Levonorgestrel Intrauterine System Insertion Research Articles

Efficacy of Levonorgestrel Intrauterine System in the Management of Abnormal Uterine Bleeding: A Retrospective Analysis of a 100 Women.

Abnormal uterine bleeding (AUB) is a common gynaecological complaint affecting around 10-30% women during reproductive years. It adversely affects a woman's life, leading to psychological, medical, social and sexual problems. We aim to study the efficacy of a levonorgestrel intrauterine system (LNG-IUS) in 100 women suffering from AUB. A retrospective study was carried out at a private nursing home in Mumbai over a period of 4years. A total of 100 patients aged 30years to 50years (average age = 42.9years) who underwent LNG-IUS insertion for abnormal uterine bleeding were studied. Cases were evaluated according to clinical findings, hemogram and transvaginal ultrasound. The women were called for follow-up at 1week, 1month, 6months, 1 and 2years to analyse type and amount of bleeding and development of amenorrhea. At the end of 6months, 75% patients experienced decreased menstrual blood loss. Five patients underwent removal of the LNG-IUS at the end of 6months as they experienced no relief of symptoms. At the end of 2years, 95% patients were fully satisfied with the LNG-IUS insertion. A levonorgestrel intrauterine system significantly reduces bleeding in menorrhagia due to benign causes and is found to be highly effective in the management of various gynaecological pathologies such as endometrial polyps, adenomyosis and endometrial hyperplasia when insertion perfomed after dilatation and curettage/polypectomy. It has proven to be superior to various surgical and other non-surgical treatment modalities.

Factors Predicting Removals of the Levonorgestrel-Releasing Intrauterine System in an Adolescent Cohort

Use of 52-mg levonorgestrel intrauterine system (LNG-IUS) in adolescents for heavy menstrual bleeding (HMB), dysmenorrhea, and contraception has increased, yet little is known about the factors predicting removal and dissatisfaction in adolescents. The aim of this study was to identify factors predicting LNG-IUS removal in adolescents. This was a retrospective cohort study including all adolescents (9-19 years) who underwent LNG-IUS insertion between 2012 and 2021 (n = 536). A medical record review was conducted and data were collated on medical and gynecological history, age, indications for insertion, complications, expulsions, and removals. The data were analyzed using χ2 tests. Indications for LNG-IUS insertions (n = 536) among 517 individual patients (n = 517) included menstrual management (n = 142), HMB alone (n = 118), HMB and pelvic pain/dysmenorrhea (n = 105), dysmenorrhea/pelvic pain alone (n = 47), and contraception (n = 16). Associated diagnoses included intellectual disability (44.29%, 229/517), chronic pain conditions (12.77%, 66/517), and additional mental health concerns (24.37%, 126/517). Patient dissatisfaction with LNG-IUS led to removal in 61 (11.38%), mostly for pain or persistent bleeding. Higher removal rates occurred in those with associated chronic pain conditions (46.97%, χ2 = 55.9, P < .05), mental health concerns (16.67%, χ2 = 5.06, P < .05), and bleeding disorders (26.32%, χ2 = 5.09, P < .05). Among the cohort with an intellectual disability, lower rates of removal occurred (5.7%, χ2 = 11.2, P < .05). Whereas the LNG-IUS removal rate among gender-diverse youth was 23.07%, this was not statistically significant. Younger age was also not associated with a statistically significant increase in removals (13.72%, χ2 = 0.73, P > .05). Adolescents have a low dissatisfaction and removal rate (11.38%) of LNG-IUS. Chronic pain, bleeding tendency, and mental health concerns are associated with higher removal rates and intellectual disability with lower rates. These findings are useful in counselling patients and families about LNG-IUS.

