Levonorgestrel-releasing intrauterine device for symptomatic endometriosis following surgery

Objectives The aim of this study was to determine whether postoperative levonorgestrel-releasing intrauterine device (LNG-IUD) insertion in women with endometriosis improves pain and reduces symptoms compared with no treatment, placebo, or systemic therapy. Data source The following databases were searched from inception to June 2012: Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials, MEDLINE, PsycINFO, CINAHL, and the World Health Organization International Clinical Trials Registry Platform. EMBASE was searched from 2010 to June 2012. The citation lists of relevant publications, review articles, abstracts of scientific meetings, and included studies were also searched. Study selection Randomized trials comparing women who underwent LNG-IUD insertion with those who received no treatment, a placebo, or systemic therapy after surgical treatment for endometriosis within the preceding 3 months were included. Data extraction Two review authors independently selected studies for inclusion and extracted data to allow for an intention-to-treat analysis. For dichotomous data, the risk ratio (RR) and 95% confidence interval (CI) were calculated using the Mantel–Haenszel random-effects method. For continuous data, the mean difference (MD) and 95% CI were calculated using the inverse variance random-effects method. Results A total of three randomized-controlled trials were included. In two trials, there was a statistically significant reduction in the recurrence of painful menstruation in the LNG-IUD group compared with expectant management (RR 0.22, 95% CI 0.08–0.60, 95 women, I2 0%, moderate strength of evidence). The proportion of women who were satisfied with their treatment was also higher in the LNG-IUD group but did not reach statistical significance (RR 1.21, 95% CI 0.80–1.82, 95 women, I2 0%). The number of women reporting a change in their menstruation was significantly higher in the LNG-IUD group (RR 37.80, 95% CI 5.40–264.60, 95 women, I2 0%); however, the number of women who failed to complete the allocated treatment did not differ between the groups (RR 0.66, 95% CI 0.08–5.25, I2 43%). In one trial, women receiving LNG-IUD achieved slightly lower pain scores compared with women receiving gonadotropin-releasing hormone (GnRH) agonists (MD −0.16, 95% CI −2.02 to 1.70, 40 women), but this did not reach statistical significance. Conclusion There is limited but consistent evidence showing that postoperative LNG-IUD use reduces the recurrence of painful menstruation in women with endometriosis. Further well-designed randomized-controlled trials are needed to confirm these findings.