Efficacy of levonorgestrel intrauterine system in conservative management of abnormal uterine bleeding: an emerging tool

Amrita Chaurasia, Shweta Shweta, Vidhi Singh, Vandana Maurya, Ved P. Maurya
In: International Journal of Reproduction, Contraception, Obstetrics and Gynecology · 2025 · vol. 14(7) , pp. 2182–2187 · doi:10.18203/2320-1770.ijrcog20251963 · W4411679823
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This study found that the levonorgestrel intrauterine system (LNG-IUS) effectively managed heavy menstrual bleeding with higher patient satisfaction and lower persistence of heavy flow compared to oral progesterone, while also reducing endometrial thickness.

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The paper evaluated the efficacy of a levonorgestrel intrauterine system (LNG IUS) versus oral progesterone (norethisterone or medroxyprogesterone, 20–60 mg daily) in women with heavy menstrual bleeding, using baseline and follow-up measures including PBAC score and endometrial thickness. Eighty patients selected oral progesterone and 40 selected LNG IUS insertion, with LNG IUS follow-up reported at one year and oral progesterone assessed up to 6 months; both groups showed statistically significant reductions in PBAC scores and endometrial thickness, with comparable spotting at 6 months. Secondary amenorrhea and infrequent cycles were more frequent in the LNG IUS group, while heavy flow persistence and the need for hysterectomy were reported more in the oral progesterone group, and the LNG IUS was expelled in 2.5% of participants; a stated limitation is that treatment choice was not randomized. This paper is centrally about adenomyosis? Relevance to endometriosis: adenomyosis and endometriosis are mentioned in the paper’s reference list as contexts where LNG IUS has been studied, though the study itself focuses on heavy menstrual bleeding.

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Abstract

Background: Intrauterine LNG IUS, introduced in 1990, reduces hysterectomies for abnormal uterine bleeding, reducing the need for costly and incapacitating surgical treatments. Methods: Heavy menstrual bleeding patients were prescribed oral progesterone therapy with norethisterone or medroxyprogesterone in doses of 20-60 mg daily for a maximum of 6 months. 80 patients chose oral progesterone and 40 chose LNG IUS insertion. The follow-up period for patients who chose LNG IUS was conducted at a rate of one year. Results: Reduction in PBAC score pre and post treatment was statistically significant in both oral progesterone (p value <0.001) and LNG IUS group (p value <0.001). We found statistically significant reduction in endometrial thickness after 6 months of treatment with oral progesterone (p value <0.001) and LNG IUS group (p value <0.001). The most common complaint at 6 months follow-up was spotting per vaginum, which was comparable in both groups. Infrequent cycle and secondary amenorrhea were significantly more in LNG IUS group (p value <0.05) whereas heavy flow persistence and need for hysterectomy were more in oral progesterone group (p value <0.05). LNG IUS got spontaneously expelled in one patient (2.5%) after first menstrual cycle. Mean duration from insertion to amenorrhea was 8 months. After insertion, the mean Hb% showed a significant rise of 8% form baseline. Satisfaction level was more (70%) in LNG IUS users in comparison to oral progesterone (15%). Conclusions: LNG-IUS is a superior nonsurgical option for managing HMB and uterine pathologies, with lower net costs compared to medical treatment and hysterectomy. It can be improved with counselling about self-remission of spotting per vaginum and fertility preservation.
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Background

Intrauterine LNG IUS, introduced in 1990, reduces hysterectomies for abnormal uterine bleeding, reducing the need for costly and incapacitating surgical treatments.

Methods

Heavy menstrual bleeding patients were prescribed oral progesterone therapy with norethisterone or medroxyprogesterone in doses of 20-60 mg daily for a maximum of 6 months. 80 patients chose oral progesterone and 40 chose LNG IUS insertion. The follow-up period for patients who chose LNG IUS was conducted at a rate of one year.

Results

Reduction in PBAC score pre and post treatment was statistically significant in both oral progesterone (p value <0.001) and LNG IUS group (p value <0.001). We found statistically significant reduction in endometrial thickness after 6 months of treatment with oral progesterone (p value <0.001) and LNG IUS group (p value <0.001). The most common complaint at 6 months follow-up was spotting per vaginum, which was comparable in both groups. Infrequent cycle and secondary amenorrhea were significantly more in LNG IUS group (p value <0.05) whereas heavy flow persistence and need for hysterectomy were more in oral progesterone group (p value <0.05). LNG IUS got spontaneously expelled in one patient (2.5%) after first menstrual cycle. Mean duration from insertion to amenorrhea was 8 months. After insertion, the mean Hb% showed a significant rise of 8% form baseline. Satisfaction level was more (70%) in LNG IUS users in comparison to oral progesterone (15%).

