Women's experience, satisfaction, and continuation with the levonogestrel-containing intrauterine system: A cross-sectional study

The levonorgestrel-containing intrauterine system (LNG-IUS) is a safe, long-acting, and reversible contraceptive method. [ 1 – 5 ] LNG-IUS suppresses endometrial cell proliferation, thickens cervical mucus, and disrupts tubal motility due to the high levonorgestrel concentration in the endometrium. [ 6 , 7 ] These effects of LNG-IUS reduce the risk of conception and development of pelvic inflammatory disease. [ 8 , 9 ] LNG-IUS reduces the intensity and duration of menstrual bleeding after its application. [ 10 , 11 ] In addition to its contraceptive effects, this method is also used for indications such as dysmenorrhea, excessive menstrual bleeding, adenomyosis, leiomyoma, endometriosis, endometrial hyperplasia, and early stage endometrial cancer because of its effects on the endometrium. [ 2 , 8 , 9 , 12 , 13 ] Especially in developed countries, approximately 7% of women with endometrial cancer, which is the most common gynecological malignancy, are under 45 years of age, and the treatment of endometrial cancer in young women who want to preserve fertility poses some difficulties due to the standard surgical method. LNG-IUS is a good option for preserving fertility in early stage endometrial cancers. [ 14 , 15 ] When LNG-IUS is correctly inserted by trained and experienced practitioners such as gynecologists and midwives, side effects and complications are very low. [ 16 ] As it contains only progestin, it is a contraceptive option that can be safely used during breastfeeding. It has high contraceptive protection (99.9%) and can be used safely for 5 years, and fertility returns rapidly after removal. [ 2 , 8 , 16 ] The use of intrauterine devices (IUD) worldwide is approximately 14.3%, and has been a popular and effective contraceptive method for many years. [ 17 , 18 ] In our country, the rate of LNG-IUS use is included in the frequency of IUD use. The frequency of IUD use ranks third among all contraceptive methods used (14%). In this case, LNG-IUS is not mentioned separately because of the small number of people who know about and use LNG-IUS. [ 19 ] In Turkey, LNG-IUS is generally prescribed and administered in gynecology and obstetrics clinics for gynecological treatment indications, and women who want to use LNG-IUS for contraception must obtain LNG-IUS by their own means. [ 9 ] Limited accessibility of LNG-IUS may affect its frequency of use. Owing to the small number of users and the fact that it is mostly applied for treatment purposes, treatment outcomes have generally been examined in the literature on LNG-IUS. This study was planned because there is limited data on the experiences of users. [ 10 , 16 , 20 ] There is a need for research that can reveal more comprehensive information about women’s experiences with LNG-IUS use in a way that reflects our cultural characteristics. The information obtained is expected to contribute positively to planning women’s physical and mental health and service provision by revealing the cultural and structural characteristics of their LNG-IUS use experiences. This study aimed to examine women’s experiences, satisfaction, and continuation with the levonorgestrel-containing intrauterine system.

Conceptualization: Ayşegül Dönmez. Data curation: Ayşegül Dönmez, Yeşim Yeşil. Formal analysis: Ayşegül Dönmez. Methodology: Ayşegül Dönmez, Yeşim Yeşil. Supervision: Ayşegül Dönmez, Yeşim Yeşil. Writing – original draft: Ayşegül Dönmez, Yeşim Yeşil. Writing – review & editing: Ayşegül Dönmez, Yeşim Yeşil.

This is a cross-sectional study. This study was conducted between October 2023 and March 2024. This study was approved by the local ethics committee approval (Ministry of Health, İzmir Tepecik Training and Research Hospital, non-interventional research ethics committee, Protocol No: 2023/09-15). The women were informed about the study and their questions were answered. Written informed consent was obtained from the women who agreed to participate in the study. The study population consisted of women who applied to the obstetrics and gynecology outpatient clinic of a training and research hospital and who used or had previously used a levonorgestrel-containing intrauterine system. The study included 627 women who visited the Women’s Health Outpatient Clinic of a Training and Research Hospital in Izmir Province and were randomly sampled. The inclusion criteria were age between 18 and 55 years, using/using LNG-IUS, and not being diagnosed with any mental illness. Women who did not meet the inclusion criteria and who did not speak Turkish were excluded from the study. The study population consisted of women using LNG-IUS who visited the women’s health outpatient clinic of the hospital where the study was conducted. Descriptive information of the participants is presented in Table 1 . Women’s descriptive characteristics (N = 627) COC = combined oral contraceptive, IUD = intrauterine device, LNG-IUS = levonorgestrel-containing intrauterine system. Kruskal Wallis test. The research data were obtained using a questionnaire prepared by the researchers based on the literature [ 2 , 3 , 13 ] which consisted of 25 questions. The form consisted of 25 questions about women’s sociodemographic characteristics (age, educational status, and employment status) and LNG-IUS use (reason for use, duration, and side effects encountered). To ensure content validity of the questionnaire, the opinions of 5 experts with experience in scientific research were obtained. After the rearrangements were made in line with the suggestions, a pre-application was made with 10 women to improve the comprehensibility and applicability of the questionnaire. The data obtained in the preliminary application were excluded from the analysis. The questionnaire form was filled face-to-face by the researcher after obtaining written consent from the women. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) 23.0. Frequency and percentage for categorical data and mean, standard deviation, median, minimum, and maximum for continuous data were presented as descriptive values. The sum of the percentages may not be 100 because of the rounding. “Pearson Chi-Square or Fisher Exact Test” was used to compare groups. For variables with more than 2 categories, it was observed that there was no normal distribution in the categories in general; therefore, the “Kruskal–Wallis test” was applied. The results were considered statistically significant when the P value was less than .05.

