Evaluation of clinical performance when intrauterine devices are inserted by different categories of healthcare professional.

OBJECTIVE: We evaluated clinical performance when the TCu380A intrauterine device (IUD) and the levonorgestrel (LNG) 52-mg intrauterine system (IUS) were inserted by different categories of healthcare professionals. METHODS: A retrospective study was conducted at the University of Campinas, Brazil. The medical records were reviewed of all women in whom an IUD was inserted between January 1980 and December 2018, with data for at least 1 year, and for whom information on the healthcare provider who inserted the device was available. RESULTS: Overall, 19 132 (76.9%) IUD and 5733 (23.1%) LNG-IUS insertions were included, with residents/interns performing 13 853 (55.8%), nurses 7024 (28.2%), and physicians 3988 (16.0%). Removals for pregnancy and infection were significantly higher when physicians inserted the device, while removals for bleeding/pain and other medical reasons were more common when nurses performed the insertion. Expulsion and removals for personal reasons were similar for all three categories. CONCLUSION: Clinical outcomes were similar regardless of whether trained nurses, residents/interns, or physicians inserted the device, and were irrespective of users' age and parity. These results could stimulate other healthcare services, particularly in regions where there is a shortage of physicians, to invest in training nurses to perform insertions of IUDs.

Adjuvant therapy in conservative surgery for adenomyosis.

OBJECTIVE: To investigate the significance of perioperative levonorgestrel-releasing intrauterine system (LNG-IUS) and/or gonadotropin-releasing hormone agonists (GnRHa) as adjuvant therapy in preventing recurrences or progression of diseases. METHODS: Medical records were collected from patients diagnosed with adenomyosis who underwent uterus-sparing surgeries from March 1, 2012 to December 31, 2018. The associations of perioperative adjuvant therapy with recurrence of disease and symptoms were analyzed with the Kaplan-Meier method and proportional hazards models with hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS: A total of 322 eligible patients were included, of whom 173 (58.1%) received perioperative adjuvant therapy. Perioperative adjuvant therapy (HR 0.44, 95% CI 0.22-0.91, P = 0.022) and perioperative GnRHa therapy (HR 0.48, 95% CI 0.24-0.99, P = 0.042) significantly reduced disease recurrence. No patient using perioperative LNG-IUS therapy experienced recurrence. In the multivariate analysis, increased age (>35 years at surgery) was the only risk factor for disease recurrence (HR 2.35, 95% CI 1.01-5.45, P = 0.047). CONCLUSION: Perioperative adjuvant therapy with GnRHa and/or the LNG-IUS can significantly reduce disease recurrence or progression for adenomyosis patients undergoing uterus-sparing surgery. Older patients are more likely to experience disease recurrence.

Access to intrauterine contraceptives in the Southern District Health Board catchment.

AIM: Recent changes in funding have reduced the cost of the highly effective levonorgestrel-releasing intrauterine system (LIUS) contraceptives (Mirena and Jaydess). This paper explores equity of access to intrauterine contraceptives for Maori and the general population by locating and surveying all potential providers within the Southern District Health Board catchment area. METHODS: Using online survey, e-mail or phone, we asked if intrauterine contraceptive insertion was provided, what device was provided, cost and number of appointments required. ArcGIS 10.6.1 software was used to estimate population distribution, and to create service areas showing distance to nearest current providers for Maori and the general population. RESULTS: All 88 potential providers agreed to participate; two thirds (66.3%) provided some intrauterine contraceptive insertion. Approximately three quarters of the Maori and general population live within 5km of a primary provider. Costs ranged from $0 to $270, in addition to the cost of the required consultations. Number of consultations required varied from one to three. CONCLUSIONS: Cost and travel time likely remain barriers to accessing intrauterine contraceptives for a significant population within this catchment. Increasing the capacity for all primary providers to offer insertion, funding the insertion process, minimising the number of appointments required and providing mobile services would improve access.

Combined transcervical endometrial resection and levonorgestrel device treatment compared to transcervical endometrial resection for abnormal uterine bleed.

INTRODUCTION: Transcervical resection of the endometrium (TCRE) is a first-line surgical treatment of abnormal uterine bleeding. However, many women experience unsuccessful results, causing hysterectomy in up 17% of cases. The aim of this study was to describe the odds of hysterectomy in women with abnormal uterine bleeding, treated with TCRE and levonorgestrel intrauterine contraceptive device (TCRE + LNG-IUCD) or TCRE alone. The secondary aim was to analyze the rate of amenorrhea. MATERIAL AND METHODS: Designed as a retrospective cohort study, and conducted at Odense University Hospital, Denmark, the study included women with abnormal uterine bleeding, who underwent TCRE from January 2013 to December 2015. The decision of treatment with respect to LNG-IUCD was at the woman's discretion. Data were collected from medical records and a self-reported retrospective bleeding-pattern questionnaire. A multivariate regression model was used, enabling adjustment for potential and identified confounders. RESULTS: Out of 432 women, 276 (62%) consented to inclusion and of these, 16 (4%) were excluded. In total 88 (34%) received combined treatment and 172 (66%) received TCRE alone. Ten women (11%) treated with TCRE + LNG-IUCD underwent hysterectomy, compared with 27 (16%) treated with TCRE alone (OR = 0.69, 95% CI 0.28-1.56; P = .34). Multivariate analysis disclosed a significant effect of TCRE + LNG-IUCD (OR = 0.35, 95% CI 0.13-0.97; P = .04) on hysterectomy. The presence of fibromas was shown to increase the odds of treatment failure, resulting in hysterectomy (OR 2.69, 95% CI 1.15-6.31; P = .02). Furthermore, the incidence of amenorrhea was 59% in the TCRE + LNG-IUCD group and 36% in the TCRE alone group (OR = 2.56, 95% CI 1.46-4.49; P < .01). CONCLUSIONS: The study showed significantly lower odds of hysterectomy in the TCRE + LNG-IUCD group when adjusted for confounders. Combination treatment improves the bleeding patterns significantly compared with monotherapy with TCRE.

