Abnormal bleeding in your female patient? Consider a progestin IUD

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Applied Evidence

Abnormal bleeding in your female patient? Consider a progestin IUD

J Fam Pract. 2014 January;63(1):17-21

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References

1. Shabaan MM, Zakherah MS, El-Nashar SA, et al. Levonorgestrelreleasing intrauterine system compared to low dose combined oral contraceptive pills for idiopathic menorrhagia: a randomized clinical trial. Contraception. 2011;83:48-54.

2. Blumenthal PD, Dawson L, Hurskainen R. Cost-effectiveness and quality of life associated with heavy menstrual bleeding among women using the levonorgestrel-releasing intrauterine system. Int J Gynaecol Obstet. 2011;112:171-178.

3. de Souza S, Camargos A, Ferreira M, et al. Hemoglobin levels predict quality of life in women with heavy menstrual bleeding. Arch Gynecol Obstet. 2010;281:895-900.

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5. Royal College of Obstetricians and Gynaecologists, London, National Collaborating Centre for Women’s and Children’s Health, Clinical guideline. Heavy menstrual bleeding. 2007. Available at: http://www.nice.org.uk/nicemedia/pdf/CG44NICEGuideline.pdf. Accessed December 11, 2013.

6. Wu JM, Wechter ME, Geller EJ, et al. Hysterectomy rates in the United States, 2003. Obstet Gynecol. 2007;110:1091-1095.

7. Merrill RM. Hysterectomy surveillance in the United States, 1997 through 2005. Med Sci Monitor. 2008;14:CR24-CR31.

8. Mirena [package insert]. Wayne, NJ: Bayer HealthCare Pharmaceuticals, Inc; 2013.

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11. Sayed GH, Zakherah MS, El-Nashar SA, et al. A randomized clinical trial of a levonorgestrel-releasing intrauterine system and a low-dose combined oral contraceptive for fibroid-related menorrhagia. Int J Gynecol Obstet. 2011;112:126-130.

12. Heikinheimo O, Gemzell-Danielsson K. Emerging indications for the levonorgestrel-releasing intrauterine system (LNG-IUS). Acta Obstet Gynecol Scand. 2012;91:3-9.

13. Zapata LB, Whiteman MK, Tepper NK, et al. Intrauterine device use among women with uterine fibroids: a systematic review. Contraception. 2010;82:41-55.

14. Wildemeersch D, Schacht E, Wildemeersch P. Treatment of primary and secondary dysmenorrhea with a novel ‘frameless’ intrauterine levonorgestrel-releasing drug delivery system: a pilot study. Eur J Contracept Reprod Health Care. 2001;6:192-198.

15. Schaedel ZE, Dolan G, Powell MC. The use of the levonorgestrelreleasing intrauterine system in the management of menorrhagia in women with hemostatic disorders. Am J Obstet Gynecol. 2005;193:1361-1363.

16. Kilic S, Yuksel B, Doganay M, et al. The effect of levonorgestrelreleasing intrauterine device on menorrhagia in women taking anticoagulant medication after cardiac valve replacement. Contraception. 2009;80:152-157.

17. Vilos GA, Marks J, Tureanu V, et al. The levonorgestrel intrauterine system is an effective treatment in selected obese women with abnormal uterine bleeding. J Minim Invasive Gynecol. 2011;18:75-80.

18. Kaunitz AM, Bissonnette F, Monteiro I, et al. Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding: a randomized controlled trial. Obstet Gynecol. 2010;116:625-632.

19. Hurskainen R, Teperi J, Rissanen P, et al. Clinical outcomes and costs with the levonorgestrel-releasing intrauterine system or hysterectomy for treatment of menorrhagia: randomized trial 5-year follow-up. JAMA. 2004;291:1456-1463.

20. Gupta J, Kai J, Middleton L, et al. Levonorgestrel intrauterine system versus medical therapy for menorrhagia. N Engl J Med. 2013;368:128-137.

