{"paper_id":"e62ac5b1-2bdb-4aff-ba3e-8a599021d644","body_text":"352\nNon-contraceptive Effects of Subdermal Levonogestrel \nImplant on Endometriosis Patient : A Case Report\nCopy Right@ Kawtar Nassar\nThis work is licensed under Creative Commons Attribution 4.0 License  AJBSR.MS.ID.001659.\nAmerican Journal of\nBiomedical Science & Research\nwww.biomedgrid.com\n---------------------------------------------------------------------------------------------------------------------------------\nISSN: 2642-1747\nCase Report\nEka Rusdianto Gunardi, Beryliana Maya Anisa and Yogi Pasidri*\nDepartment of Obstetrics and Gynecology, Cipto Mangunkusomo General Hospital, Indonesia\n*Corresponding author: Yogi Pasidri, Department of Obstetrics and Gynecology, Cipto Mangunkusomo General Hospital, Faculty of \nMedicine Indonesia University, Emerald Town House AG/01 Bintaro Sector 9, South Tangerang, Banten, Indonesia.\nTo Cite This Article: Eka Rusdianto Gunardi, Beryliana Maya Anisa, Yogi Pasidri, Non-contraceptive Effects of Subdermal Levonogestrel Implant \non Endometriosis Patient : A Case Report. Am J Biomed Sci & Res. 2021 - 11(4). AJBSR.MS.ID.001659. DOI: 10.34297/AJBSR.2021.11.001659.\nReceived: \n   January 08, 2021;  Published: \n   January 20, 2021\nIntroduction\nEndometriosis is characterized as the presence of ectopic \nendometrial gland outside the uterus. It affects around 10-15% \nwomen of reproductive age. To date, there is still no definitive \netiology of endometriosis. There are a few hypothesis regarding \nthe mechanism of this disease, one of which is the retrograde \nmenstruation. Retrograde flow of menstrual bleeding is thought \nto cause seeding of endometrial gland outside the uterus. Other \nfactors such as hormonal, inflammatory, and immunologic milieu \nmay play an important part on lesion location and progression [1]. \nEndometriosis on the ovary is called endometrioma or chocolate \ncyst, due to its dark brown appearance inside the cyst. Around 17-\n44% patients with endometriosis develop endometrioma. During \nmenstruation, endometrial gland inside the ovary bleeds causing \nhematoma. Unlike normal hematoma which observed during \nnormal ovulation, endometrioma contains more fibrous tissue. This \ncondition commonly cause adhesion to the surrounding area and \ncause significant pain [2].\n \nLevonorgestrel (LNG) subdermal implant is a reversible \ncontraception with high effectivity. It is implanted under the skin of \nthe upper arm. This contraception works by releasing hormone to \nthe circulation at a constant rate. Cumulative pregnancy rate of LNG \nimplant at 5 years is less than 2 pregnancies per 100 women [3]. \nLNG implant works by disrupting follicular growth and ovulatory \nprocess, causing anovulation and insufficient luteal function. \nCommonly it causes changes in menstrual bleeding patient. Normal \nfertility returns rapidly after removal of LNG implant [4]. In this \nliterature, we report a case of endometrioma with significant pain \nreduction following insertion of LNG implant.\nCase Report\nA 38-year-old patient presented to the gynecology clinic \nwith chief complaint of pain in the left lower abdomen during \nmenstruation for 8 months before admission. Pain intensity was at \nvisual analog scale (VAS) 3-4 but had increased incredibly to VAS \nAbstract\nIntroduction: Endometriosis is characterized as the presence of ectopic endometrial gland outside the uterus. Levonorgestrel (LNG) subdermal \nimplant is a reversible contraception with high effectivity. we report a case of endometrioma with significant pain reduction following insertion of \nLNG implant.\nCase Report: 38 years-old patients with bilateral endometrial cyst. Patient complained of pain in left lower abdomen during menstruation with \nVAS 7-8. Patient had undergone surgery to remove the right endometrial cyst, however, follow up ultrasonography examination 5 months following \nsurgery showed recurrence of cyst on the right ovary. We treated the patient with levonogestrel subdermal implant.\nDiscussion: Studies showed high effectiveness of ENG implant in improving pain symptoms, however there is still limited data regarding LNG \nimplant effectiveness. At 1 month follow up examination following LNG implant insertion, there was significant pain reduction to VAS 3. At 3 month \nfollow up, patient reported pain with VAS 3 and no difficulties in doing daily tasks. We conclude that LNG implant is as effective as other progestin \nonly therapy in reducing pain symptom.\nConclusion: Levonorgestrel subdermal implant have high effectiveness in reducing pain in patient with endometrioma.