Levonorgestrel-Releasing Intrauterine System: A Promising Choice after Uterovaginal Anastomosis in Patients with Cervical Dysgenesis

BackgroundCervical dysgenesis is categorized into cervical fragmentation, cervical fibrous cord, and cervical obstruction. The definitive management for cervical dysgenesis is either uterovaginal anastomosis (UVA) or hysterectomy. ObjectiveTo compare the prevalence of dysmenorrhea, hematometra, and need for dilatation after UVA with and without postprocedural placement of a levonorgestrel intrauterine system (LNG-IUS). MethodsThis was a retrospective cohort study in which 14 patients with cervical dysgenesis were included. Patients had undergone UVA between May 2015 and January 2022 at the Department of Obstetrics and Gynecology of the Cairo University Teaching Hospital. Six patients who had an LNG-IUS inserted after UVA were included in group A, and 8 patients who had undergone UVA without LNG-IUS insertion were included in group B. Transabdominal and/or transvaginal ultrasound was performed monthly for the first 3 months after LNG-IUS insertion in group A and after UVA in group B. Thereafter, the patients were followed up every 6 months. The primary outcomes were dysmenorrhea, hematometra, and need for dilatation of the anastomosis site. ResultsThe number of patients who developed hematometra was significantly lower in group A than in group B (0 [0%] vs 6 [75%], P = .01). The number of patients who required dilatation was significantly lower in group A than in group B (0 [0%] vs 6 [75%], P = .01). There was no significant difference in the incidence of dysmenorrhea between the 2 groups. ConclusionWe recommend offering LNG-IUS after UVA for adolescents who present with cervical dysgenesis. LNG-IUS decreases the recurrence of hematometra and subsequent surgical interventions.

Does Timing of Levonorgestrel Insertion in Women with Abnormal Uterine Bleeding Affect its Expulsion and Bleeding Pattern? A Follow-Up Study.

Levonorgestrel Intra Uterine System insertion for contraception is preferred in the follicular phase. However, the ideal time of insertion for Abnormal Uterine Bleeding is not stated clearly. The aim of our study is to find out the effect of timing of insertion on expulsion and irregular bleeding pattern post insertion. A follow-up study of patients with LNG-IUS for AUB was conducted. They were grouped into four based on the day of insertion from Last Menstrual Period (LMP). The pattern of irregular bleeding post insertion was compared with odds ratio and the expulsion rate was compared with log rank test. The most common indication for the 76 patients was ovulatory dysfunction (39.4%) followed by Adenomyosis (36.84%). Those who had LNG-IUS insertion from day 22-30 had quicker expulsions of 25% of patients by 3 months. By 6 months and later expulsion rate was much higher in the luteal phase than the follicular phase (p < 0.03). The least risk of moderate or heavy bleeding was for the 8-15day group when compared to the 22-30day group, the odds ratio being 0.03 [95% CI: (0.01-0.2)]. Based on expulsion rate alone, insertion of LNG-IUS at any time in the follicular phase is ideal. Considering both expulsion rate and pattern of bleeding the ideal time would be late follicular phase, that is 8-15th day.

Use of the Levonorgestrel Intrauterine System to Treat Heavy Menstrual Bleeding in Adolescents and Young Adults with Inherited Bleeding Disorders and Ehlers-Danlos Syndrome.

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. 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. 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.

The levonorgestrel intrauterine system (LNG-IUS) for prevention of endometrial cancer in women with obesity is cost effective

