multivariate analysis (odds ratio 0.13, 95% confidence interval 0.02–0.66). Conclusions Patient profiling as described is not helpful in counselling women for intentional LNG-IUS use, especially not if it is planned as a method of managing menorrhagia.

Advantages wth Using the Levonorgestrel-Releasing Intrauterine System in Females with Hemostatic Disorders.

BACKGROUND: The levonorgestrel-releasing intrauterine system (LNG-IUS) is a small device placed within the uterus that is used for both contraception and treatment of menorraghia. This system releases 20 micrograms of levonorgestrel every 24 hours over 5 years. We hypothesized that females with inherited or acquired bleeding disorders would have decreased menstrual bleeding with the LNG-IUS and improved quality of life.METHODS: A small, retrospective case series of females with hemostatic disorders who used the LNG-IUS within a 2 year period and who were seen at a tertiary medical center.RESULTS: Seven females were treated with the LNG-IUS for menorrhagia and contraception. We did not reverse anticoagulation for placement of the device and there were no bleeding complications associated with the LNG-IUS insertion. The average age was 36.7 years (range 28 – 48 years). Four females had von Willebrand's disease (VWD). Four females were on antithrombotic therapy, 2 warfarin and 2 aspirin. One female with VWD was heterozygous for factor V Leiden and was on warfarin for treatment of deep venous thrombosis. Six females had menorrhagia and one had bleeding most of the time. The average days of menstrual bleeding prior to LNG-IUS was 8.3 days which improved to 4.5 days after placement of the LNG-IUS. Three of 7 females discontinued use of the LNG-IUS, yet one had the LNG-IUS removed because she no longer required contraception. This female became pregnant and after an uncomplicated normal spontaneous vaginal delivery elected to use the LNG-IUS again for contraception and the benefit of decreased menstrual bleeding. The other 2 females (2/7, 29%) discontinued use of the LNG-IUS because there was worsening of heavy menses or ‘failed' therapy - one with VWD and one on anticoagulation. The female on anticoagulation in this case also had significant uterine fibroids. A ten item quality of life questionnaire developed by Kouides was administered, and showed overall improvement in quality of life.CONCLUSION: The levonorgestrel-releasing intrauterine system is an effective method of contraception and an effective treatment for heavy menses. For females with hemostatic disorders, this device has unique advantages: it is technically easy to use in females at increased bleeding risk, offers effective control of menorrhagia, and may likely improve overall quality of life. Additional prospective large scale studies are required to validate these findings.

Re-audit: transcervical resection of the endometrium for heavy menstrual bleeding and the treatment of post-resection uterine stenosis and haematometra by cervical dilatation and the insertion of a levonorgestrel-releasing intra-uterine system

The audit objectives: To assess the outcome of the treatment of: (1) heavy menstrual bleeding by transcervical resection of the endometrium, (2) post-resection uterine stenosis and haematometra by cervical dilatation and levonorgestrel-releasing intra uterine system. The audit design: A retrospective re-audit. The setting: A district general hospital in the North West region of England, U.K. The patients: Forty-seven women with heavy menstrual bleeding that required treatment with transcervical resection of the endometrium. The interventions: Transcervical resection of the endometrium, cervical dilatation and the insertion of levonorgestrel-releasing intra uterine system. The main outcome measures: Clinical improvement and the need for further surgery, including hysterectomy. The results: Transcervical resection of the endometrium improved the symptoms of 80.9% of the women. The problem of six out of seven women with post-resection uterine stenosis and haematometra was resolved by cervical dilatation and the insertion of levonorgestrel-releasing intra-uterine system. The conclusion: Transcervical resection of the endometrium for heavy menstrual loss is a safe and effective procedure. Cervical dilatation and the insertion of levonorgestrel-releasing intra-uterine system saved some women with post-resection uterine stenosis and haematometra from having further surgery. The two interventions combined saved 93.6% of the women from having hysterectomies.

Experience with the levonorgestrel-releasing intrauterine system among HIV-infected women

Background Safe and effective contraception is needed for women infected with human immunodeficiency virus (HIV). The levonorgestrel-releasing intrauterine system (LNG-IUS) is an effective long-term contraceptive that reduces menstrual bleeding and may reduce the risk of pelvic inflammatory disease. Yet, little is known about LNG-IUS use in HIV-infected women. Subjects and Methods Six HIV-infected women had the LNG-IUS inserted between March 1998 and October 2002, and were systemically followed for a mean of 45 months. Indications for LNG-IUS use were contraception in four women and menorrhagia in two women. Results The LNG-IUS was well tolerated, and menstrual bleeding was reduced in all women. Blood hemoglobin levels increased in each subject, with mean levels being 123 g/L (SD=11.7) before LNG-IUS insertion and 135 g/L (SD=8.7) at 1 year (p=.01). Levels of circulating CD4 lymphocytes and Pap smear findings remained unchanged. Conclusions Our limited experience with LNG-IUS use in HIV-infected women is encouraging. The LNG-IUS may be used as an alternative to uterine surgery in HIV-infected women with menorrhagia.