\nKeywords: levonorgestrel; Implant; Endometrial cyst; Pain\n\n\nAmerican Journal of Biomedical Science & Research\nAm J Biomed Sci & Res                                     Copy@ Kawtar Nassar\n353\n7-8 these past 5 months. Pain especially felt during menstruation \nand defecation. There was no pain during urination or sexual \nintercourse. Patient had been diagnosed with bilateral endometrial \ncysts and underwent surgery to remove right endometrial cyst 5 \nmonths prior in previous hospital. Cytology examination showed \nresult appropriate to hemorrhage cyst with no malignant cell. \nPatient had her first menstruation at 14 years old and had regular \nmenstruation cycle. Patient has been married and blessed with 2 \nchildren age 15 and 10 years old. History of using any contraception \nmethod was denied. Patient appeared alert with normotensive blood \npressure (104/70 mmHg), heart rate 81x/minute, respiration rate \n20x/minute, and temperature 36oC. Body mass index was at 26,37 \nkg/m2. There was unremarkable finding on general examination. \nCervix portio was smooth, closed, with no fluor, fluxus, or active \nbleeding. There was a cystic mass sizing 6 cm in diameter palpated \nat posterior uterus. Ultrasonography examination following \nadmission showed diffuse adenomyosis, bilateral endometrial cyst \n(right: 68x64x70 mm, left: 52x51x47 mm), and internal genital \nadhesion. Laboratory examination showed E2 level at 105 pg/\nmL and CA 125 marker at 44,9 U/mL. Long term medication was \ndecided as treatment plan. Patient chose subdermal implant as her \ncontraceptive method.\nDiscussion\nEndometrioma is the most common form of endometriosis. The \nexact etiology of this disease is still unknown, however there are a \nfew hypothesis regarding its pathogenesis. Retrograde menstrual \nflow in addition to hormonal, inflammatory, and immunologic factor \nare believed to play part in development of this lesion. Retrograde \nflow of menstrual blood causes adhesion of endometrial gland on \nthe ovarian surface. During every menstruation cycle, endometrial \ngland forms blood filled cyst on the ovarian surface. Cyst will \ndevelop steadily by invaginating ovarian cortex. Endometrioma \ncyst is not surrounded by thick capsule and usually spreads to \nother pelvic organ. Studies showed there is an association between \nendometrioma and ovarian cancer. Malignant transformation of \nendometrioma cyst was observed in 0,7-1% patient [5].\nTreatment of endometrioma is consists of medical and surgical \ntherapy. The choice of treatment is decided based upon targeted \nsymptoms and fertility restoration. Pain is the most common \nsymptom of endometrioma. It occurs due to chronic inflammation \nof the pelvic and peritoneum. Around 60-70% patients present \nwith chief complaint of dysmenorrhea. Hormonal agents can \nhelp reduce pain by creating hypoestrogenic, hyperandrogenic, \nor hyperprogestogenic condition that suppresses proliferation \nof endometrial cell [6]. Endometriosis is an estrogen-dependent \ndisease so progesterone-only contraception method is more \npreferable. Treatment of choice include oral desogestrel or oral \ndienogest, DMPA, ENG implant, and LNG IUS [7].\nSince endometriosis cause chronic inflammation, a non-\nsteroidal anti-inflammatory agent can be used alone or in \ncombination with hormonal therapy. COC is the first line treatment \nfor endometrioma due to its effectiveness and low cost. Some studies \nshowed that treatment with COC cause reduction of endometrioma \nsize. Progestin derivative is also considered as first line treatment. \nSecond line treatment includes GnRH analogues and aromatase \ninhibitors. If pain persists despite medical therapy, lesion resection \nor ablation and adhesion lysis should be performed by operation. \nHowever, it should be noted that endometriosis has high recurrence \nrate. The rate of re-operation at 2, 5, and 7 years follow up are 21%, \n47%, and 55% respectively. Studies showed that neither medical \ntherapy nor surgery is more preferred to improve pregnancy rates. \nCurrently there is no trial comparing the effectiveness of medical \nand surgical therapy in reducing endometriosis-associated pain, \nbut studies of each modality showed promising result. It can be \nconcluded that both treatment are equally effective in reducing \npain and treatment decision should be individualized based on \npatient symptom and plan for future pregnancy [6].\nThere are three types of subdermal progestin implant, a single \nENG rod, single LNG rod, and LNG two rod system. Single LNG \nrod has been presented in Indonesia, this kind of implant has \nmore advantage since it is easier to be used and removed. ENG \nrod has 3 years lifespan and more commonly used in developed \ncountries. Meanwhile LNG rod has 5 years lifespan and mainly \nused in developing countries due to its lower cost. The exact \nmechanism of progestin in reducing endometriosis related pain is \nstill not clearly understood. Pain from endometriosis may rise from \nactive bleeding from endometric lesion, overexpression of growth \nfactors and proinflammatory cytokines, and irritation of pelvic \nnerves. Progestin induced endometrial atrophy, anovulation, and \ninhibit anti-inflammatory actions. It also reduces GnRH