21. Sweet MG, Schmidt-Dalton TA, Weiss PM, et al. Evaluation and management of abnormal uterine bleeding in premenopausal women. Am Fam Physician. 2012;85:35-43.

22. United States Medical Eligibility Criteria (USMEC) for Contraceptive Use. Centers for Disease Control and Prevention Web site. 2010. Available at: http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm. Updated September 18, 2013. Accessed April, 2012.

23. Whiteman MK, Zapata LB, Tepper NK, et al. Use of contraceptive methods among women with endometrial hyperplasia: a systematic review. Contraception. 2010;82:56-63.

24. Ozdegirmenci O, Kayikcioglu F, Akgul MA, et al. Comparison of levonorgestrel intrauterine system versus hysterectomy on efficacy and quality of life in patients with adenomyosis. Fertil Steril. 2011;95:497-502.

25. Sheng J, Zhang WY, Zhang JP, et al. 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. Contraception. 2009;79:189-193.

26. Cho SH, Nam A, Kim HY, et al. Clinical effects of the levonorgestrel-releasing intrauterine device in patients with adenomyosis. Am J Obstet Gynecol. 2008;198:373.e1-373.e7.

27. Anpalagan A, Condous G. Is there a role for use of levonorgestrel intrauterine system in women with chronic pelvic pain? J Minim Invasive Gynecol. 2008;15:663-666.

28. Vercellini P, Viganò P, Somigliana E. The role of the levonorgestrel-releasing intrauterine device in the management of symptomatic endometriosis. Curr Opinion Obstet Gynecol. 2005;17:359-365.

29. Abou-Setta AM, Al-Inany HG, Farquhar CM. Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery. Cochrane Database Syst Rev. 2006;(4):CD005072.

30. Küçük T, Ertan K. Continuous oral or intramuscular medroxyprogesterone acetate versus the levonorgestrel releasing intrauterine system in the treatment of perimenopausal menorrhagia: a randomized, prospective, controlled clinical trial in female smokers. Clin Exp Obstet Gynecol. 2008;35:57-60.

31. Yoo HJ, Lee MA, Ko YB, et al. The efficacy of the levonorgestrel-releasing intrauterine system in perimenopausal women with menorrhagia or dysmenorrhea. Arch Gynecol Obstet. 2012;285:161-166.

32. Sitruk-Ware R. The levonorgestrel intrauterine system for use in peri- and postmenopausal women. Contraception. 2007;75(6 suppl):S155-S160.

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34. Chin J, Konje JC, Hickey M. Levonorgestrel intrauterine system for endometrial protection in women with breast cancer on adjuvant tamoxifen. Cochrane Database Syst Rev. 2009;(4):CD007245.

35. Nothnagle M, Sicilia JM, Forman S, et al; STFM Group on Hosptial Medicine and Procedural Training. Required procedural training in family medicine residency: a consensus statement. Fam Med. 2008;40:248-252.

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Medical management of endometrial proliferation

Endometrial hyperplasia, often found in women with abnormal uterine bleeding patterns and recurrent anovulatory cycles,²¹ is sometimes treated with supplemental progesterone. According to the Centers for Disease Control and Prevention (CDC)’s US Medical Eligibility Criteria for Contraceptive Use, the LNG-IUD can be used without restriction in this patient population, as well.²²

A systematic review of 9 studies of women with endometrial hyperplasia without atypia found the LNG-IUD to be both safe and effective. In 7 of the 9 studies, 100% of participants experienced disease regression; regression rates for the other 2 studies were 90% and 67%.²³ The only caveat: Both endometrial atypia and endometrial cancer should be excluded prior to IUD insertion.