The levonorgestrel-releasing intrauterine system (LNG-IUS) in HIV-infected women—effects on bleeding patterns, ovarian function and genital shedding of HIV

Safe and effective contraceptives are needed for human immunodeficiency virus (HIV)-infected women. The levonorgestrel-releasing intrauterine system (LNG-IUS) is a highly effective contraceptive with additional health benefits. The objective of this study was to evaluate the effects of the LNG-IUS among HIV-infected women. Twelve systematically managed HIV-infected women were studied prospectively. Following a 2-month run-in period, the subjects had an LNG-IUS inserted and were followed up for 1 year. Patterns of bleeding, blood haemoglobin and CD4-lymphocyte content, plasma HIV RNA, serum levels of LNG, of estradiol (E(2)) and of ferritin and genital shedding of HIV RNA were monitored. Menstrual bleeding was reduced significantly during the use of the LNG-IUS; this was associated with slight increases in serum haemoglobin and ferritin levels. Serum E(2) concentrations remained in the follicular range in all subjects. Among subjects using antiretroviral medication, the proportion of cervicovaginal lavage specimens with detectable HIV RNA was 10% before and after the insertion of the LNG-IUS. The effects of the LNG-IUS on bleeding patterns, body iron stores and ovarian function were similar to those seen in healthy women. Genital shedding of HIV RNA was not affected by the LNG-IUS. These data encourage further studies on the effects of the LNG-IUS on reproductive health among HIV-infected women.

The use of levonorgestrel‐releasing intrauterine system for treatment of menorrhagia in women with inherited bleeding disorders

The levonorgestrel-releasing intrauterine system (LNG-IUS) is used commonly by gynaecologists as a contraceptive and to treat menorrhagia. However, its efficacy has not been examined in women with inherited bleeding disorders. A prospective pilot study. A teaching hospital in north London with a designated haemophilia centre. Female patients with a known inherited bleeding disorder. Sixteen women with subjective and objective menorrhagia caused by inherited bleeding disorders (13 von Willebrand's Disease, two factor XI deficiency and one Hermansky-Pudlak syndrome), who had previously undergone unsuccessful medical treatment were followed up for nine months after LNG-IUS insertion. Bleeding was measured by pictorial chart and haemoglobin concentration. All women reported that their periods were improved, pictorial chart scores were lower and 56% became amenorrhoeic. None reported side effects. The LNG-IUS is well tolerated and effective and improves quality of life.

The effect of a levonorgestrel-releasing intrauterine system on angiogenic growth factors in the endometrium.

The study aim was to investigate the effects of a levonorgestrel-releasing intrauterine system (LNG-IUS) on the secretion profiles and level of mRNA transcripts for angiogenic growth factors including vascular endothelial growth factor (VEGF), transforming growth factor (TGF)-beta1, basic fibroblast growth factor (bFGF) and endothelial growth factor (EGF) in the endometrium, and their levels in plasma. Blood and endometrial samples were collected from 15 women using LNG-IUS at pre-insertion and at 1, 3, 6 and 12 months following the use of contraception. Using enzyme-linked immunosorbent assay (ELISA) and semi-quantitative reverse transcription techniques, angiogenic growth factors were measured in the plasma and endometrial tissue extracts. A significant increase in endometrial tissue levels of VEGF at 3 and 6 months (P < 0.007, P < 0.01), TGF-beta1 at 6 and 12 months (P < 0.002, P < 0.007) and bFGF at 1 and 6 months (P < 0.004, P < 0.008) respectively were observed following insertion of LNG-IUS. A corresponding increase in mRNA expression of TGF-beta1 and bFGF were also observed. The LNG-IUS had no effect on endometrial EGF levels. No significant differences were noted in plasma levels of bFGF, EGF and TGF-beta1, while VEGF was not detectable in all plasma samples assayed. A positive correlation was observed between endometrial tissue VEGF and bleeding/spotting days in the reference period (r = 0.705, P < 0.015). These results provide the first evidence that more than one angiogenic factor could be implicated in aberrant endometrial angiogenesis resulting in breakthrough bleeding in LNG-IUS acceptors.