The descriptive findings of the women in the study group are presented in Table 1 . The mean age of the women who participated in the study was 38.27 ± 7.407 years. It was found that 45.1% of women had 0 to 8 years of education, 35.7% had 9 to 12 years of education, and 19.1% had ≥ 13 years of education. It was found that 76.2% of the women were from nuclear families, 38.3% were employed in an income-generating job, and 91.1% had health insurance. It was determined that 55.2% of the women had planned pregnancies and 73.0% did not want to have children. The mean, standard deviation, minimum and maximum number of pregnancies, and number of living children (2.35 ± 1.02, 1 to 7; 2.09 ± 0.82, 1 to 5, respectively) and the median number of abortions were found to be 0.19 ± .44, 0 to 2. It was determined that 84.2% of the women were very satisfied with using LNG-IUS and 96.2% planned to use it again. In addition, a statistically significant correlation was found between the descriptive characteristics of the women, such as age, educational status, fertility goal, and previous contraceptive method, and those who used LNG-IUS for treatment or contraception ( P  < .05). The number of therapeutic users increased with increasing age; the majority had 0 to 8 years of education, no longer wanted children, and had used copper IUDs (Table 1 ). When the reasons for women’s use of LNG-IUS are examined; It was determined that women used it due to menometrorrhea (48.2%), contraception (25.2%), dysmenorrhea (9.4%), myoma uteri (13.4%), and endometriosis (3.8%) (Fig. 1 ). Reasons for women to use levonogestrel containing intrauterine system. The distribution of the reasons for satisfaction, reuse, and withdrawal of women using LNG-IUS according to duration of use is given in Table 2 . When the table was analyzed, it was observed that the duration of LNG-IUS use in the contraception group (86.1%) was higher than that in the treatment group (74.0%). It was determined that both the treatment and contraception groups were very satisfied (83.6% and 86.1%, respectively) and thought of using LNG-IUS again (96.8% and 94.3%, respectively), and the highest rate among the reasons for removal was menopause in the treatment group (11.7%), while in the contraception group it was “headache (n = 2), vaginal discharge (n = 1), and emotional change (n = 1) (2.5%). Among those who used it for the longest period of time (49–60 months), it was determined that some continued to use it in both groups (n = 6 in the treatment group; n = 7 in the contraception group) and those who voluntarily stopped using it (n = 7 in the treatment group; n = 1 in the contraception group) (Table 2 ). Distribution of satisfaction, reuse, and reasons for withdrawal of women using levonorgestrel-containing intrauterine system based on usage duration (N = 627). LNG-IUS = levonorgestrel-containing intrauterine system. The distribution of some characteristics of women’s continued total LNG-IUS use is shown in Table 3 . When the table was examined, it was determined that 86.7% of those who used it for ≤ 12 months were ≤ 30 years old, 78.0% had one delivery, and 75.0% paid a fee. Among those who used LNG-IUS for the longest time (49–60 months) in the treatment group, 5.1% were ≥ 40 years old, 3.4% had ≥ 2 births, 3.5% had used injectable methods before, and 3.3% did not pay a fee during LNG-IUS application. Among those who used contraception for ≤ 12 months, 82.8% were in the 30 to 39 age group, 82.8% had ≥ 2 births, 88.9% had previously used combined oral contraceptives, and 80.0% paid a fee. In the contraception group, 13.6% were ≥ 40 years of age, 6.0% had ≥ 2 births, 7.5% had previously used copper IUD, and 6.5% had not paid a fee during LNG-IUS application (Table 3 ). Distribution of women’s characteristics regarding their continuation of total levonorgestrel-containing intrauterine system use (N = 627) COC = combined oral contraceptive, IUD = intrauterine device, LNG-IUS = levonorgestrel-containing intrauterine system.

