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Paper 2
Published in Aalia Khan, Ramsey Jabbour, Almas Rehman, nMRCGP Applied Knowledge Test Study Guide, 2021
Aalia Khan, Ramsey Jabbour, Almas Rehman
Reference: http://guidance.nice.org.uk/CG44. Familiarise yourselves with new NICE guidelines; they are popular exam topics and can afford you easy marks if you have done a bit of reading. It is now good practice to offer the levonorgestrel-releasing intrauterine system as first-line therapy for menorrhagia.
Endometriosis
Published in David M. Luesley, Mark D. Kilby, Obstetrics & Gynaecology, 2016
The levonorgestrel-releasing intrauterine system (LNG-IUS) does not suppress ovulation but acts locally on the endometrium. Its effect on extrauterine endometrial tissue is therefore locally mediated. A multicentre randomised trial comparing the LNG-IUS with a GnRH agonist18 reported no difference in pain scores after 6 months [B]. A systematic review of its use following laparoscopic treatment of endometriosis19 reported a significantly reduced incidence of recurrence of painful periods with the LNG-IUS compared with no treatment after 12 months and no significant difference when compared with a GnRH agonist. Although bleeding scores were higher with the LNG-IUS compared with the GnRH agonist, there was no difference in pain or quality-of-life assessments between the two groups. On the basis of these results, the LNG-IUS seems to have a role in the management of pain associated with endometriosis whether as a primary treatment [B] or for prevention of recurrence of pain following surgical treatment [A].
Estrogens in the treatment of climacteric depression, premenstrual depression, postnatal depression and chronic fatigue syndrome
Published in Barry G. Wren, Progress in the Management of the Menopause, 2020
Although estrogens elevate the mood there is still a problem, as women with a uterus would need cyclical progestogen to prevent excess endometrial proliferation. We have previously demonstrated that progestogen may produce depression and irritability, i.e. symptoms of PMS, and depressed women are often progestogen-intolerant30. It is often necessary to change the progestogen, or reduce the dose or the duration each month in order to cut down the progestogenic side-effects31. Early work suggests that the levonorgestrel-releasing intrauterine system (LNG IUS) may be valuable in this situation. The LNG IUS can prevent endometrial proliferation in perimenopausal women using oral or transdermal estradiol32,33. Plasma concentrations of levonorgestrol achieved by the LNG IUS are lower than those seen with oral progestogens; also, unlike with use of oral progestogens, levels with use of the LNG IUS do not display peaks and troughs. It is therefore postulated that using the LNG IUS rather than an oral progestogen to prevent endometrial hyperplasia, would be an ideal way of avoiding progestogenic side-effects in women being treated with estrogens. Work recently completed in our unit showed that adverse progestogenic effects and severity of bleeding were reduced to a minimum when progestogen-intolerant menopausal patients using mainly estradiol implants, even with relatively high serum estradiol levels, were switched from oral progestogens to the LNG IUS. Endometrial suppression was uniform with no cases of endometrial proliferation or hyperplasia at I year and a greater than 60% rate of amenorrhea at this time34.
Progestin or anti-estrogen treatment for endometrial cancer: choosing the best option for selected patients
Published in Gynecological Endocrinology, 2021
Marta Caretto, Tommaso Simoncini
Fertility-sparing treatments should be restricted to women with atypical hyperplasia/endometrioid intra-epithelial neoplasia (AH/EIN) or grade 1 endometrioid carcinoma without myometrial invasion. Hysteroscopic resection followed by the progestin therapy achieve the highest complete remission rate according to recent literature. The progestin therapy includes oral progestin as well as intrauterine progestin application. Medroxyprogesterone acetate (400–600 mg/day) or megestrol acetate (160–320 mg/day) are the recommended oral treatments [3]. Only patients undergoing oral treatment should be informed of major risks or the presentation of systemic adverse effects. Instead, in case of the intrauterine progestin therapy such as levonorgestrel-releasing intrauterine system combined with gonadotropin-releasing hormone receptor agonist or progestin a satisfactory pregnancy rate and a low recurrence rate have been reported. The combination of levonorgestrel intrauterine device with oral progestins with or without gonadotropin-releasing hormone analogs can also be considered. There is a lack of evidence for anti-estrogenic treatment in women who wish to preserve fertility [4].
The effect of a levonorgestrel-releasing intrauterine device on female sexual function
Published in Journal of Obstetrics and Gynaecology, 2021
Gokce Turan, Pinar Yalcin Bahat, Berna Aslan Cetin, Nurullah Peker
The levonorgestrel-releasing intrauterine system (LNG-IUS) was first introduced in 1990 (Gemzell-Danielsson et al. 2013). The main indications of LNG-IUSs include contraception, treatment of heavy menstrual bleeding (HMB), endometriosis and endometrial protection during oestrogen replacement (Hurskainen et al. 2004; Philip et al. 2019). Hysterectomy and LNG-IUSs are the most effective treatment methods (Hurskainen et al. 2004). LNG-IUSs secrete low serum concentrations of levonorgestrel (LNG) (340–380 pmol/l) and are well tolerated (Cim et al. 2018). LNG-IUS creates local effects by secreting daily in the uterine cavity. With this local effect, cervical mucus becomes thickened and inhibits the mobility and activity of sperms (Zalel et al. 2003). In addition, it also stimulates the production of glycodelin A, which is a glycoprotein, from the endometrium, and prevents oocytes and sperm binding, which acts as a contraception effect (Shulman et al. 2004; McCarthy 2006). As well as the contraceptive effect, LNG-IUS causes significant decreases in the volume and duration of the menstrual bleeding because it suppresses the endometrial glands in the endometrium and has a protective effect on the endometrium. For this reason, there is also an increasing use in the treatment of HMB (Phillips 2003). Again, with a similar effect, it also relieves the symptoms of dysmenorrhoea. As well as contraception and HMB treatment, LNG-IUS has been approved for endometrial protection as the part of hormone therapy for menopause symptoms with LNG it releases (Sitruk-Ware and Inki 2005).
Fibroid management in premenopausal women
Published in Climacteric, 2019
J. Donnez, G. E. Courtoy, M.-M. Dolmans
Oral contraceptives, progestins, and the levonorgestrel-releasing intrauterine system may be used ‘off-label’ to treat women with gynecological bleeding disorders, but they are not indicated for management of uterine fibroids because fibroids are progesterone sensitive27 (Table 1). Moreover, the levonorgestrel-releasing intrauterine system is contraindicated in the case of fibroids that distort the uterine cavity28. Gonadotropin-releasing hormone agonist (GnRHa) cannot be used for more than 3–6 months at a time, as it has side-effects (like hot flushes and vaginal dryness) and may reduce bone mineral density. Control of bleeding is achieved faster with newer drugs like ulipristal acetate (UPA; see later) than with GnRHa and, importantly, UPA delivers a sustained effect, while rapid fibroid regrowth is observed after completion of GnRHa therapy29 (Figure 2).