Objectives: To estimate the cost-effectiveness of the levonorgestrel intrauterine system (LNG-IUS) as an endometrial cancer prevention strategy in women with obesity. Methods: A Markov decision-analytic model was used to compare 5 strategies in women with a body mass index of 30 or greater: 1) Usual care 2) LNG-IUS for 5 years 3) LNG-IUS for 7 years 4) LNG-IUS for 5 years, replaced once for a total of 10 years 5) LNG-IUS for 7 years, replaced once for a total of 14 years. Obesity was presumed to be associated with a 3-fold relative risk of endometrial cancer incidence and a 2.65-fold disease-specific mortality. The LNG-IUS was assumed to confer a 50% reduction in cancer incidence over the period of the LNG-IUS insertion. Costs of LNG-IUS and cancer care were included. Outcomes were incremental cost-effectiveness ratios, calculated in 2019 Canadian dollars per year of life saved. One-way and two-way sensitivity analyses were performed. Results: The LNG-IUS strategy was considered cost-effective if the cost of the intervention is less than 66 400 CAD (50 000 USD) per year of life saved. The strategy becomes cost-effective if 1 LNG-IUS is inserted in 57-year-old women for 5 years, 1 LNG-IUS is inserted in 52-year-old women for 7 years, 2 subsequent LNG-IUS for a total of 10 years are inserted in 51-year-old women or 2 subsequent LNG-IUS for a total of 14 years are inserted in 45-year-old women, when compared to usual care. The results are stable to variations in cost but sensitive to the estimated risk reduction of the LNG-IUS and the impact of obesity on endometrial cancer incidence and disease-specific mortality. Conclusions: The LNG-IUS is a cost-effective method of endometrial cancer prevention in women with obesity. This intervention warrants investigation in a prospective study in this high-risk population.

The combined use of endometrial ablation or resection and levonorgestrel-releasing intrauterine system in women with heavy menstrual bleeding: A systematic review.

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. 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. Six studies with a retrospective design and one case series with a follow-up duration varying from 6 to 55months 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. 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.

The levonorgestrel intrauterine system for prevention of endometrial cancer in women with obesity: A cost-effectiveness study

ObjectiveTo estimate the cost-effectiveness of the levonorgestrel intrauterine system (LNG-IUS) as an endometrial cancer prevention strategy in women with obesity. MethodsA Markov decision-analytic model was used to compare 5 strategies in women with a body mass index of 30 or greater: 1) Usual care 2) LNG-IUS for 5 years 3) LNG-IUS for 7 years 4) LNG-IUS for 5 years, replaced once for a total of 10 years 5) LNG-IUS for 7 years, replaced once for a total of 14 years. Obesity was presumed to be associated with a 3-fold relative risk of endometrial cancer incidence and a 2.65-fold disease-specific mortality. The LNG-IUS was assumed to confer a 50% reduction in cancer incidence over the period of the LNG-IUS insertion. Outcomes were incremental cost-effectiveness ratios, calculated in 2019 Canadian dollars (CAD) per year of life saved. One-way and two-way sensitivity analyses were performed. ResultsThe LNG-IUS strategy was considered cost-effective if the cost of the intervention is less than $66,400 CAD ($50,000 US dollars) per year of life saved. The strategy becomes cost-effective if the LNG-IUS is inserted at age 57 (strategy #2), at age 52 for strategy #3, at age 51 for strategy #4 and at age 45 for strategy #5, when compared to usual care. The results are stable to variations in cost but sensitive to the estimated risk reduction of the LNG-IUS and the impact of obesity on endometrial cancer incidence and disease-specific mortality. ConclusionThe LNG-IUS is a cost-effective method of endometrial cancer prevention in women with obesity.

Postplacental Insertion of Levonorgestrel Intrauterine System Versus Copper Intrauterine Device: A Prospective Study.

To compare between postplacental insertion of levonorgestrel intrauterine system versus copper intrauterine device regarding expulsion rates, patient satisfaction, complications, and continuation rates. This prospective observational study was conducted on 1100 participants divided in to two groups: group (1) CU-IUD group and group (2) LNG-IUS group where women were assigned for postplacental insertion of either CU-IUD or LNG-IUS, respectively. Follow-up at 6weeks, 3 and 6months postpartum and data were collected and analyzed to evaluate outcomes. No statistical difference between both groups regarding patients' characteristics, the overall expulsion rate was higher in LNS-IUS group than CU-IUD group; 77 patients (14%) and 50 patients (9%), respectively, (P value < 0.05), odds ratio: 1.63 at CI: (1.12-2.37). No significant difference between the two groups regarding pain intensity, perforation, abnormal uterine bleeding, and clinical endometritis (P > 0.05). Overall satisfaction rate at six months was 478(87%) in the CU-IUD group and 472(85.8%) in the LNS-IUS group (P value > 0.05), odds ratio: 1.1 at CI: (0.78-1.55). Continuation rate at s6 months was comparable between the two groups 485 (88.2%) and 480 (87.3%) in CU-IUD group and LNS-IUS group respectively, (P value < 0.05), odds ratio: 1.09 at CI: (0.76-1.56). The rate of expulsion of LNG-IUS is higher than copper IUD when inserted postplacental, yet the continuation and acceptability rates were comparable between the two groups.