Free-of-charge long-acting reversible contraception: two-year discontinuation, its risk factors, and reasons.

BACKGROUND: Since 2013, the residents of the city of Vantaa, Finland, have been offered their first long-acting reversible contraceptive method (levonorgestrel-releasing intrauterine system, implant, and copper intrauterine device) free of charge. OBJECTIVE: The primary aim of this study was to assess the 2-year cumulative discontinuation rates of long-acting reversible contraceptive methods when provided free of charge for first-time users in a real-world setting. Additional aims were to describe factors associated with discontinuation and to evaluate the reasons for discontinuation. STUDY DESIGN: This is a retrospective register-based cohort study of 2026 nonsterilized women aged 15 to 44 years, who initiated a free-of-charge long-acting contraceptive method in 2013-2014 in the city of Vantaa. Removals within 2 years after method initiation and reasons for discontinuation were obtained from electronic health records and from national registers. We calculated the 2-year cumulative incidence rates of discontinuation with 95% confidence intervals for each method. Furthermore, we assessed crude and adjusted incidence rate ratios of discontinuation with 95% confidence interval by Poisson regression models comparing implants and copper intrauterine device with levonorgestrel-releasing intrauterine systems. RESULTS: During the 2 -year follow-up, 514 women discontinued, yielding a cumulative discontinuation rate of 28.3 per 100 women-years (95% confidence interval, 26.2-30.4). Among the 1199 women who initiated the levonorgestrel-releasing intrauterine system, the cumulative discontinuation rate was 24.2 per 100 women-years (95% confidence interval, 21.7-26.9); among the 642 implant users, 33.3 per 100 women-years (95% confidence interval, 29.5-37.4); and among the 185 copper intrauterine device users, 37.8 per 100 women-years (95% confidence interval, 31.0-45.7). Compared with women aged 30 to 44 years, women aged 15 to 19 years (adjusted incidence rate ratio, 1.58; 95% confidence interval, 1.17-2.14) and 20 to 29 years (adjusted incidence rate ratio, 1.35; 95% confidence interval, 1.11-1.63) were more likely to discontinue. We observed a higher discontinuation rate in women who had given birth within the previous year (adjusted incidence rate ratio, 1.36; 95% confidence interval, 1.13-1.65), spoke a native language other than Finnish or Swedish (adjusted incidence rate ratio, 1.31; 95% confidence interval, 1.06-1.63), and had a history of a sexually transmitted infection (adjusted incidence rate ratio, 1.62; 95% confidence interval, 1.07-2.46). No association was found in marital status, overall parity, history of induced abortion, socioeconomic status, education level, or smoking status. The most common reason for discontinuation was bleeding disturbances, reported by 21% of women who discontinued the levonorgestrel-releasing intrauterine system, by 71% who discontinued the implant, and by 41% who discontinued the copper intrauterine device. One in 4 women who discontinued the copper intrauterine device reported heavy menstrual bleeding, whereas only 1% who discontinued the levonorgestrel-releasing intrauterine system and none who discontinued implants reported this reason. Abdominal pain was the reported reason for discontinuation in 20% of both intrauterine device users and in only 2% who discontinued implants. CONCLUSION: At 2 years, the use of implants and copper intrauterine devices was more likely to be discontinued than that of the levonorgestrel-releasing intrauterine system. Women younger than 30 years and those who gave birth in the preceding year, spoke a native language other than Finnish or Swedish, or had a history of sexually transmitted infections were more likely to discontinue. The levonorgestrel-releasing intrauterine system was least likely to be removed owing to bleeding disturbances.

Indications and reasons for discontinuing the levonorgestrel-releasing intrauterine system (LNG-IUS) / Indicações e razões para descontinuação do sistema intra-uterino liberador de levanogestrel (SIU-LNG)

Abstract Objectives: to identify the main indications and reasons for discontinuing the use of the Levonorgestrel-Releasing Intrauterine System (LNG-IUS). Methods: a cross-sectional study was carried out from medical records of 327 women who used the LNG-IUS 52mg between January 2011 and December 2016 at a public hospital in the Northeast of Brazil. Results: the main indications for the use of the LNG-IUS were: contraception (32.7%), myoma/metrorrhagia (28.7%) and endometriosis/pelvic pain (22.3%). Of the 327 women, 68 (20.8%) had discontinued using the device. The most frequent reasons for discontinuation were: expulsion (9.2%), LNG-IUS expiration (3.7%), bleeding (2.4%) and pain (1.5%). Most patients had no difficulty in the insertion and did not require anesthesia/sedation. Among the 30 women who expelled the device, 17 (56.7%) had used it for metrorrhagia and myoma, 8 (26.7%) for contraception, and 5 (16.6%) for endometriosis/pelvic pain. Conclusions: the LNG-IUS is a well-accepted contraceptive method, with therapeutic applications for some gynecological conditions and a low expulsion rate.