releasing \nfrequency causing reduce secretion of FSH and LH. Long term \nprogestin used will suppress steroidogenesis from the ovary with \nanovulation and low ovarian steroid levels. The hypoestrogenic and \nhypergestagenic state will cause decidual transformation in both \neutopic and ectopic endometrium [8]. Study on 50 women with \nsymptomatic endometriosis showed that ENG implant reduce pain \nseverity and menstrual symptoms. Dysmenorrhea visual analogue \nscale score (VAS) kept decreasing from 7,08 + 2,09 at baseline to \n3,72 + 2,04 at 4th week then 0,84 + 1,67 at 12th week [9]. Another \nstudy comparing effectiveness of ENG implant and DMPA on 41 \nsubjects with symptomatic dysmenorrheal showed that pain \nreduction occurred in both groups. At 6 months follow up, there \nwere 68% reduction of pain in ENG implant group and 53% in \nDMPA group [10]. Study comparing effectiveness of ENG implant \nand LNG IUS showed similar result [11]. Data regarding use of LNG \nsubdermal implant as endometriosis treatment is still limited [12].\n\nAm J Biomed Sci & Res\nAmerican Journal of Biomedical Science & Research\nCopy@ Kawtar Nassar\n354\nIn our case, patient had undergone surgery to remove right \nendometrial cyst. However, follow up ultrasonography examination \n5 months after surgery showed recurrence of endometrial cyst. \nThere was also no improvement of pain following surgery. With \nthis in mind, we chose for long term medication therapy to reduce \nsymptoms. Patient was educated about various hormonal agent \navailable for treatment. Patient chose subdermal implant as \ntherapy due to its long lifespan and high effectiveness in preventing \npregnancy. LNG subdermal implant is available in Indonesia and \nprovided for free. At 1 month after insertion follow up examination \nfollowing LNG implant insertion, there was significant pain \nreduction from 7 to VAS 3. Same as 2 and 3 month follow up, patient \npresents during menstruation with pain level at VAS 3 and no \ndifficulties in doing daily tasks. We report the effectiveness of LNG \nsubdermal implant in reducing pain in patient with endometrioma. \nWe plan to do further research involving more subjects to observe \nthe mechanism of pain relief after LNG subdermal implant insertion \nin patient with endometrial cyst (Table 1).\nTable 1: Hormonal agents used to reduce pain in endometriosis patient [5,7].\nAgent Mechanism of action Side effect\nProgesterone-releasing IUS\n· Endometrial atrophy and inflammation response · Increases viscosity of cervical \nmucous · Reduction in local angiogenesis, innervations, and pelvic vascular con-\ngestion · Increase lesion apoptosis\nMood changes, acne, breast \ntenderness, headache\nSubdermal progesterone implant\nENG implant · Prevent surge of luteinizing hormone causing ovarian follicular \ndevelopment without ovulation LNG implant · Disrupts follicular growth and \novulatory process causing anovulation and insufficient luteal function\nAmenorrhea, spotting\nDepot medroxyprogesteron \nacetate · Suppress endometrial cell proliferation · Enhance endometrial cell apoptosis\nDecreases bone density, \ndelayed return of fertility, \nmenstrual irregularities\nCombined estrogen/progester-\none contraceptives (COC) · Endometrial tissue decidualization followed by atrophy Headache, nausea, breast \ntenderness\nGnRH analogs · Endometrial atrophy due to gonadotropin suppression followed by hypoestro-\ngenic condition Decrease bone density\nAromatase inhibitor · Inhibit conversion of androgen to estrogen Stimulation of ovariaum in \npre-menopausal women\nConclusion\nLevonorgestrel subdermal implant have high effectiveness in \nreducing pain in patient with endometrioma and make patient has \nno difficulties in doing daily tasks.\nAcknowledgements\nThe authors thank to Department of Obstetrics and Gynecology, \nFaculty of Medicine University of Indonesia for support this case \nreport.\nConflict of Interest\nThe authors declare no conflict of interest.\nReferences\n1. 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Gezer A, Oral E (2015) Progestin therapy in endometriosis. Women’s \nHealth 11(5): 642-652.\n9. Ponpuckdee J, Taneepanichskul S (2005) The effects of implanon in the \nsymptomatic treatment of endometriosis. J Med Assoc Thai 88 Suppl 2: \nS7-S10.\n10. Walch K, Unfried G, Huber J, Kurz C, van Trotsenburg M, et al. (2008) \nImplanon versus medroxyprogesteron acetate: effects on pain scores in \npatients with symptomatic endometriosis - - a pilot study.\n11. Margatho D, Carvalho NM, Buhamondes L (2020) Endometriosis-\nassociated pain scores and biomarkes in users of the etonogestrel-\nreleasing subdermal implant or the 52-mg levonorgestrel-releasing \nintrauterine system for up to 24 months. Eur J Contracept Reprod Health \nCare 25(2): 133-140.\n12. Gunardi ER, Khusen D (2019) New Single Rod Implant Innovation in \nIndonesia. Am J Biomed Sci & Res.","source_license":"CC0","license_restricted":false}