This study examined women’s LNG-IUS experience, satisfaction, and continuity. Women’s age, education level, fertility goal, and previous contraceptive method significantly affected LNG-IUS use. In addition, it was determined that the duration of LNG-IUS use was higher in the contraception group than in the treatment group; both groups were very satisfied and thought of using LNG-IUS again, and the highest rate among the reasons for removal was menopause in the treatment group and other reasons (headache, vaginal discharge, emotional change) in the contraception group. In this study, it was determined that women who underwent LNG-IUS had a wide age range (26–55), but younger women (≤30 years) were younger (6.9%). When the studies on this topic were examined, it was seen that the age groups of women who were used for both contraception and treatment were similar. [ 9 , 13 , 21 – 23 ] It is estimated that the reason for the low number of young women using LNG-IUS is that, in Turkey, LNG-IUS is usually prescribed and administered by doctors in gynecology and obstetrics clinics, and those who want to use it for contraception purposes obtain it for a fee. [ 9 , 23 ] Based on these results, LNG-IUS is a good option for women of all ages, with no age limit for the reproductive age. However, it may also be recommended to facilitate accessibility. This study found that A significant proportion of participants (73.0%) no longer wanted to have children. In the literature, the desire to become pregnant before the end of the 3-year study period was reported as the main reason for early discontinuation of LNG-IUS use. [ 8 ] Similarly, another study reported that women discontinued LNG-IUS use because of their desire to become pregnant (12.6%). [ 4 ] A multicenter study evaluating the efficacy and safety of LNG-IUS reported that some women (5.5%) discontinued the method because of a desire to become pregnant. [ 24 ] The lack of desire to have children among the participants in this study may be due to regional and cultural differences between the study groups. In this study, the duration of LNG-IUS use was longer in the contraception group (86.1%) than in the treatment group (74.0%). However, most of the treatment and contraception groups continued to use LNG-IUS. In a study examining the continuity of contraception methods used and in another study reviewing 10 years of clinical experience in Belgium, 5-year continuations were similarly reported to be very high (86.4% and 87.1%, respectively). [ 4 , 10 ] In another study examining the 2-year continuity in the use of LNG-IUS, similar rates (78.5%) were reported. [ 5 ] Based on these results, LNG-IUS may be a good option, particularly for women who want long-term contraception. In this study, when the satisfaction level of women with LNG-IUS was examined, it was determined that both groups were very satisfied and considered using it again. A study on this subject reported that most women (86.1%) were satisfied. [ 22 ] In subgroup analyses of data from the phase III trial of LNG-IUS users, a significant proportion of women (>70%) were described as either “very satisfied” or “somewhat satisfied.” [ 8 ] A systematic review reported that most studies reported over 90% satisfaction, and one study reported that participants wanted to continue using this method. [ 7 ] In this study, we found that the most common reasons for LNG-IUS discontinuation among women were menopause in the treatment group (11.7%), and amenorrhea and spotting in the contraception group (5.7%). In a study conducted on this subject, the reasons for early discontinuation among LNG-IUS users included abdominal and/or back pain, mood swings, acne, vaginal discharge, headache/migraine, and hair loss. [ 13 ] Another study reported that 5% of LNG-IUS users discontinued the method because of bleeding and/or cramping. [ 1 ] In a retrospective cohort study examining LNG-IUS continuation rates and reasons for discontinuation, amenorrhea, pain, and hormone-related adverse events (20% of all discontinuations) were reported as the most common reasons for LNG-IUS discontinuation. [ 25 ] A systematic review also reported frequent intermenstrual bleeding and spotting in the first few months after LNG-IUS implantation. [ 26 ] Counselling is critical in dealing with the side effects encountered during the continuation of contraception. Counselling can prevent the discontinuation of the method because of acceptable temporary side effects. [ 27 , 28 ] These results show that some simple side effects during LNG-IUS use are a reason to discontinue the method. However, it may be recommended that midwives, who mostly interview women, provide counseling on this issue.

Women’s age, educational status, fertility goals, and previous contraceptive method use were found to significantly affect LNG-IUS use. The duration of LNG-IUS use in the contraception group was longer than that in the treatment group. Both groups were very satisfied with LNG-IUS use and thought of using LNG-IUS again. The results of this study are important in terms of determining women’s experiences, satisfaction, and continuity of LNG-IUS use, and guiding the planning of service provision. It may be recommended that various training sessions be organized to raise awareness of both healthcare professionals and the public about the accessibility, effectiveness, and reliability of LNG-IUS use, and that local governments and health administrators should provide support and an environment for multicenter, quantitative, and qualitative studies with broad participation where women’s experiences on the subject can be shared. As this research is cross-sectional, the results reflect only the opinions and statements of the research sample. The data obtained may vary depending on sample group, time, and regional differences. In addition, there are insufficient studies on the experiences of LNG-IUS users. There is a need for more multicenter, qualitative, and quantitative studies on women’s experiences with LNG-IUS, where their cultural characteristics can also be reflected.

Thank you to the women who participated in this study.