CONTRACEPTION

Levonorgestrel intrauterine system has benefits beyond contraception

The levonorgestrel intrauterine system (LNG-IUS) has been shown to significantly decrease blood loss and increase hemoglobin and serum ferritin levels in women with idiopathic menorrhagia.¹⁵ The LNGIUS reduces blood loss to a greater degree (as much as 96% after 1 year) than do placebo, nonsteroidal anti-inflammatory drugs, antifibrinolytic medication, and oral contraceptives.¹⁶ In one study,¹⁶ the LNG-IUS was the only treatment that reduced menstrual bleeding to less than 80 mL/day—the upper limit of normal.

LNG-IUS compares favorably to endometrial ablation

The LNG-IUS provides nonoperative, local, and minimally invasive treatment of menorrhagia, producing clinical results similar to those of different endometrial ablation methods for dysfunctional uterine bleeding or menorrhagia. The LNG-IUS is comparable to endometrial resection in its reduction of blood loss, patient satisfaction, rate of amenorrhea, and recurrent menorrhagia.¹⁷ It also is equivalent to thermal balloon ablation in its reduction of bleeding and increased quality of life and hemoglobin level.^18,19 And it produces a higher amenorrhea rate than expectant management after endometrial resection in women with adenomyosis, and averts the need for further procedures, such as hysterectomy and repeat resection.²⁰

In many women, LNG-IUS renders hysterectomy unnecessary

In a controlled trial involving 56 women on a waiting list for hysterectomy, 64% of those who received the LNG-IUS and 14% of those in a control group removed themselves from the list at the end of 6 months because they were satisfied with symptom control (P.001>21 In a trial involving 236 women with menorrhagia randomized to LNG-IUS or hysterectomy, the groups had similar quality-of-life scores at 1 and 5 years of follow-up—and costs associated with the LNG-IUS were significantly lower than those associated with hysterectomy, even after 50 women randomized to the LNG-IUS opted for and underwent hysterectomy.⁴¹

Consider the LNG-IUS a first-line therapy for symptomatic fibroids

The LNG-IUS continuously decreases fibroid and uterine volume and blood loss and increases ferritin levels over time among women with symptomatic fibroids.²² It should therefore be routinely considered a first-line therapy for women with fibroids who wish to preserve their childbearing potential.

Endometrial hyperplasia is reduced

The LNG-IUS can prevent and induce regression of endometrial hyperplasia.^23,24 In addition, it reduces bleeding and spotting among women using hormone replacement therapy.^25,26 Studies also suggest it may be beneficial in the treatment of stage I endometrial cancer, although further research into this effect is needed.²⁷

Endometriosis-related pain is eased

In a randomized trial comparing the LNG-IUS with a gonadotropin-releasing hormone (GnRH) analogue among women with chronic pelvic pain due to endometriosis, both treatments reduced pain and improved psychological well-being to the same degree—but the LNG-IUS caused no systemic hypoestrogenic symptoms, unlike the GnRH analogue.²⁸ In a randomized trial comparing the LNGIUS with expectant management among women who had undergone laparoscopic resection of endometriosis, women in the LNG-IUS arm had significantly decreased recurrent dysmenorrhea.²⁹

In addition, the LNG-IUS is effective for as long as 5 years, can be used in conjunction with systemic estrogen, and is an effective contraceptive.

Continuous oral contraceptive regimens: 4 effective options

Oral contraceptives (OCs) can be prescribed for continuous use to achieve a number of different goals³⁰:

• decrease the number of placebo days per cycle
  
• reduce the number of placebo weeks or withdrawal weeks per year
  
• eliminate withdrawal weeks from the cycle entirely
  
• reduce the incidence of breakthrough bleeding
  

Reduce the number of placebo days

Compared with the standard 28-day regimen (21 days of active pills followed by 7 days of placebo), extended regimens significantly reduce ovarian activity and produce smaller follicles and a lower estrogen level.^31,32 Extended regimens may involve fewer days of placebo pills per cycle, or very small amounts of estrogen throughout the withdrawal week of the regimen. These modifications may translate into increased efficacy. In two randomized trials comparing extended regimens with a standard regimen, the extended regimens were highly effective, with a Pearl index of up to 1.29 (1.29 pregnancies for every 100 woman-years of use), and produced shorter withdrawal bleeds.^33,34

Decrease the number of placebo or withdrawal weeks

The FDA approved the first OC to be packaged for extended use (Seasonale) in 2003. Each pack contains 84 active tablets of ethinyl estradiol (0.03 mg) and levonorgestrel (0.15 mg), followed by seven placebo pills. This highly effective regimen has a failure rate of 0.60 per 100 woman-years.³⁵ Another extended-use OC (Seasonique) contains 7 days of ethinyl estradiol (10 μg) instead of placebo pills and may, therefore, suppress follicular development to an even greater degree during the withdrawal week.³⁶