Contraception as a therapeutic option in the treatment of menorrhagia
H.O.D. Critchley
University of Edinburgh, Scotland
The levonorgestrel-releasing intrauterine system (Mirena®) is used by over
three million women. Mirena® is an extremely effective contraceptive
particularly for the woman who seeks a long-term, reversible method. A major
feature of the Mirena® system is the non-contraceptive but very beneficial
associated health benefits with use. Use is associated with a dramatic reduction
in menstrual blood loss and there is a documented lower risk of anaemia with use
of a Mirena® system. The mechanism of action by which menstrual blood loss is
reduced or abolished is a consequence of the local action of levonorgestrel on
the endometrium. Excessive menstrual bleeding (menorrhagia; greater than 80 ml
loss of blood per menses) is a common gynaecological problem in women of
reproductive age. At least 50% of patients who complain of excessive
menstruation have no evidence of any uterine pathology. In Europe, heavy
menstrual bleeding has become a major indication for use of this intrauterine
contraceptive system.
Effective medical treatments suitable for long-term use
include the Mirena® sytem, antifibrinolytic agents (tranexamic acid) and
non-steroidal anti-inflammatory agents (mefenamic acid). There are not
sufficient good-quality trial data to provide the evidence to adequately assess
the effectiveness of the combined oral contraceptive pill. Long-acting depo
progestogens may offer health benefits in women with heavy menses requiring
contraception. Up to two-thirds of users experience amenorrhoea by 2 years of
use. Concerns do, however, exist about related side-effects with long-term use
(a small decrease in bone density after 5 years and changes in lipid profiles
among long-term users). Importantly, amenorrhoea is now being seen by women as
an advantageous side-effect of certain regimens of hormonal management, for both
contraception and menstrual blood flow problems.
Until recently, hysterectomy
was the only surgical option for women with menorrhagia resistant to medical
treatment. Recent developments in gynaecological endoscopy have given rise to
new and less invasive techniques, such as transcervical resection of the
endometrium and other second-generation endometrial ablative techniques, as
conservative surgical approaches to management of menorrhagia. A long-term (mean
5.1 years follow-up) review has reported that hysterectomy may be avoided in 76%
of women, with no overall difference in satisfaction between the hysterectomy
and endometrial resection groups. There is evidence from randomized controlled
trials that efficacy in reduction of menstrual blood loss with a Mirena® system
is equivalent to the blood loss reduction achieved with endometrial ablation.
Two-thirds of women were reported to defer their plans for hysterectomy after a
6-month trial of a Mirena® intrauterine system. Recently published data
concerning clinical outcomes and costs of Mirena® and hysterectomy at 5 years of
follow-up indicate that, although 42% of women assigned in a randomized
controlled trial to treatment with Mirena® subsequently underwent hysterectomy,
the overall direct costs and productivity losses were 40% lower in the Mirena®
group. The women in general were equally satisfied with Mirena® and hysterectomy.The
levonorgestrelreleasing intrauterine system therefore provides an excellent
reversible alternative to surgery for women with menorrhagia who also seek
reliable long-term contraception.
