Ethno-Racial Differences in Age and Symptom Severity Among Pre-Menopausal Women Commencing Treatment for Benign Gynecological Conditions with a Levonorgestrel-Releasing Intrauterine Device

Joacy G. Mathias, Whitney R. Robinson, Annie Green Howard, Erin T. Carey, Lauren G. Anderson, Mollie E. Wood, Natalie A. Rivadeneira, Kemi M. Doll, Wanda K. Nicholson, Michael J. Green, Til Stürmer‎, Timothy S. Carey, Evan R. Myers
2025 · doi:10.17615/31w7-zh68 · W4415242616
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Hispanic patients were older than White patients at LNG-IUD insertion for benign gynecological conditions, and Black and Hispanic patients reported more severe bleeding and bulk symptoms than White patients.

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This study used electronic health system data from the U.S. South (April 2014–September 2019) to compare age and pre-insertion symptom severity among 783 pre-menopausal women (18–44) starting a levonorgestrel-releasing intrauterine device (LNG-IUD) for benign gynecological conditions, stratified as White (n=455), Black (n=208), and Hispanic (n=120). Symptom severity scores for uterine bleeding, pelvic pain, and uterine bulk were abstracted from medical notes prior to insertion, and regression models adjusted for factors including insurance status, parity, prior treatments, and diagnoses of fibroids and endometriosis. Black and Hispanic patients had higher estimated severity of bleeding and uterine bulk than White patients, and Hispanic patients were older at LNG-IUD insertion, with some attenuation after adjustment; the authors note that differences were associated with lack of insurance coverage, higher parity, fibroids, and prior medical management, consistent with potential barriers to earlier LNG-IUD treatment. This paper is centrally about endometriosis only insofar as it includes prior endometriosis diagnosis as a covariate when examining ethno-racial differences in symptom severity at LNG-IUD insertion for benign gynecological conditions.