Preventive therapeutic options for postoperative recurrence of ovarian endometrioma: gonadotropin-releasing hormone agonist with or without levonorgestrel intrauterine system insertion.

Here, we compared endometrioma recurrence rates in patients who have undergone a laparoscopic cystectomy and treated with a gonadotropin-releasing hormone agonist (GnRHa) alone or a GnRHa combined with a levonogestrel intrauterine system (LND-IUS). We enrolled endometrioma patients who underwent laparoscopic cyst enucleation and divided them into two groups according to postoperative management: GnRHa alone and GnRHa in combination with LND-IUS. We compared preoperative history, perioperative parameters, postoperative endometrioma recurrence, and symptoms between these two groups. A total of 320 patients were included in the final analysis. With a median 84.6months of follow-up, we detected significant differences between the two groups with respect to age at surgery (31.6 ± 4.8 vs. 37.6 ± 4.2years, χ2 = 1.978, p < 0.001), gravida (0 vs. 2, χ2 = 4.391, p < 0.001), parity (0 vs. 1, χ2 = 0.035, p < 0.001), body mass index (21.0 ± 2.5 vs. 21.9 ± 2.4, χ2 = 0.0096, p = 0.009), r-AFS score (48 vs. 64, χ2 = 4.888, p = 0.001), and operation time (60 vs. 75min, χ2 = 9.119, p = 0.003). Patients treated with both GnRHa and LND-IUS achieved significantly less endometrioma recurrence (23.6 vs. 11.5%, χ2 = 5.202, p = 0.023) and higher rates of pain remission (92.1 vs. 100%, χ2 = 6.511, p = 0.011), while those with GnRHa alone suffered more recurrent and painful symptoms (χ2 = 9.280, p = 0.026). Multivariate analysis using a Cox regression demonstrated that combined GnRHa and LNG-IUS treatment correlated with a decreased endometrioma recurrence rate after laparoscopic cystectomy (RR 0.369, 95% CI 0.182-0.749, p = 0.006). Combination treatment of GnRHa and LNG-IUS exhibited superior pain relief and recurrence prevention among endometrioma patients after fertility-sparing surgery. Thus, combination treatment is a preferable long-term option for patients without intent for pregnancy in the near future.

Levonorgestrel Salınımlı Rahimiçi Sistemin Kontraseptif Kullanımı: Olgu Serisi

Aim: Levonorgestrel intrauterine system (LNG-RIS) is a highly effective, safe and reversible contraceptive method. It suppresses endometrial cell proliferation, thickens cervical mucus, disrupts tubal motility by creating a high levonorgestrel concentration in the endometrium and tubal mucosa. In our country, LNG-RIS is mostly used in Gynecology and Obstetrics clinics in the treatment of pathologies such as adenomyosis, endometriosis, hyperplasia and their symptoms such as menorrhagia, dysmenorrhea, pelvic pain, and is prescribed at the hospitals due to a medication report. It has a high level of protection (99.9%), and its contraceptive effect is considered to last five years, and fertility returns rapidly after removal. In this study it was aimed to evaluate retrospectively the continuation rate, the presence of unwanted effects and the patient satisfaction after insertion of LNG-RIS. Method: This is a retrospective, descriptive study of women who had been inserted LNG-IUS with contraceptive purpose in the family planning unit of the Marmara University Pendik Training and Research Hospital, between 2013-2019; the data of a total 38 patients were retrospectively analyzed. Results: The average age of the participants was 36±5 years. No pregnancy is detected during the use of the method. Five-year usage rate was 21% among users. A total of nine patients discontinued the method; one because being diagnosed with a glial tumor, two because of excessive bleeding, one other patient because having hysterectomy due to myoma uteri, two patients because the threads were not visible, two others because they have been told that their LNG-IUS had slipped down and one patient because of her pregnancy plan. The satisfaction rate was 52.6%. There was a decrease in both the duration and the amount of bleeding of menstruation but this decrease was not statistically significant. Conclusion: LNG-RIS is an effective, reliable contraception method with low side effect. It is still limited in primary care and it will be more appropriate to spread its use.