Resumo Objetivos: identificar as principais indicações e razões para a descontinuação do uso do sistema intra-uterino liberador de levanogestrel (SIU-LNG). Métodos: foi realizado um estudo transversal a partir de prontuários de 327 mulheres que usaram o SIU-LNG 52mg entre janeiro de 2011 e dezembro de 2016 em um hospital público do Nordeste do Brasil. Resultados: as principais indicações para o uso do SIU-LNG foram: contracepção (32,7%), mioma / metrorragia (28,7%) e endometriose / dor pélvica (22,3%). Das 327 mulheres, 68 (20,8%) haviam descontinuado o uso do dispositivo. Os motivos mais frequentes de descontinuação foram: expulsão (9,2%), expiração de SIU-LNG (3,7%), sangramento (2,4%) e dor (1,5%). Conclusão: a maioria dos pacientes não teve dificuldade na inserção e não necessitou de anestesia / sedação. Entre as 30 mulheres que expulsaram o dispositivo, 17 (56,7%) o utilizaram para metrorragia e mioma, 8 (26,7%) para contracepção e 5 (16,6%) para endometriose / dor pélvica. O SIU-LNG é um método contraceptivo bem aceito, com aplicações terapêuticas para algumas condições ginecológicas e baixa taxa de expulsão.

The use of levonorgestrel-releasing intrauterine devices in adolescents - own experience.

It is estimated that 19% of adolescents in Poland begin their sexual life when they are 15 years old and more than 50% of people aged 17-19 years have already had their first sexual contact. World Health Organization recommends teenagers to use the method of 'dual protection' (condom and other method of contraception, i.e. intrauterine devices). In this study, we sought to present our own experience in the field of the use of levonorgestrel-releasing intrauterine devices in adolescents and to compare it with the experience of other researchers worldwide. Low- dose levonorgestrel-releasing intrauterine device is safe and effective method of contraception in adolescents. It is also an alternative treatment used in heavy chronic abnormal uterine bleeding. It can be also used as an alternative in women with cyanotic heart disease who have contraindications for standard contraception. Gynecologists and pediatricians should be well informed in the topic of intrauterine device use among adolescents and they should provide them reliable knowledge in this field.

Consecutive Use of the 52 mg Levonorgestrel-releasing Intrauterine System: Variations in Bleeding Patterns.

OBJECTIVE: Changes in bleeding patterns could influence the decisions of healthcare professionals to change the levonorgestrel-releasing intrauterine system (LNG-IUS) before 7 years of use, the recommended period of extended use. We evaluated changes in the bleeding patterns of users of the 52 mg LNG-IUS at the end of use of the first (IUS-1) and during the second device (IUS-2) use. METHODS: We performed an audit of the medical records of all women who used two consecutive LNG-IUSs at the Family Planning clinic. We evaluated the sociodemographic/gynecological variables, the length of use, and the bleeding patterns reported in the reference periods of 90 days before removal of the IUS-1 and at the last return in use of IUS-2. We used the McNemar test to compare bleeding patterns. Statistical significance was established at p < 0.05. RESULTS: We evaluated 301 women aged (mean ± SD) 32 (±6.1) years, with lengths of use of 68.9 (±16.8) and 20.3 (±16.7) months for the IUS-1 and IUS-2, respectively. No pregnancies were reported. Bleeding patterns varied significantly among women who used the IUS-2 for ≥ 7 months to 6 years when compared the bleeding patterns reported in IUS-1 use. Eighty-nine out of 221 (40%) women maintained amenorrhea and infrequent bleeding; 66 (30%) evolved to bleeding patterns with light flow, and 66 (30%) maintained or evolved to heavy flow patterns (p = 0.012). No differences were observed among the 80 women with ≤ 6 months of use. CONCLUSION: Changes in bleeding patterns occur during the use of LNG-IUS and should not be decisive for the early replacement of the device.

