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.