Predictors of severe pain during insertion of the levonorgestrel 52 mg intrauterine system among nulligravid women

ObjectiveTo identify sociodemographic and clinical variables associated with severe pain with levonorgestrel 52 mg intrauterine system (IUS) placement among nulligravid women. Study designWe performed a secondary analysis of a randomized trial that evaluated intracervical anesthesia before IUS insertion. We assessed factors associated with severe pain (visual analog scale pain score ≥7) immediately after insertion using bivariate and multiple regression analyses. ResultsOverall, 137/300 (45.7%) subjects reported severe pain. In multiple regression analysis, only intracervical anesthesia [RR 0.55, 95% CI 0.37–0.80] and a history of dysmenorrhea [RR 1.36, 95% CI 1.08–1.72)] were associated with severe pain. ConclusionsAmong nulligravid women, a history of dysmenorrhea increases, and intracervical block decreases severe pain during levonorgestrel IUS insertion. ImplicationsDysmenorrhea increases the risk of severe pain at levonorgestrel intrauterine system insertion, while receiving an intracervical lidocaine block decreases this risk. This information can be useful for counseling women prior to device placement and for selecting candidates who may particularly benefit from interventions to reduce pain.

Effects of the levonorgestrel intrauterine system on the endometrium after long-term exposure to mifepristone: Secondary outcomes of a randomized controlled trial

ObjectiveLong-term treatment with progesterone receptor modulators (PRM) is associated with a distinct histological entity termed progesterone receptor modulator associated endometrial changes (PAEC). While accumulating evidence implies that these changes are benign and reversible after cessation of treatment, there are currently no data underpinning their development. Consequently, as a precaution, endometrial shedding is recommended after long-term PRM intake. Avoiding endometrial shedding after treatment with a PRM and prior to the start of a progestin treatment would be beneficial for women in reproductive age to avoid pregnancy and bleeding. However, the endometrial morphology with such a treatment regimen is unknown. The aim of this study was to delineate the endometrial morphology following continuous long-term treatment with the PRM mifepristone and subsequent placement of a levonorgestrel intrauterine system (LNG-IUS) without prior shedding of the endometrium. Study designThis study reports the secondary outcome from a double-blinded randomized controlled trial conducted at Karolinska University Hospital, Sweden, November 2009 to January 2015. Healthy women aged 18–43 years with regular menstrual cycles were included. Eligible women were randomized to receive either 50 mg of mifepristone (n = 29) or a comparator (n = 29), every other day for two months followed by insertion of an LNG-IUS 52 mg. Endometrial biopsies were obtained at baseline and three months after placement of the device. The samples were histologically assessed. The main outcome measure of this sub-study was the endometrial morphology including presence of PAEC three months after LNG-IUS insertion. ResultsNine and eight paired biopsies from the mifepristone and comparator group, respectively, were included in the histological analysis. There were no differences in baseline characteristics between the groups and all baseline endometrial biopsies were physiological. Three months after LNG-IUS placement the endometrial morphology was still benign without PAEC in all samples treated with either mifepristone or comparator. A progestin effect on the endometrium was seen in all samples. ConclusionsPlacement of an LNG-IUS immediately following two months’ treatment with the PRM mifepristone, without any prior shedding of the endometrium, may represent a feasible approach in terms of endometrial safety. However, larger studies are needed to confirm our results.