Adenomyosis is caused by the presence of ectopic endometrial glands and stroma within the myometrium and frequently results in pelvic pain, menorrhagia, and dysmenorrhea.¹⁰ Hysterectomy is often regarded as the mainstay of treatment. But medical management with the LNG-IUD is also an option, as it has demonstrated similar improvements to hysterectomy both in hemoglobin levels and quality of life.²⁴ Three years after insertion of the LNG-IUD to treat moderate or severe adenomyosis-associated dysmenorrhea, one study found, women reported significant improvement in their symptoms—and 73% were satisfied with their treatment.²⁵ The LNG-IUD also appears to decrease uterine volume, although this effect may begin to decrease 2 years after insertion.²⁶

Endometriosis, another common cause of dysmenorrhea and chronic pelvic pain,²⁷ can also be treated with the LNG-IUD. The local progestin administration to pelvic structures that the device provides has been found to significantly decrease both endometrial proliferation and monthly blood flow.²⁸ Additional studies of the LNG-IUD as a treatment for endometriosis and pelvic pain are ongoing and encouraging. After surgery for endometriosis, a Cochrane review found, women who had the LNG-IUD inserted had a lower rate of recurrence of dysmenorrhea than those without it.²⁹

Helping women through perimenopause

Compared with oral or intramuscular progesterone therapy, the LNG-IUD has been found to be superior for the treatment of perimenopausal symptoms.³⁰ Two years after insertion, one study found, perimenopausal women had a 95% reduction in blood loss and a 63% decrease in dysmenorrhea.³¹ The LNG-IUD also provides reliable endometrial protection for women receiving estrogen therapy³² and for those who are taking adjuvant tamoxifen because of a history of breast cancer.^33,34

IUD insertion is a safe office procedure

The Society of Teachers of Family Medicine cites IUD insertion in its core list of routine procedures to be included in family medicine residency programs.³⁵ The risk associated with insertion is small—uterine perforation occurs in about 2.6/1000 insertions³⁶—and there is a small and transient increase in the risk of IUD-related infection in the first few weeks to months after insertion. IUD insertion does not increase the overall risk of pelvic inflammatory disease in women at low risk for sexually transmitted infections.^37,38

Who is not a candidate?

While IUDs are safe for most women, there are several absolute contraindications to the LNG-IUD:
• current breast, cervical, or endometrial cancer
• current pelvic inflammatory disease, cervicitis, chlamydia, or gonorrhea
• having just had a septic abortion.³⁸

Teach patients about the benefits and adverse effects

For women who are potential candidates for the LNG-IUD, education is vital. Evidence suggests that satisfaction levels are very high, provided patients receive adequate counseling about the benefits and adverse effects. Risks (of uterine perforation and infection) are small, as noted earlier.³⁹

Contraceptive efficacy, of course, is a major benefit, and has been well The risk associated with insertion is small—uterine perforation occurs in about 2.6/1000 insertions—and there is a small and transient risk of infection in the first few weeks to months after insertion.documented: The LNG-IUD has an estimated failure rate of just 0.2%.⁴⁰ Unlike user-dependent methods such as OCPs, the patch, and the ring, the IUD has a perfect-use failure rate that is the same as the typical use rate. Thus, it is an excellent choice for women who want to preserve their fertility yet avoid an unintended pregnancy. For women approaching menopause—a time when estrogen may be contraindicated—the LNG-IUD can safely protect women against unwanted pregnancy.

Lower cost, less invasive. The ability to treat HMB and dysmennorhea with an IUD inserted in a family practice setting, without referrals to specialists for additional invasive treatments, increases cost savings.¹⁹ In addition, the LNG-IUD is less invasive and generally more acceptable to women than hysterectomy, endometrial ablation, uterine artery embolization, and myomectomy.^18,41 It leads to a greater reduction in menstrual bleeding than OCPs, oral progestins, tranexamic acid, and oral mefenamic acid.⁴¹ And, unlike some progestational agents, there is no evidence that the LNG-IUD has any adverse effects on bone density, vaginal tone, or urinary continence.⁴²