The role of levonorgestrel intra‐uterine system in the management of adenomyosis: A systematic review and meta‐analysis of prospective studies

Abstract

Introduction: The levonorgestrel intrauterine system (LNG-IUS) is a long-acting hormone-releasing uterine device that has many non-contraceptive benefits. The study aims to assess the safety and efficacy of LNG-IUS in the management of adenomyosis. Material and methods:We searched the following bibliographic databases: MEDLINE via PubMed, SCOPUS, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE and Google Scholar for the relevant studies which used LNG-IUS in management of patients with clinically or ultrasonographic diagnosed adenomyosis.The main outcome measures are pain score at the end of follow-up, bleeding, symptomatic relief, uterine volume (mL), endometrial thickness (mm) and/or hemoglobin level.Results: Ten prospective studies (patients n = 551) were included. The overall effect estimates showed that the LNG-IUS led to significant reductions in pain score after 12 months (standardized mean difference [SMD[ −3.87, 95% confidence interval [CI] −5.51 to −2.23, P < .001), 24 months (SMD −5.56, 95% CI −9.80 to −1.32, P = .01) and 36 months of insertion (SMD −3.81, 95% CI −4.27 to −3.36, P < .001). Similarly, the Pictorial Blood Assessment Chart (PBAC) showed significant reduction up to 36 months after LNG-IUS insertion (SMD −2.32, 95% CI −2.91 to −1.73, P < .001).The LNG-IUS led to significant reductions in the uterine volume 12 months (SMD −.60, 95% CI −0.88 to −.31, P < .001) and 36 months after insertion (SMD −0.42, 95% CI −0.69 to −0.14, P = .003). Conclusions:LNG-IUS is a promising and effective option for the management of adenomyosis. Its use effectively reduced the severity of symptoms, uterine volume and endometrial thickness, and improved laboratory outcomes. K E Y W O R D Sadenomyosis, hormonal intrauterine device, levonorgestrel intrauterine system, pain relief

Current and Prospective Treatment of Adenomyosis

“…The overall effect estimates showed that the use of LNG-IUD leads to significant reduction of pain scores starting at 3 months (standard mean difference [SMD] −1.91, p = 0.002) and persisting at 36 months (SMD −3.81, p < 0.001). Similar trends were noted when assessing heavy menstrual bleeding (SMD −3.58, p < 0.001 at 3 months, SMD −2.32, p < 0.001 at 36 months), and uterine volume (SMD −0.47, p < 0.001 at 6 months, SMD −0.42, p < 0.001 at 36 months) [ 27 ]. Hemoglobin levels were also shown to significantly increase after treatment with the hormonal IUD at 6 months (SMD 1.71, p < 0.001) continuing till 12 months after insertion (SMD 1.6, p = 0.004) [ 27 ].…”

“…Similar trends were noted when assessing heavy menstrual bleeding (SMD −3.58, p < 0.001 at 3 months, SMD −2.32, p < 0.001 at 36 months), and uterine volume (SMD −0.47, p < 0.001 at 6 months, SMD −0.42, p < 0.001 at 36 months) [ 27 ]. Hemoglobin levels were also shown to significantly increase after treatment with the hormonal IUD at 6 months (SMD 1.71, p < 0.001) continuing till 12 months after insertion (SMD 1.6, p = 0.004) [ 27 ].…”

“…Uterine volume was also shown to decrease in both treatment arms but more significantly in the LNG-IUD group (10.23 to 7.63 mL with the use of IUD versus 10.42 to 8.32 in the OCP group) [ 26 ]. In a recent systematic review by Abbass et al, LNG-IUD was found to be a highly effective option for the management of adenomyosis [ 27 ]. The overall effect estimates showed that the use of LNG-IUD leads to significant reduction of pain scores starting at 3 months (standard mean difference [SMD] −1.91, p = 0.002) and persisting at 36 months (SMD −3.81, p < 0.001).…”

Progesterone Actions and Resistance in Gynecological Disorders

“…GnRH agonists are effective in causing systemic hypoestrogenism to reduce the size of adenomyosis and improve adenomyosis-associated symptoms [ 153 , 154 , 155 ], whereas the side effects of GnRH agonists (menopausal symptoms) limit their use. LNG-IUD has been considered most effective and successfully used to treat adenomyosis because it is efficient in suppressing menstrual bleeding [ 156 , 157 , 158 , 159 , 160 ]. The efficacy of LNG-IUD is generally higher than other progestin-based treatments [ 151 , 152 ].…”

Barriers to self‐management of patients with adenomyosis: A qualitative study

“…Multiple treatments have been recommended, including hormone therapy, traditional Chinese medicine treatment (CMT), surgery, interventional radiology, minimally invasive therapy and high‐intensity focused ultrasound (HIFU) (Streuli et al., 2014 ; Vannuccini et al., 2018 ; Zeng & Li, 2017 ; Zhou et al., 2011 ). Hysterectomy is the only definitive treatment to cure adenomyosis (Abbas et al., 2020 ); however, it is unacceptable for those young patients who want to keep their fertility.…”