The role of levonorgestrel intra-uterine system in the management of adenomyosis: A systematic review and meta-analysis of prospective studies.

The levonorgestrel intrauterine system (LNG-IUS) is a long-acting hormone-releasing uterine device that has many non-contraceptive benefits. The study aims to assess the safety and efficacy of LNG-IUS in the management of adenomyosis. We searched the following bibliographic databases: MEDLINE via PubMed, SCOPUS, Web of Science, Cochrane CentralRegister of Controlled Trials (CENTRAL), EMBASE and Google Scholar for the relevant studies which used LNG-IUS in management of patients with clinically or ultrasonographic diagnosed adenomyosis.The main outcome measures are pain score at the end of follow-up, bleeding, symptomatic relief, uterine volume (mL), endometrial thickness (mm) and/or hemoglobin level. Ten prospective studies (patients n=551) were included. The overall effect estimates showed that the LNG-IUS led to significant reductions in pain score after 12months (standardized mean difference [SMD[ -3.87, 95% confidence interval [CI] -5.51 to -2.23, P<.001), 24months (SMD -5.56, 95% CI -9.80 to -1.32, P=.01) and 36months of insertion (SMD -3.81, 95% CI -4.27 to -3.36, P<.001). Similarly, the Pictorial Blood Assessment Chart (PBAC) showed significant reduction up to 36months after LNG-IUS insertion (SMD -2.32, 95% CI -2.91 to -1.73, P<.001). The LNG-IUS led to significant reductions in the uterine volume 12months (SMD -.60, 95% CI -0.88 to -.31, P<.001) and 36months after insertion (SMD -0.42, 95% CI -0.69 to -0.14, P=.003). LNG-IUS is a promising and effective option for the management of adenomyosis. Its use effectively reduced the severity of symptoms, uterine volume and endometrial thickness, and improved laboratory outcomes.

Preliminary report on the use of a levonorgestrel intrauterine system for the treatment of intermenstrual bleeding due to previous cesarean delivery scar defect.

To evaluate the efficacy of levonorgestrel intrauterine system (LNG-IUS) treatment in patients with previous cesarean delivery scar defect (PCDS)-related intermenstrual bleeding. A total of six premenopausal patients who experienced PCDS-related intermenstrual bleeding were enrolled for conservative therapy with LNG-IUS (levonorgestrel 20 μg/24 h) insertion. The durations of menstruation before and after LNG-IUS insertion at 1, 6 and 12 months were recorded. A total of three missed menstrual cycles was defined as amenorrhea. Any side effects and the device expulsion rate were also recorded. Patient follow-up was at an outpatient clinic. Any missing data were obtained by telephone. At the start of the study the median duration of intermenstrual bleeding was 6.5 days (range 3-22 days). After 6 months treatment, two of the six patients had developed amenorrhea and two patients experienced cessation of vaginal spotting. One patient reported expulsion of the device. All patients except the one with device expulsion responded to the conservative treatment after 1 year. The findings of the current study support LNG-IUS being effective for the treatment of PCDS-related intermenstrual bleeding. The authors recommend LNG-IUS as a treatment option for PCDS-related intermenstrual bleeding.

Postinsertional Pain after Intrauterine Device Placement among Nulliparous Adolescents.

