Insertion of the levonorgestrel intrauterine system (LNG-IUS) in
post-menopausal women
T. Masters (3), R.E. D’Souza (1), W. Bounds (2), J. Guillebaud (2)
Margaret Pyke Memorial Trust Research Unit, Department of Obstetrics and
Gynaecology, University College London, UK (1); Retired from Margaret Pyke
Memorial Trust Research Unit (2); Formerly Margaret Pyke Memorial Trust Research
Unit, now Brook (Avon), Bristol, UK (3)
Objective: There is growing evidence to support intrauterine
progestagen delivery in HRT and this can be achieved with the LNG-IUS (Mirena®
– Schering). However, clinicians may be concerned that insertion of the LNG-IUS
in the post-menopausal state might be difficult. We present information on the
insertion procedures of a cohort of post-menopausal women who had an LNG-IUS
fitted.
Design & Methods: One hundred and ten women aged between 45 and 60
years with confirmed post-menopausal status had an attempted fitting of the
LNG-IUS within an open randomized comparative trial of the LNG-IUS plus oral
oestrogen versus a combined oral sequential preparation. These insertion data
were secondary outcome measures within the study, which took place at a research
unit in central London. Intervention: Those with no previous HRT use (n=72) used
estriol cream 0.1% vaginally for one week prior to the insertion. There was no
wash-out period for current HRT users (n=38). The procedure was performed on a
flat examination couch by one of four experienced clinicians. Pre-insertion oral
analgesia and paracervical block (with 10ml 1% lidocaine) was used, unless the
woman declined either. The IUS inserter used was the old 2-handed version. The
clinician assessed the insertion as ‘easy’ or ‘difficult’ and the woman
assessed the pain of insertion as ‘none’, ‘mild’, ‘moderate’ or ‘severe’.
Results: In only one woman was insertion not achieved (the procedure
was abandoned because the uterine cavity felt abnormally small on sounding). The
clinician rated the insertion procedure as ‘easy’ in 66 (60%) and ‘difficult’
in 43 (40%). Ninety three women (85%) had a paracervical block and 43 (39%) had
cervical dilatation. 17 (16%), 66 (61%), 21 (19%) and 5 (5%) described no, mild,
moderate or severe pain, respectively. In five women the LNG-IUS was
inadvertently removed during removal of the applicator (n= 3), speculum (n= 1)
or whilst cutting the threads (n= 1). All immediately had a subsequent
straightforward reinsertion. In one case ultrasound assessment was required to
establish uterine position prior to insertion.
Conclusions: There was a low level of problems during insertion of the
IUS within this group of postmenopausal women. Clinicians experienced in IUS
insertion and familiar with local anaesthetic techniques and cervical dilation
are unlikely to encounter excessive problems during IUS insertion for
post-menopausal women.