OBJETIVO: Variações no padrão de sangramento podem afetar a decisão de troca do sistema intrauterino de levonorgestrel (SIU-LNG) antes do período de uso estendido recomendado de 7 anos. Nós avaliamos mudanças no padrão de sangramento de usuárias ao final do uso do primeiro SIU-LNG 52 mg (SIU-1) e durante o uso do segundo dispositivo (SIU-2). MéTODOS: Revisamos os prontuários de todas as mulheres que inseriram consecutivamente o SIU-LNG no ambulatório de Planejamento Familiar. Foram avaliadas as variáveis sociodemográficas/ginecológicas, o tempo de uso, e os padrões de sangramento relatados nos períodos de referência de 90 dias antes da remoção do SIU-1 e no último retorno em uso do SIU-2. Usamos o teste de McNemar para comparar os padrões de sangramento. A significância estatística foi estabelecida em p < 0,05. RESULTADOS: Analisamos os dados de 301 mulheres com idade (média ± desvio padrão [DP]) de 32 (±6,1) anos e tempo de uso de 68,9 (±16,8) e 20,3 (±16,7) meses para o SIU-1 e SIU-2, respectivamente. Nenhuma gravidez foi relatada. Os padrões de sangramento variaram significativamente durante o uso do SIU-2 (≥ 7 meses a 6 anos) em relação ao padrão relatado no SIU-1. Oitenta e nove das 221 (40%) mulheres mantiveram amenorreia e sangramento infrequente; 66 (30%) evoluíram para padrões de sangramento com fluxo leve e 66 (30%) mantiveram ou evoluíram para padrões de fluxo intenso (p = 0,012). Não foram observadas diferenças entre as 80 mulheres que utilizavam o SIU-2 há ≤ 6 meses. CONCLUSãO: Mudanças nos padrões de sangramento ocorrem durante o uso do LNG-IUS e não devem ser decisivas para a troca precoce do dispositivo.

Consecutive use of the 52 mg levonorgestrel-releasing intrauterine system: variations in bleeding patterns / Uso consecutivo do sistema intrauterino de levonorgestrel 52 mg: variações no padrão de sangramento

Abstract Objective Changes in bleeding patterns could influence the decisions of healthcare professionals to change the levonorgestrel-releasing intrauterine system (LNG-IUS) before 7 years of use, the recommended period of extended use. We evaluated changes in the bleeding patterns of users of the 52 mg LNG-IUS at the end of use of the first (IUS-1) and during the second device (IUS-2) use. Methods We performed an audit of the medical records of all women who used two consecutive LNG-IUSs at the Family Planning clinic. We evaluated the sociodemographic/gynecological variables, the length of use, and the bleeding patterns reported in the reference periods of 90 days before removal of the IUS-1 and at the last return in use of IUS-2. We used the McNemar test to compare bleeding patterns. Statistical significance was established at p < 0.05. Results We evaluated 301 women aged (mean ± SD) 32 (±6.1) years, with lengths of use of 68.9 (±16.8) and 20.3 (±16.7) months for the IUS-1 and IUS-2, respectively. No pregnancies were reported. Bleeding patterns varied significantly among women who used the IUS-2 for ≥ 7 months to 6 years when compared the bleeding patterns reported in IUS-1 use. Eighty-nine out of 221 (40%) women maintained amenorrhea and infrequent bleeding; 66 (30%) evolved to bleeding patterns with light flow, and 66 (30%) maintained or evolved to heavy flow patterns (p = 0.012). No differences were observed among the 80 women with ≤ 6 months of use. Conclusion Changes in bleeding patterns occur during the use of LNG-IUS and should not be decisive for the early replacement of the device.

Resumo Objetivo Variações no padrão de sangramento podem afetar a decisão de troca do sistema intrauterino de levonorgestrel (SIU-LNG) antes do período de uso estendido recomendado de 7 anos. Nós avaliamos mudanças no padrão de sangramento de usuárias ao final do uso do primeiro SIU-LNG 52 mg (SIU-1) e durante o uso do segundo dispositivo (SIU-2). Métodos Revisamos os prontuários de todas as mulheres que inseriram consecutivamente o SIU-LNG no ambulatório de Planejamento Familiar. Foram avaliadas as variáveis sociodemográficas/ginecológicas, o tempo de uso, e os padrões de sangramento relatados nos períodos de referência de 90 dias antes da remoção do SIU-1 e no último retorno em uso do SIU-2. Usamos o teste de McNemar para comparar os padrões de sangramento. A significância estatística foi estabelecida em p < 0,05. Resultados Analisamos os dados de 301 mulheres com idade (média ± desvio padrão [DP]) de 32 (±6,1) anos e tempo de uso de 68,9 (±16,8) e 20,3 (±16,7) meses para o SIU-1 e SIU-2, respectivamente. Nenhuma gravidez foi relatada. Os padrões de sangramento variaram significativamente durante o uso do SIU-2 (≥ 7 meses a 6 anos) em relação ao padrão relatado no SIU-1. Oitenta e nove das 221 (40%) mulheres mantiveram amenorreia e sangramento infrequente; 66 (30%) evoluíram para padrões de sangramento com fluxo leve e 66 (30%) mantiveram ou evoluíram para padrões de fluxo intenso (p = 0,012). Não foram observadas diferenças entre as 80 mulheres que utilizavam o SIU-2 há ≤ 6 meses. Conclusão Mudanças nos padrões de sangramento ocorrem durante o uso do LNG-IUS e não devem ser decisivas para a troca precoce do dispositivo.

Relative Risk of Cervical Neoplasms Among Copper and Levonorgestrel-Releasing Intrauterine System Users.

