Contraception as a therapeutic option in the treatment of menorrhagia

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.

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