Endometriosis
David M. Luesley, Mark D. Kilby in 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
Barry G. Wren in 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.
Paper 2
Aalia Khan, Ramsey Jabbour, Almas Rehman in nMRCGP Applied Knowledge Test Study Guide, 2021
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.
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).
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].
High-intensity focused ultrasound (HIFU) combined with gonadotropin-releasing hormone analogs (GnRHa) and levonorgestrel-releasing intrauterine system (LNG-IUS) for adenomyosis: a case series with long-term follow up
Published in International Journal of Hyperthermia, 2019
Sun Haiyan, Wang Lin, Huang Shuhua, Wei Wang
HIFU ablation was performed using the HIFUNIT-9000 system (Shanghai A&S Co. Ltd, Shanghai, China). The patients were placed in the supine position. First, location, size, and morphological characteristic of adenomyosis were identified by external b-mode sonography. Next, the detecting head of this system would complete the re-localization of the therapy area. Finally, the ablation energy focus was controlled to move along with a three-dimensional axis orderly until to cover the target lesions. The main HIFU parameters of treatment in this study were the following: ultrasonic frequency, 1 MHz ± 50KHz; output power, >3000 W/cm2; therapy depth, 2–15 cm; practice-focused sphere,3 × 3 × 8 mm; unit transmit time (t1) 150 × 300 ms; intermission time (t2), 200–400ms; and HIFU times at each lesion, 8–10 times; time spend of single session of HIFU, 40 min; the average power per sonication, 80–100 W. All of the parameters could be varied depending on the depth of the tumor. As adjuvant therapy, within 1 week after the last time of HIFU ablation, GnRHa (triptorelin) was given at a dose of 3.75 mg by intramuscular injection every four weeks for a total of 6 doses. Levonorgestrel-releasing intrauterine system (LNG-IUS) was also performed within 1–3 days after the last dose of GnRHa. For the majority of patients, LNG-IUS would be removed after 5 years.
Related Knowledge Centers
- Birth Control
- Endometrial Hyperplasia
- Fertility
- Levonorgestrel
- Uterus
- Intrauterine Device
- Progestogen
- Hormone
- Heavy Menstrual Bleeding
- Hormone Replacement Therapy