OBJECTIVE: To evaluate the relative risk of cervical neoplasms among copper intrauterine device (Cu IUD) and levonorgestrel-releasing intrauterine system (LNG-IUS) users. METHODS: We performed a retrospective cohort analysis of 10,674 patients who received IUDs at Columbia University Medical Center. Our data were transformed to a common data model and are part of the Observational Health Data Sciences and Informatics network. The cohort patients and outcomes were identified by a combination of procedure codes, condition codes, and medication exposures in billing and claims data. We adjusted for confounding with propensity score stratification and propensity score 1:1 matching. RESULTS: Before propensity score adjustment, the Cu IUD cohort included 8,274 patients and the LNG-IUS cohort included 2,400 patients. The median age for both cohorts was 29 years at IUD placement. More than 95% of the LNG-IUS cohort used a device with 52 mg LNG. Before propensity score adjustment, we identified 114 cervical neoplasm outcomes. Seventy-seven (0.9%) cervical neoplasms were in the Cu IUD cohort and 37 (1.5%) were in the LNG-IUS cohort. The propensity score matching analysis identified 7,114 Cu IUD and 2,174 LNG-IUS users, with covariate balance achieved over 16,827 covariates. The diagnosis of high-grade cervical neoplasia was 0.7% in the Cu IUD cohort and 1.8% in the LNG-IUS cohort (2.4 [95% CI 1.5-4.0] cases/1,000 person-years and 5.2 [95% CI 3.7-7.1] cases/1,000 person-years, respectively). The relative risk of high-grade cervical neoplasms among Cu IUD users was 0.38 (95% CI 0.16-0.78, P<.02) compared with LNG-IUS users. By inspection, the Kaplan-Meier curves for each cohort diverged over time. CONCLUSION: Copper IUD users have a lower risk of high-grade cervical neoplasms compared with LNG-IUS users. The relative risk of cervical neoplasms of LNG-IUS users compared with the general population is unknown.

Endometrial ablation or resection versus levonorgestrel intra-uterine system for the treatment of women with heavy menstrual bleeding and a normal uterine cavity: a systematic review with meta-analysis.

BACKGROUND: Endometrial ablation/resection and the levonorgestrel intra-uterine system (LNG-IUS) are well-established treatment options for heavy menstrual bleeding to avoid more invasive alternatives, such as hysterectomy. OBJECTIVE: The aim was to compare the efficacy and safety of endometrial ablation or resection with the LNG-IUS in the treatment of premenopausal women with heavy menstrual bleeding and to investigate sources of heterogeneity between studies. SEARCH METHODS: We searched the databases MEDLINE, EMBASE, CENTRAL, Web of Science, Biosis and Google Scholar as well as citations and reference lists published up to August 2019. Two authors independently screened 3701 citations for eligibility. We included randomized controlled trials published in any language, comparing endometrial ablation or resection to the LNG-IUS in the treatment of premenopausal women with heavy menstrual bleeding and a normal uterine cavity. OUTCOMES: Thirteen studies (N = 884) were eligible. Two independent authors extracted data and assessed the quality of included studies. Random effect models were used to compare the modalities and evaluate sources of heterogeneity. No significant differences were observed between endometrial ablation/resection and the LNG-IUS in terms of subsequent hysterectomy (primary outcome, risk ratio (RR) = 1.13, 95% CI 0.60 to 2.11, P = 0.71, I2 = 14%, 12 studies, 726 women), satisfaction, quality of life, amenorrhea and treatment failure. However, side effects were less common in women treated with endometrial ablation/resection compared to the LNG-IUS (RR = 0.52, 95% CI 0.37 to 0.71, P < 0.001, I2 = 0%, 10 studies, 580 women). Three complications were reported in the endometrial ablation/resection group and none in the LNG-IUS group (P = 0.25). Mean age of the studied populations was identified as a significant source of heterogeneity between studies in subgroup analysis (P = 0.01). In fact, endometrial ablation/resection was associated with a higher risk of subsequent hysterectomy compared to the LNG-IUS in younger populations (mean age ≤ 42 years old, RR = 5.26, 95% CI 1.21 to 22.91, P = 0.03, I2 = 0%, 3 studies, 189 women). On the contrary, subsequent hysterectomy seemed to be less likely with endometrial ablation/resection compared to the LNG-IUS in older populations (mean age > 42 years old), although the reduction did not reach statistical significance (RR = 0.51, 95% CI 0.21 to 1.24, P = 0.14, I2 = 0%, 5 studies, 297 women). Finally, sensitivity analysis taking into account the risk of bias of included studies and type of surgical devices (first and second generation) did not modify the results. Most of the included studies reported outcomes at up to 3 years, and the relative performance of endometrial ablation/resection and LNG-IUS remains unknown in the longer term. WIDER IMPLICATIONS: Endometrial ablation/resection and the LNG-IUS are two excellent treatment options for heavy menstrual bleeding, although women treated with the LNG-IUS are at higher risk of experiencing side effects compared to endometrial ablation/resection. Otherwise, younger women seem to present a lower risk of eventually requiring hysterectomy when treated with the LNG-IUS compared to endometrial ablation/resection.

Comparison of Combined Bipolar Radiofrequency Impedance-Controlled Endometrial Ablation with Levonorgestrel Intrauterine System versus Bipolar Radiofrequency Endometrial Ablation Alone in Women with Abnormal Uterine Bleeding.