To quantify the "normal" adolescent experience after intrauterine device insertion, to provide appropriate counseling for future adolescents. Prospective cohort study. Marshall University Department of Obstetrics and Gynecology generalist and adolescent gynecology clinics. Nulliparous adolescents age 13-18years and parous adults 18years of age or older who received a levonorgestrel intrauterine system (LNG-IUS). Visual analogue scale (VAS) pain score and medication log was used for data collection for 2weeks after LNG-IUS insertion. A separate chart review was completed for demographic factors and indications for procedure. VAS pain scores and medication use was compared between groups. Ninety-three subjects returned the VAS record and medication log (46 adolescents and 47 adults). There was no difference in the incidence of endometriosis or dysmenorrhea, but there was a higher prevalence of menorrhagia among adolescents (30/46, 65.2%vs 10/47, 21.3%; P<.001). Forty-five of forty-seven (95.7%) adults vs 25/46 (54.3%) adolescents had contraception as an indication for intrauterine device use (P<.001). Pain scores were statistically higher among the adolescent group each day (P<.05) in the 2-week study period. The greatest mean differences occurred in the first 4days. More adolescents (15/46, 32.6%) than adults (6/47, 12.8%) had a pain score greater than 5 during the first 3days (P=.022). A statistical difference in amount of ibuprofen recorded was only noted on day 1 (P=.023) and day 4 (P=.046). Nulliparous adolescents who undergo LNG-IUS placement experience more postinsertional discomfort compared with parous adults; however, this method should still be considered first-line treatment in this age group.

Immunologic evaluation of the endometrium with a levonorgestrel intrauterine device in solid organ transplant women and healthy controls

ObjectiveThe objective was to describe the endometrial milieu of stable transplant patients and healthy women before and after levonorgestrel intrauterine system (LNG-IUS) insertion. Study designWomen between 18 and 45 years of age desiring LNG-IUS insertion were enrolled with a 2:1 ratio of healthy to stable solid organ transplant patients. The first visit entailed a blood draw, uterine lavage and endometrial biopsy followed by LNG-IUS insertion. Follow-up visit involved a repeat serum draw, uterine lavage and endometrial biopsy. Cytokine levels were measured in the uterine lavage and serum by quantifying inflammatory biomarkers. Immunohistochemistry staining was performed on the endometrial tissue to measure macrophage levels. Statistical analysis included a nonparametric analysis that compared medians of the marker levels before and after intrauterine device (IUD) insertion within the group and between the two groups. ResultsSixteen participants completed the study: 5 solid organ transplant patients and 11 healthy patients. For the serum, there were no marked changes in the cytokines or soluble receptor levels in either group after IUD insertion. However, in the uterine lavage, there was an increase in cytokine levels post-IUD insertion for both healthy and transplant women. For the endometrial tissue, there was evidence of macrophage activity in both groups after device insertion. ConclusionsThis pilot study investigated the uterine environment of the transplant patient population. Findings have pointed to the strong local inflammatory response following LNG-IUS insertion for the transplant recipients. In addition, these preliminary findings will help power a larger study that can investigate the safety and effectiveness of the IUD in this patient population. ImplicationsFindings from this pilot study suggest that the IUD is inducing a local inflammatory reaction in the uterus of the transplant patient as in the healthy control. A larger study can build on these preliminary results to pursue the efficacy and safety of IUD use among solid organ transplant patients.

Uterine Length in Adolescents with Developmental Disability: Are Ultrasound Examinations Necessary before Insertion of the Levonorgestrel Intrauterine System?

