Grand Rounds: Don't forget the other benefits of the levonorgestrel IUS

January 1, 2007

Although officially approved as a contraceptive, the device is also finding a role in several benign gynecologic disorders. One expert examines the evidence for its use in menorrhagia, fibroids, endometriosis, adenomyosis, and endometrial hyperplasia.

While millions of women worldwide enjoy the contraceptive benefits of the levonorgestrel intrauterine system (LNG IUS), clinicians sometimes forget about the noncontraceptive benefits of the system. The device can help treat a variety of gynecologic problems in symptomatic patients even when they have no need for a contraceptive.

While the health benefits of hormonal contraception are well established, estrogen is contraindicated in some patients, and not all women tolerate systemic progestin.1 The LNG IUS offers many of the same health benefits of systemic hormonal contraception, including reduction in menstrual flow, dysmenorrhea, and pelvic pain symptoms. But in contrast to the systemic delivery of pills, patches, injections, and rings, the IUS releases levonorgestrel directly into the uterine cavity, which means it keeps systemic levels relatively low. For most patients, this translates into fewer hormone-related symptoms.2 Although contraception remains the only FDA-approved indication for the LNG IUS, the system's strong local effects on the endometrium and cervix benefit women with various benign gynecological conditions, including menorrhagia, dysmenorrhea, leiomyomata, adenomyosis, and endometriosis.3 There is also evidence to suggest the device protects the endometrium during postmenopausal estrogen replacement therapy and it's possible the device may also be of value in treating endometrial hyperplasia.4-6

A unique approach to menorrhagia

More importantly, this strong endometrial suppression leads to a marked reduction in menstrual blood loss (hypomenorrhea) or to amenorrhea in women with excessive bleeding. This powerful effect has made treatment of menorrhagia the leading off-label non-contraceptive indication for the LNG IUS. [A number of studies support the use of the LNG IUS as an effective, conservative option for women with idiopathic menorrhagia that also preserves reproductive function and avoids the costs and risks of surgery.] In one study, women failing conventional therapy for bleeding saw a 98% drop in average menstrual blood loss 2 years after insertion of the device. It's important to note that this improvement occurred early on, with approximately one third of the women reporting amenorrhea and one fourth reporting spotting by 6 months.9 In fact, the LNG IUS outperforms other hormonal and nonhormonal medical options for bleeding.10,11

An alternative to surgery

Not surprisingly, since excessive menstrual bleeding is a common cause of anemia in fertile women, the profound reduction in bleeding associated with the IUD causes sustained increases in hemoglobin, hematocrit, and serum ferritin.2,17,18