STUDY OBJECTIVE: This study aims to evaluate the efficacy of the combination of bipolar radiofrequency impedance-controlled endometrial ablation (NovaSure; Hologic Inc., Bedford, MA) and levonorgestrel intrauterine system (LNG-IUS; Mirena; Schering AG, Berlin, Germany) placement in comparison with NovaSure endometrial ablation alone in patients with abnormal uterine bleeding (AUB). DESIGN: A propensity score matching study. SETTING: Beijing Tiantan Hospital, Capital Medical University, Beijing, China. PATIENTS: A retrospective study was conducted on 246 patients with AUB who underwent NovaSure endometrial ablation with (NovaSure+LNG-IUS group) or without (NovaSure group) LNG-IUS between January 2013 and August 2016. To overcome selection bias, propensity score matching was used to establish a 1:1 match between these 2 groups. Accordingly, 41 patients were included in each group. INTERVENTION: NovaSure endometrial ablation, immediately followed by LNG-IUS insertion in the NovaSure+LNG-IUS group, and NovaSure endometrial ablation alone in the control group. MEASUREMENTS AND MAIN RESULTS: Follow-up assessments performed at postablation months 6, 12, and 24 revealed the following: The rate of amenorrhea (78.05% vs 46.34%, 85.37% vs 53.65%, and 87.80% vs 58.54%, respectively; p <.005) and the rate of dysmenorrhea remission (100% vs 70.59%, 100% vs 64.70%, and 100% vs 64.70% [p <.05, p <.01, and p <.01], respectively) were significantly higher in the NovaSure+LNG-IUS group than in the NovaSure group. The rate of reinterventions was similar for both groups at postablation month 6. However, at postablation months 12 and 24, these rates were significantly lower in the NovaSure+LNG-IUS group than in the NovaSure group (0 vs 14.63% and 2.44% vs 21.95% [p <.05 and p <.01], respectively). CONCLUSION: For women with AUB, the combination of NovaSure endometrial ablation and LNG-IUS is more effective than NovaSure alone in achieving amenorrhea, alleviating dysmenorrhea and reducing reinterventions.

Provision of immediate postpartum intrauterine contraception after vaginal birth within a public maternity setting: Health services research evaluation.

INTRODUCTION: Expanding access to postpartum intrauterine contraception (PPIUC) can reduce unintended pregnancies and short inter-pregnancy intervals; however, provision across Europe is limited. Our aim was to determine the feasibility, clinical outcomes and patient satisfaction of providing immediate PPIUC after vaginal birth using a health services research model. MATERIAL AND METHODS: Phased introduction of PPIUC across two Lothian maternity hospitals; all women intending vaginal birth during the study period without a contraindication to use of the method were eligible to receive PPIUC. Midwives and obstetric doctors were trained in vaginal PPIUC insertion using Kelly forceps. Women received information antenatally and had PPIUC insertion of either a levonorgestrel intrauterine system or a copper intrauterine device within 48 hours of vaginal birth. Follow-up was conducted in-person at 6 weeks postpartum and by telephone at 3, 6 and 12 months. Primary outcomes were: uptake, complications (infection, uterine perforation), expulsion and patient satisfaction at 6 weeks; and method of continuation up to 12 months. Secondary outcomes included hazard ratio for expulsion adjusted for demographic and insertion-related variables. RESULTS: Uptake of PPIUC was 4.6% of all vaginal births; 465/447 (96.1%) of those requesting PPIUC successfully received it and most chose a levonorgestrel intrauterine system (73%). At 6 weeks postpartum, the infection rate was 0.8%, there were no perforations and 98.3% of women said they would recommend the service. The complete expulsion rate was 29.8% (n = 113) and most had symptoms (n = 79). Of the additional 121 devices removed, 118 were because of partial expulsion. The rate of complete/partial expulsion was higher for insertions by midwives compared with those by doctors. The re-insertion rate after expulsion/removal was 87.6% and method continuation at 12 months was 79.6%. CONCLUSIONS: Routine PPIUC at vaginal birth is feasible. Complications were extremely rare. High expulsion rates may be observed in early stages of service introduction and with inexperienced providers. Re-insertion and therefore longer-term continuation rates of intrauterine contraception were very high. In settings with low rates of attendance for interval postpartum intrauterine contraception insertion, PPIUC could be a useful intervention to prevent unintended and closely spaced pregnancies.

Differences in continuation rates and early removal between contraceptive and therapeutic use of the levonorgestrel-releasing intrauterine system 52 mg.

Objective: To investigate differences in continuation rates between contraceptive and therapeutic use of the levonorgestrel-releasing intrauterine system 52 mg (LNG-IUS) and factors associated with early removal.Methods: Study design: Retrospective consecutive cohort design.Cohort: Women with the insertion of the LNG-IUS for contraceptive or therapeutic use from 1 January 2006 through 1 January 2009 at the Zuyderland Medical Centre, The Netherlands, with a follow-up of 5 years. The continuation period and reasons of early removal were noted. Univariable and multivariable analysis were performed.Results: Follow-up was possible in 2481 women, 1855 (74.8%) in the contraception group, and 626 (25.2%) in the therapy group. Multivariable Cox proportional hazards models showed, that therapeutic use was associated with an increased risk of early removal of the LNG-IUS (HR 1.23; 95% CI 1.08-1.41), as was having one child (HR 1.20; 95% CI 1.04-1.38), and a decreased risk with advancing age (HR 0.96; 95% CI 0.95-0.97). In both groups, an unacceptable bleeding pattern and adverse events were the main reasons of early removal, resulting in very low continuation rates over the years.Conclusion: Therapeutic use, having one child and a younger age are independent risk factors of early removal of the LNG-IUS, in contrast with previous LNG-IUS use which is associated with a lower risk. In both the contraception group and the therapy group, the main reasons for LNG-IUS discontinuation are continuation with a new LNG-IUS, and no more need for an LNG-IUS (for contraception or therapy). An unacceptable bleeding pattern or adverse events are associated with the lowest continuation rates in both groups.