Conclusions

LNG-IUS is a superior nonsurgical option for managing HMB and uterine pathologies, with lower net costs compared to medical treatment and hysterectomy. It can be improved with counselling about self-remission of spotting per vaginum and fertility preservation. Metrics

References

National Institute of Health and Care Excellence. Heavy menstrual bleeding: assessment and management. NICE guideline. 2018. Available from: https://www.nice.org.uk/guidance/ng88. Accessed on 11 January 2025. Engstrom JL, Rose R, Brill AI, Polhill KM, Lukanich CM, Fritz L. Midwifery care of the woman with menorrhagia. J Nurse Midwife. 1999;44:89-105. DOI: https://doi.org/10.1016/S0091-2182(99)00029-4 Wright RC. Hysterectomy: past, present, and future. Obstet Gynecol. 1969;33:560-3. Dhamangaonkar PC, Anuradha K, Saxena A. Levonorgestrel intrauterine system (Mirena): an emerging tool for conservative treatment of abnormal uterine bleeding. J Midlife Health. 2015;6(1):26-30. DOI: https://doi.org/10.4103/0976-7800.153615 Hidalgo MM, Hidalgo-Regina C, Bahamondes MV, Monteiro I, Petta CA, Bahamondes L. Serum levonorgestrel levels and endometrial thickness during extended use of the levonorgestrel-releasing intrauterine system. Contraception. 2009;80:84-9. DOI: https://doi.org/10.1016/j.contraception.2009.01.004 Seeber B, Ziehr SC, Gschliesser A, Moser C, Mattle V, Seger C, et al. Quantitative levonorgestrel plasma level measurements in patients with regular and prolonged use of the levonorgestrel-releasing intrauterine system. Contraception. 2012;86:345-9. DOI: https://doi.org/10.1016/j.contraception.2012.01.015 Silverberg SG, Haukkamaa M, Arko H, Nilsson CG, Luukkainen T. Endometrial morphology during long-term use of levonorgestrel-releasing intrauterine devices. Int J Gynecol Pathol. 1986;5:235-41. DOI: https://doi.org/10.1097/00004347-198609000-00005 Lumsden M, Stanton SL, eds. Gynaecology. 2nd ed. London: Churchill Livingstone; 1997:421-439. Lähteenmäki P, Haukkamaa M, Puolakka J, Riikonen U, Sainio S, Suvisaari J, et al. Open randomised study of use of levonorgestrel releasing intrauterine system as alternative to hysterectomy. BMJ. 1998;316:1122-6. DOI: https://doi.org/10.1136/bmj.316.7138.1122 Gunes M, Ozdegirmenci O, Kayikcioglu F, Haberal A, Kaplan M. The effect of levonorgestrel intrauterine system on uterine myomas: a 1-year follow-up study. J Minim Invas Gynecol. 2008;15:735-8. DOI: https://doi.org/10.1016/j.jmig.2008.08.011 Cho S, Nam A, Kim H, Chay D, Park K, Cho DJ, et al. Clinical effects of the levonorgestrel-releasing intrauterine device in patients with adenomyosis. Am J Obstet Gynecol. 2008;198:373.e1-7. DOI: https://doi.org/10.1016/j.ajog.2007.10.798 Ozdegirmenci O, Kayikcioglu F, Akgul MA, Kaplan M, Karcaaltincaba M, Haberal A, 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. DOI: https://doi.org/10.1016/j.fertnstert.2010.10.009 Bragheto AM, Caserta N, Bahamondes L, Petta CA. Effectiveness of the levonorgestrel-releasing intrauterine system in the treatment of adenomyosis diagnosed and monitored by magnetic resonance imaging. Contraception. 2007;76:195-9. DOI: https://doi.org/10.1016/j.contraception.2007.05.091 Grigorieva V, Chen-Mok M, Tarasova M, Mikhailov A. Use of a levonorgestrel-releasing intrauterine system to treat bleeding related to uterine leiomyomas. Fertil Steril. 2003;79:1194-8. DOI: https://doi.org/10.1016/S0015-0282(03)00175-4 Petta CA, Ferriani RA, Abrao MS, Hassan D, Rosa E, Silva JC, et al. Randomized clinical trial of a levonorgestrel-releasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis. Hum Reprod. 2005;20:1993-8. DOI: https://doi.org/10.1093/humrep/deh869 Matorras R, Ballesteros A, Prieto B, Ocerin I, Expósito A, Pijoan JI, et al. Efficacy of the levonorgestrel-releasing intrauterine device in the treatment of recurrent pelvic pain in multi treated endometriosis. J Reprod Med. 2011;56:497-503. Sheng J, Zhang WY, Zhang JP, Lu D. The LNG-IUS study on adenomyosis: a 3-year follow-up on the efficacy and side effects of the use of levonorgestrel intrauterine system for the treatment of dysmenorrheal associated with adenomyosis. Contraception. 2009;79:189-93. DOI: https://doi.org/10.1016/j.contraception.2008.11.004 Desai RM. Efficacy of levonorgestrel releasing intrauterine system for the treatment of menorrhagia due to benign uterine lesions in perimenopausal women. J Midlife Health. 2012;3:20-3. DOI: https://doi.org/10.4103/0976-7800.98812 Mukherjee K, Jones K. The treatment of dysfunctional uterine bleeding with the Mirena IUS: a survival analysis. Gynecol Surg. 2005;2:251-4. DOI: https://doi.org/10.1007/s10397-005-0131-7

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