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Abstract

Introduction: Levonorgestrel-releasing intrauterine devices (LNG-IUDs) can be effective treatments for benign gynecological conditions, but there may be ethno-racial differences in how patients receive treatment. Methods: Data were from a health care system in the U.S. South (April 2014–September 2019). We identified 783 female patients aged 18–44 years with an LNG-IUD for a benign gynecological condition (455 White, 208 Black, and 120 Hispanic patients). Abstraction of medical notes preceding insertion gave symptom severity scores for uterine bleeding, pelvic pain, and uterine bulk. Linear and negative binomial regression models assessed differences in patients’ age and symptom severity scores, respectively. Covariates included insurance status, parity, prior treatments, and fibroid and endometriosis diagnoses. Results: White patients’ mean age was 32.4 years. Black patients were similarly aged (+0.9 years [95% confidence interval: −0.4 to 2.1]), whereas Hispanic patients were older (+3.4 years [2.0–4.9]), and adjustment attenuated this difference (+0.7 [−0.7 to 2.0]). Estimated ratios indicated more severe bleeding and bulk symptoms for Black and Hispanic than White patients (bleeding: Black: 1.7[1.5–2.0], Hispanic: 1.7[1.4–2.1]; bulk: Black: 1.5[1.3–1.9], Hispanic: 1.5[1.2–1.9]). Adjustment for covariates attenuated estimates, especially for Hispanic patients (bleeding: Black: 1.4[1.2–1.6], Hispanic: 1.2[1.0–1.4]; bulk: Black: 1.3[1.1–1.6], Hispanic: 1.2[1.0–1.6]). Discussion: At the time of LNG-IUD insertion, Hispanic patients were older than White patients. Black and Hispanic patients had more severe symptoms than White patients. Differences in age and symptom severity were associated with lack of insurance coverage, higher parity, presence of fibroids, and prior medical management, potentially indicating barriers to early LNG-IUD treatment for Black and Hispanic patients.
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Ethno-Racial Differences in Age and Symptom Severity Among Pre-Menopausal Women Commencing Treatment for Benign Gynecological Conditions with a Levonorgestrel-Releasing Intrauterine Device Public DepositedAdd to collection Downloadable Content Download PDFCitation MLA Green, Michael J, et al. Ethno-racial Differences In Age and Symptom Severity Among Pre-menopausal Women Commencing Treatment for Benign Gynecological Conditions with a Levonorgestrel-releasing Intrauterine Device. Mary Ann Liebert, 2025. https://doi.org/10.17615/31w7-zh68APA Green, M., Doll, K., Wood, M., Howard, A., Anderson, L., Mathias, J., Rivadeneira, N., Carey, E., Carey, T., Nicholson, W., Stürmer, T., Myers, E., & Robinson, W. (2025). Ethno-Racial Differences in Age and Symptom Severity Among Pre-Menopausal Women Commencing Treatment for Benign Gynecological Conditions with a Levonorgestrel-Releasing Intrauterine Device. Mary Ann Liebert. https://doi.org/10.17615/31w7-zh68Chicago Green, Michael J., Kemi M Doll, Mollie E Wood, Annie G Howard, Lauren G Anderson, Joacy G Mathias, Natalie A Rivadeneira et al. 2025. Ethno-Racial Differences In Age and Symptom Severity Among Pre-Menopausal Women Commencing Treatment for Benign Gynecological Conditions with a Levonorgestrel-Releasing Intrauterine Device. Mary Ann Liebert. https://doi.org/10.17615/31w7-zh68- Creator - Green, Michael J. - Other Affiliation: Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA. - Doll, Kemi M. - Other Affiliation: Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington, USA. - Wood, Mollie E. - Gillings School of Global Public Health, Department of Epidemiology - Howard, Annie G. - Gillings School of Global Public Health, Department of Epidemiology - Anderson, Lauren G. - Other Affiliation: Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA. - Mathias, Joacy G. - Other Affiliation: Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA. - Rivadeneira, Natalie A. - Gillings School of Global Public Health, Department of Epidemiology - Carey, Erin T. - School of Medicine, Department of Obstetrics and Gynecology - Carey, Timothy S. - Cecil G. Sheps Center for Health Services Research - Nicholson, Wanda - Other Affiliation: Milken Institute School of Public Health, George Washington University, Washington, DC, USA. - Stürmer, Til - Gillings School of Global Public Health, Department of Epidemiology - Myers, Evan R. - Other Affiliation: Department of Obstetrics and Gynecology and Margolis Center for Health Policy, Duke University School of Medicine, Durham, North Carolina, USA. - Robinson, Whitney R. - Other Affiliation: Department of Obstetrics and Gynecology and Margolis Center for Health Policy, Duke University School of Medicine, Durham, North Carolina, USA. - Green, Michael J. - Abstract Introduction: Levonorgestrel-releasing intrauterine devices (LNG-IUDs) can be effective treatments for benign gynecological conditions, but there may be ethno-racial differences in how patients receive treatment. Methods: Data were from a health care system in the U.S. South (April 2014–September 2019). We identified 783 female patients aged 18–44 years with an LNG-IUD for a benign gynecological condition (455 White, 208 Black, and 120 Hispanic patients). Abstraction of medical notes preceding insertion gave symptom severity scores for uterine bleeding, pelvic pain, and uterine bulk. Linear and negative binomial regression models assessed differences in patients’ age and symptom severity scores, respectively. Covariates included insurance status, parity, prior treatments, and fibroid and endometriosis diagnoses. Results: White patients’ mean age was 32.4 years. Black patients were similarly aged (+0.9 years [95% confidence interval: −0.4 to 2.1]), whereas Hispanic patients were older (+3.4 years [2.0–4.9]), and adjustment attenuated this difference (+0.7 [−0.7 to 2.0]). Estimated ratios indicated more severe bleeding and bulk symptoms for Black and Hispanic than White patients (bleeding: Black: 1.7[1.5–2.0], Hispanic: 1.7[1.4–2.1]; bulk: Black: 1.5[1.3–1.9], Hispanic: 1.5[1.2–1.9]). Adjustment for covariates attenuated estimates, especially for Hispanic patients (bleeding: Black: 1.4[1.2–1.6], Hispanic: 1.2[1.0–1.4]; bulk: Black: 1.3[1.1–1.6], Hispanic: 1.2[1.0–1.6]). Discussion: At the time of LNG-IUD insertion, Hispanic patients were older than White patients. Black and Hispanic patients had more severe symptoms than White patients. Differences in age and symptom severity were associated with lack of insurance coverage, higher parity, presence of fibroids, and prior medical management, potentially indicating barriers to early LNG-IUD treatment for Black and Hispanic patients. - Date of publication - February 1, 2025 - Keyword - insertion - pelvic pain - endometriosis - South - commencing treatment - devices - treatment - symptom severity - white patients - uterine - presence - differences - endometriosis diagnosis - LNG-IUD insertion - covariates - parity - associated with lack - care system - age - estimation - levonorgestrel-releasing intrauterine device - regression models - patients' mean age - benign gynecologic conditions - black patients - binomial regression models - mean age - bleeding - Hispanic patients - coverage - Black - diagnosis - pain - management - model - U.S. South - patients - patient age - medical notes - symptom severity scores - bulk - medical management - system - symptoms - higher parity - estimated ratios - insurance status - conditions - female patients - data - effective treatment - adjustment - status - insurance coverage - severity score - ethno-racial differences - severity - gynecologic conditions - negative binomial regression models - intrauterine device - insurance - barriers - Abstract - lack of insurance coverage - U.S. - uterine bleeding - assessed differences - notes - health care system - pre-menopausal - presence of fibroids - time - years - severe symptoms - severe bleeding - scores - fibroids - ratio - health - DOI - Identifier - Dimensions ID: pub.1189577066 - DOI: https://dx.doi.org/10.1089/heq.2024.0238 - Resource type - Article - Rights statement - In Copyright - License - Attribution 4.0 International - Journal title - Health Equity - Journal volume - 9 - Journal issue - 1 - Page start - 326 - Page end - 338 - Version - Publisher - Funder - National Center for Advancing Translational Sciences - National Institute on Aging - National Institute on Minority Health and Health Disparities - ISSN - 2473-1242 - Publisher - Mary Ann Liebert Relations - Parents: This work has no parents. 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