The effect of early vs. delayed postpartum insertion of the LNG-IUS on breastfeeding continuation: a systematic review and meta-analysis of randomised controlled trials.

Objective: The aim of the study was to compare early vs. delayed postpartum insertion of the 52 mg levonorgestrel intrauterine system (LNG-IUS). Methods: The databases of PubMed, Scopus, Web of Science and CENTRAL were searched to February 2019. The search comprised randomised controlled trials (RCTs) comparing early vs. delayed postpartum insertion of the LNG-IUS. Data were extracted and combined in a meta-analysis. Pooled results were expressed as the relative risk (RR) with 95% confidence interval (CI). The main outcome measures were breastfeeding continuation, LNG-IUS expulsion, uterine perforation, LNG-IUS use, satisfaction and number of pregnancies. Results: Twelve RCTs were included, comprising 1006 women in total. Our analysis indicated no significant difference between early and delayed insertion of the LNG-IUS in terms of any breastfeeding continuation (RR 0.99; 95% CI 0.84, 1.16; p = 0.88). After removal of heterogeneity, there was a statistically significant superiority in LNG-IUS use at the endpoint in the early insertion group compared with the delayed insertion group (RR 1.27; 95% CI 1.07, 1.51; p = 0.006). LNG-IUS expulsion was significantly less in the delayed insertion group in comparison with the early insertion group (RR 5.32; 95% CI 2.68, 10.53; p = 0.00001). No significant differences were found between the groups in satisfaction, number of pregnancies and risk of uterine perforation. Conclusion: Early postpartum insertion of the LNG-IUS has no negative effects on breastfeeding continuation. Early postpartum insertion may be used as an alternative to delayed postpartum insertion.

Tratamiento de adenomioma polipoide atípico en paciente nuligesta mediante resección histeroscópica y dispositivo intrauterino de levonorgestrel / Treatment of atypical polypoid adenomyoma in a nulligravida patient by hysteroscopic resection and levonorgestrel-releasing intrauterine system

El adenomioma polipoide atípico uterino fue descrito por primera vez por Mazur. Tradicionalmente ha sido considerado un tumor benigno, sin embargo, recientes estudios han demostrado su potencial de malignización y una posible relación con la hiperplasia endometrial atípica y el carcinoma endometrial. La edad media de aparición es de 35-40 años, por lo que es fundamental el tratamiento conservador, ya que en muchos casos se trata de pacientes nuligestas. Así pues, una opción terapéutica en estos casos puede ser la resección histeroscópica transcervical, que permite de forma concomitante tanto el tratamiento como el diagnóstico definitivo, asociado a tratamiento hormonal con gestágenos. En este artículo, reportamos el caso clínico de una mujer nuligrávida con el diagnóstico de adenomioma polipoide atípico, que se trata mediante una resección histeroscópica y la inserción posterior de un dispositivo intrauterino liberador de levonorgestrel

Atypical polypoid adenomyoma of the uterus was first reported by Mazur. Traditionally it was considered to be a benign tumor, but recent studies demonstrated a possible relation with atypical endometrial hyperplasia, endometrial carcinoma and its potential for malignancy. The common age of onset is approximately 35-40 years, so conservative treatment is essential, since in many cases these patients are nulligravida. So, a man option can be a hysteroscopic resection transcervical for the treatment and the diagnosis at the same time, associated with hormonal treatment with gestagens. In this article, we report a case of a nulligravida woman with an atypical polypoid adenomyoma, which is treated by hysteroscopic resection and the postinsertion of a levonorgestrel-releasing intrauterine system

Prevalence and predictors of initiation of intrauterine devices and subdermal implants immediately after surgical abortion.

