Levonorgestrel-Releasing Intrauterine Device (LNG-IUD) for Symptomatic Endometriosis Following Surgery

A Cochrane review [Abstract] 1 included 4 RCTs with a total of 157 women. There was a reduction in the recurrence of painful periods in the LNG-IUS group compared with expectant management (delta of median visual analogue scale (VAS) 81 versus 50 in two trials, P=0.006, n=55; and the fall in VAS was 50 (35 to 65) versus 30 (25 to 40) in a third trial, P=0.021, n=40). The proportion of women who were satisfied with their treatment was higher in the LNG-IUD group than in the control group (75% vs 50% in one trial and more women were "very satisfied" in another trial).

A meta-analysis 2 included 4 RCTs (n=212), 1 prospective cohort study (n=88), and 2 retrospective studies (n=191). Efficacy of LNG-IUS was compared with other treatments as a postoperative maintenance therapy. LNG-IUS was effective in reducing pain after surgery (MD = 12.97, 95% CI 5.55 to 20.39), with a comparable effect to gonadotropin-releasing hormone analogues (MD = -0.16, 95% CI -2.02 to 1.70). LNG-IUS was also effective in decreasing the recurrence rate (RR = 0.40, 95% CI 0.26 to 0.64), with an effect comparable to oral contraceptives (OR = 1.00, 95% CI 0.25 to 4.02), and danazol (RR = 0.30, 95% CI 0.03 to 2.81). Furthermore, patients' satisfaction with LNG-IUS was significantly higher than that with oral contraceptives (OR = 8.60, 95% CI 1.03 to 71.86). However, vaginal bleeding was significantly higher in the LNG-IUS group than in the gonadotropin-releasing hormone analogue group (RR = 27.0, 95% CI 1.71 to 425.36).

An RCT 4 evaluated the clinical and cost-effectiveness of 150 mg depot medroxyprogesterone acetate or 52 mg LNG-IUS compared with the combined oral contraceptive pill (COC, 30 µg EE with 150 µg levonorgestrel) in preventing recurrence (n=405). In 3 years follow-up, pain scores improved in both groups (24 and 23 points on average) compared with preoperative values, there was no difference between the groups. The long-acting reversible contraceptive group underwent fewer surgical procedures or second-line treatments compared with the COC group (73 vs. 97; hazard ratio 0.67, 95% CI 0.44 to 1.00).

A retrospective case control study 3 assessed the effect of LNG-IUS on symptomatic postoperative recurrence in patients with ovarian endometrioma coexisting with adenomyosis, During a median 79 months of follow-up, patients with LNG-IUS experienced a significantly lower symptomatic recurrence of either ovarian endometrioma or dysmenorrhea (11.1% vs. 31.1%, p = 0.013), compared with women under expectant observation. Patients treated with LNG-IUS demonstrated a more prominent reduction in uterine volume (-14.1 ± 20.9 vs. 8.7 ± 48.8, p = 0.003) and higher percentage of complete pain remission (95.6% vs. 86.5%).

Comment: The quality of evidence is downgraded by study quality (unclear blinding of participants and personnel).

References

• Gibbons T, Georgiou EX, Cheong YC et al. Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery. Cochrane Database Syst Rev 2021;(12):CD005072. [PubMed]
• Song SY, Park M, Lee GW et al. Efficacy of levonorgestrel releasing intrauterine system as a postoperative maintenance therapy of endometriosis: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2018;231():85-92. [PubMed]
• Shi JH, Zhu SY, Li XY, et al. The role of levonorgestrel-releasing intrauterine system for recurrence prevention after conservative surgery among patients with coexistent ovarian endometrioma and diffuse adenomyosis: A retrospective case control study with long-term follow up. J Gynecol Obstet Hum Reprod 2023;52(5):102572. [PubMed]
• Cooper KG, Bhattacharya S, Daniels JP, et al. Preventing recurrence of endometriosis-related pain by means of long-acting progestogen therapy: the PRE-EMPT RCT. Health Technol Assess 2024;28(55):1-77.[PubMed]