Therapeutic effects of the levonorgestrel-releasing intrauterine system in the treatment of idiopathic menorrhagia

Objective To investigate the effect of the levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of idiopathic menorrhagia. Design Measurements of menstrual blood loss (MBL), hemoglobin, and serum ferritin before and after LNG-IUS insertion. Setting National Research Institute for Family Planning and Beijing Gynecology and Obstetrics Hospital, Beijing, People’s Republic of China. Patient(s) Thirty-four patients with MBL over 80 mL. Intervention(s) Insertion of the LNG-IUS on cycle days 5–7 and follow-up at 3-month intervals for 3 years. Main outcome measure(s) Measurement of MBL, serum ferritin, and hemoglobin for evaluation of efficacy of treatment. Result(s) A significant reduction of MBL to 23.4 mL (78.7% decrease), 26.4 mL (83.8% decrease), 2.7 mL (97.7% decrease), and 13.7 mL (85.0% decrease) at 6, 12, 24, and 36 months, respectively. After 6 months, one-third of the patients experienced amenorrhea, and one-fourth, spotting. Hemoglobin increased significantly from 121.5 g/L preinsertion to 135.5 g/L after 36 months, while serum ferritin levels increased significantly from 21.9 ng/mL before insertion to 92.8 ng/mL after 36 months. In women using the LNG-IUS for 3–4 years, the E 2 levels in 20 samples were 239.4 pmol/L, P levels were 11.1 nmol/L, and serum LNG levels were maintained at an average of 511 pmol/L. Conclusion(s) The significant reduction of MBL and the increase in hemoglobin and serum ferritin levels in the treatment of menorrhagia with the LNG-IUS has great implications for women’s reproductive health, particularly in developing countries.

Intrauterine system preferred for treatment of menorrhagia

A recent study suggests that the levonorgestrel-releasing intrauterine system (IUS) is more suitable for treating menorrhagia (excessively heavy or prolonged uterine bleeding) than are surgical procedures, such as transcervical endometrial resection.Menorrhagia can be caused by medical problems or hormone imbalances, and accounts for more than 10% of outpatient referrals to gynaecology consultants. Olave Istre and Birgitta Trolle of the Central Hospital of Hedmark County in Hamar, Norway randomly assigned 30 patients suffering from the condition to levonorgestrel-releasing IUS insertion and 30 patients to endometrial resection (Fertil. Steril. 76, 304–309). In both groups, there was a significant reduction in pain, but IUS was more effective than was surgery in reducing blood loss, with 90% and 67% of patients, respectively, achieving a pictorial blood loss assessment score of 75 or less (P = 0.005). Although adverse effects were reported more frequently among patients treated with the levonorgestrel-releasing IUS, the authors recommend this treatment because it is reversible and does not threaten postoperative complications.These recommendations are similar to those of a larger study of menorrhagic patients published earlier this year that compared treatment with levonorgestrel-releasing IUS to hysterectomy (Lancet 357, 273–277). Ritva Hurskainen and colleagues found that both groups benefited from their respective treatments, and although there was no difference between groups in terms of health outcome after one year, the levonorgestrel-releasing IUS was more cost effective. HN

Effects of the levonorgestrel-releasing intrauterine system on proliferation and apoptosis in the endometrium.

The levonorgestrel-releasing intrauterine system (LNg-IUS) has been shown to be effective in the management of menorrhagia. In order to evaluate the effects of LNg-IUS on endometrial proliferation and apoptosis, proliferating cell nuclear antigen (PCNA) expression, apoptosis, Fas and Bcl-2 protein expression in the endometrium were determined at the early proliferative phase of the menstrual cycle before and 3 months after LNg-IUS insertion. PCNA, Fas and Bcl-2 protein expression were analysed using an avidin-biotin immunoperoxidase method. Apoptosis was assessed by the terminal deoxynucleotidyl transferase-mediated deoxy-UTP nick-end labelling (TUNEL) method. PCNA, immunolocalized both in the nuclei of endometrial glands and stroma was less abundant 3 months after insertion (P < 0.05). Bcl-2 protein, immunolocalized in the cytoplasm of endometrial glands but not in the stroma, became scanty 3 months after insertion. Fas antigen, immunolocalized only in endometrial glands before insertion, became prominent in both endometrial glands and stroma 3 months after insertion. The apoptosis-positive rate of the nuclei in both endometrial glands and stroma was significantly higher 3 months after insertion relative to that before insertion (P < 0.05). LNg-IUS resulted in a decrease in endometrial proliferation and an increase in apoptosis in endometrial glands and stroma. The increase in apoptosis associated with increased Fas antigen expression and decreased Bcl-2 protein expression in the endometrium may be one of the underlying molecular mechanisms by which LNg-IUS insertion causes the atrophic change of the endometrium.