Study Objective(1) To determine if there are any differences in uterine length between adolescents with developmental disability (DD) compared with their normally developing (ND) peers that might necessitate ultrasonography before insertion of levonorgestrel intrauterine system (LNG-IUS) in patients with DD; and (2) to characterize the LNG-IUS insertion procedure in adolescents with disabilities. Design, Setting, Participants, and InterventionsThis was a retrospective cohort study of 223 female adolescents with or without DDs. Seventy-five adolescents had DD; 33 underwent intrauterine system insertion in the operating room and 42 did not. A comparative cohort of 148 ND adolescents who had pelvic ultrasound examinations for abnormal uterine bleeding were included. The study period was between January 2006 and July 2013 at the Hospital for Sick Children, Toronto, Canada. Cases were identified from surgical databases and medical records. Main Outcome MeasuresMean uterine length on pelvic ultrasound, demographic characteristics (age, age at menarche, time from menarche to ultrasound, weight), and descriptive statistics on intrauterine system insertion. ResultsThere was a statistically significant difference (P = .03) in uterine length between adolescents with and without DD (6.7 vs 7.1 cm). However, this was not a clinically significant difference because insertion of the LNG-IUS in patients with DD was successful in patients with uteri more than 5 cm long. There was no difference (P = .97) in uterine length of adolescents with DD whether they had LNG-IUS insertion or not (6.7 cm). Adolescents with DD were younger than adolescents without DD at time of ultrasound examination (P = .01). However, among patients with DD, those who underwent intrauterine system insertion were older (P = .001). Incidence of uterine anomaly in patients with DD is low (2.7%) and was the same as in ND adolescents. Rates of complications and expulsions were low and there were no failures of LNG-IUS insertion in adolescents with DD. ConclusionRoutine pelvic ultrasound examinations are not necessary before insertion of the LNG-IUS for menstrual suppression in adolescents with DD. Renal abnormalities, obstructive symptoms, and very small stature might necessitate imaging. Insertion using anesthesia is often straightforward and successful with minimal complications.

Management of Endometrial Hyperplasia With a Levonorgestrel-Releasing Intrauterine System: A Korean Gynecologic-Oncology Group Study.

The aim of the study was to evaluate the efficacy of the levonorgestrel intrauterine system (LNG-IUS) for treatment of endometrial hyperplasia (EH). A prospective multicenter study was conducted from November 2010 to March 2014. Patients with histologically confirmed EH were treated with LNG-IUS. At 3, 6, and 9 months after LNG-IUS insertion, follow-up endometrial aspiration biopsies with the LNG-IUS in the uterus were undertaken. At the 12th month of follow-up, endometrial tissues were obtained via 2 methods: endometrial aspiration biopsy with the LNG-IUS in the uterus, followed by dilatation and curettage (D&C) after LNG-IUS removal. The primary outcome was the regression rate at 12 months after LNG-IUS insertion, and the secondary outcome was the consistency of the results between the endometrial aspiration biopsy and the D&C. The study population comprised 75 patients, including 37 with simple hyperplasia without atypia; 3 with atypical simple hyperplasia; 23 with complex hyperplasia without atypia, and 12 with atypical complex hyperplasia. Of these patients treated with the LNG-IUS, 38 (50.7%) were followed up at 12 months after LNG-IUS insertion. The complete regression rate at 12 months was 94.7% (36/38): 100% (6/6) of patients with atypical EH and 93.7% (30/32) with EH without atypia. In all of the cases (100%, 36/36), patients achieved complete regression within 3 months of LNG-IUS insertion. A comparison of the pathologic results from endometrial aspiration biopsy and D&C was carried out for 15 patients. In the histologic results by endometrial aspiration biopsy, 14 patients were diagnosed as "normal endometrium" and 1 as "insufficient tissue for pathologic evaluation." Among the 14 cases of normal endometrium by endometrial aspiration biopsy, 1 was diagnosed as "residual EH" by D&C, and the 1 case with insufficient tissue was diagnosed as normal endometrium by D&C. Levonorgestrel intrauterine system is an effective and favorable method for treatment of EH.

Ambulatory management of heavy menstrual bleeding.

Heavy menstrual bleeding (HMB) has significant adverse effects on the quality of life of many women, placing an economic burden on both health services and society at large. Thus, it is essential that all women with HMB have easy access to the proper diagnostic and therapeutic work-up in an outpatient fashion, avoiding the more time-consuming inpatient management. This new outpatient approach for HMB is one of the latest development of gynecological practice and can offer both diagnostic and therapeutic procedures. This manuscript aims to show the current possibilities of the modern management of HMB, which can be safely and effectively accomplished in the outpatient setting: global and directed endometrial biopsy, levonorgestrel intrauterine system insertion as well as minimally invasive surgical procedures (encompassing a variety of operative hysteroscopic procedures and second-generation endometrial ablation) are described below.