OBJECTIVES: To estimate uptake of long-acting reversible contraception (LARC) methods immediately after surgical abortion in a system that makes these methods readily available, and to determine demographic, medical, social, and visit-specific predictors of immediate post-abortion intrauterine device (IUD) and implant initiation. STUDY DESIGN: We performed a retrospective cohort study of LARC (levonorgestrel intrauterine system [IUS], copper IUD, and subdermal implant) initiation at the time of surgical abortion up to 21w0d gestation at Planned Parenthood League of Massachusetts from 2012 through 2017. We calculated proportions of IUD and implant initiation and used mixed effect logistic regression to estimate predictors of each outcome. RESULTS: Among 26,858 surgical abortion patients, 25.4% received immediate post-abortion LARC: 14.2%, 4.2%, and 7.0% received a levonorgestrel IUS, copper IUD, and implant, respectively. Compared to White women, Black women had lower odds of initiating an IUD (aOR 0.81, 95% CI 0.74-0.89). Multiparous women had greater odds than nulliparous women of initiating an IUD (aOR 1.69, 95% CI 1.57-1.82) or implant (aOR 1.36, 95% 1.20-1.53). We found age was the strongest predictor of implant initiation (<18 versus≥35: aOR 3.26, 95% CI 2.26-4.71), but was not associated with IUD uptake. Gestational age was not associated with IUD or implant uptake. Implant uptake increased from 2.4% (2012) to 8.7% (2017) (aOR 3.65, 95% CI 2.36-5.65) while IUD uptake remained fairly constant. CONCLUSION: About 25% of women chose to initiate intrauterine or implantable contraception immediately after surgical abortion when these methods are readily available. Implant uptake has increased significantly in recent years. Women who initiated IUDs and implants differed in their demographic and social profiles. IMPLICATIONS: Women seeking surgical abortion should have same-day access to IUDs and implants. Clinicians and researchers should analyze IUD and implant initiation separately.

Sexual function and quality of life in a cohort of brazilian users of two kind of intrauterine contraceptives / Função sexual e qualidade de vida em uma amostra de brasileiras usuárias de dois tipos de contraceptivos intrauterinos

Abstract Objective To compare sexual function and quality of life (QOL) among intrauterine contraceptive (copper-intrauterine device [Cu-IUD] or the 52-mg 20 μg/day levonorgestrel- releasing intrauterine system [LNG-IUS]) users. Methods This was part of a cross-sectional study. Women aged between 18 and 49 years old, in a heterosexual relationship, reporting sexual intercourse in the previous 4 weeks, using Cu-IUD (Group 1) or LNG-IUS (Group 2) responded to a questionnaire with sociodemographic information, to the Female Sexual Function Index (FSFI), to the World Health Organization QOL Questionnaire Abbreviated Version (WHOQOL-BREF), and to a questionnaire about the contraceptive method used. The Student t-test, the Pearson χ2 test or the Fisher exact test, and the Mann-Whitney test were used for the analysis. For the adjusted comparison, we have used the analysis of covariance (ANCOVA). A multiple regression analyzing factors related to FSFI 26.55 was done. Significance was established at p < 0.05. Results A total of 347 women in Group 1 (mean age of 32.3 ± 7.5 years old) and of 298 in Group 2 (mean age of 32.7 ± 6.4 years old) completed the questionnaires.Most women had ≥ 8 years of schooling, were in amonogamous relationship, and had had ≤ 2 pregnancies. A total of 122 Cu-IUD and of 87 LNG-IUS users scored ≤ 26.55 on the FSFI. Significant lower scores in physical, environmental, and overall QOL domains in the WHOQOL-BREF questionnaire were found in Group 1. More women using the Cu- IUD were not satisfied with the method. Conclusion We did not find significant differences in sexual function; there was a lower score in some domains of QOL among women who used the Cu-IUD. It was not possible to ensure that those differences were related to the contraceptive method.

Resumo Objetivo Comparar a função sexual e a qualidade de vida (QV) entre usuárias de contraceptivos intrauterinos (dispositivo intrauterino com cobre [DIU-cobre] ou sistema intrauterino liberador de levonorgestrel [SIU-LNG 52 mg 20 μg/dia]. Métodos O presente estudo foi parte de um estudo de corte transversal. Mulheres com idades entre 18 e 49 anos, em relacionamento heterossexual, relatando relação sexual nas 4 semanas anteriores, utilizando DIU-cobre (Grupo 1) ou SIU-LNG (Grupo 2) responderam ao questionário com informações sociodemográficas, ao Índice de Função Sexual Feminino (IFSF), ao Questionário de QV da Organização Mundial de Saúde, versão abreviada (WHOQOL-BREF, na sigla eminglês), e a umquestionário sobre ométodo contraceptivo utilizado criado para o presente estudo. Os testes t de Student, o teste χ2 de Pearson, o teste exato de Fisher e o teste de Mann-Whitney foram utilizados. A análise de covariância (ANCOVA) foi utilizada para a comparação ajustada. Foi realizada a análise de regressão logística multivariada analisando fatores associados ao IFSF ≤ 26.55. O nível de significância foi p < 0.05. Resultados Um total de 347 mulheres no Grupo 1 (idade média 32,3 ± 7,5 anos) e de 298 no Grupo 2 (idade média 32,7 ± 6,4 anos) completaram os questionários. A maioria das mulheres relatou ≥ 8 anos de escolaridade, estava emrelaçãomonogâmica e teve ≤ 2 gestações. Um total de 122 e de 87 usuárias do DIU-cobre e do SIU-LNG, respectivamente, pontuaram ≤ 26,55 no IFSF. Pontuações significativamente menores nos domínios físico, meio-ambiente e QV geral no WHOQOL-BREF foram encontrados no Grupo 1. Mais mulheres do Grupo 1 estavam insatisfeitas com o método. Conclusão Não encontramos diferenças na função sexual, entretanto havia menores pontuações em certos domínios da QV entre as usuárias do DIU-cobre. Não foi possível afirmar relação dessas diferenças com os métodos.