Levonorgestrel IUD offers localized progesterone delivery for endometrial protection during hormone therapy, with minimal systemic effects.
The levonorgestrel intrauterine device (IUD) may be an effective option for endometrial protection in women receiving estrogen therapy for menopause symptom management, according to Michelle Wise, MD, MSc, FRSCS, FRANZCOG, consultant gynecologist and associate professor at the University of Auckland in Auckland, New Zealand. Wise discussed these findings during a presentation at the 2025 Annual Meeting of The Menopause Society.1
Wise noted that while the hormone IUD is widely used for endometrial protection in some regions, including New Zealand, comparative data remain limited. “There’s a lot of evidence around the different progestogens to protect the endometrium from the effects of estrogen that people are using to help with their symptoms of menopause,” she said. “However, direct trials comparing the hormone IUD or the levonorgestrel intrauterine system to other types of progestogens are actually not as much as we would like.”
She explained that in New Zealand, the IUD is approved for endometrial protection during hormone therapy for five years, but this is not the case globally. “When we actually looked into the research of the evidence base for that, there’s actually only a handful of trials,” she said, adding that because endometrial hyperplasia and cancer are relatively rare, larger studies are needed to fully assess outcomes.
In clinical practice, Wise said she counsels patients about the benefits and potential side effects of IUD placement. “I usually talk about the benefits and how it’s fit and forget, and you just put it in and it’s there for five years,” she said. Early side effects can include cramping, spotting, or mild discomfort during the insertion procedure. “For the first three months, some people—it’s six months—as that lining is getting thinner and it’s shedding, they’re going to expect some unscheduled bleeding, and that’s normal,” she emphasized. “I really emphasize that point because I don’t want them to get so annoyed by that symptom and expected side effect that then they’ll want it removed.”
Wise said the decision between progesterone options should be individualized. “As far as I have read the research studies, they’re all going to be essentially equivalent,” she said. “So you’re looking at, really, what are the side effects, how tolerable it is, any potential risks of taking them. So really, it’s patient choice.”
For many patients, particularly those in perimenopause who still require contraception, the levonorgestrel IUD provides added convenience. “It’s protecting the endometrium. It’s providing amazing contraception. They don’t have to think about it, they don’t have to take pills every day,” she said. “This is delivering a tiny, tiny amount of progesterone every day, right where it needs to be, so you’re not getting full body side effects.”
Wise highlighted the need for more robust evidence comparing intrauterine and systemic progesterone delivery. “Out of those 72 trials [of hormone therapy for endometrial protection], only 3 looked at the hormone IUD,” she said.2 “I would love to do an international trial looking at the hormone IUD compared to non-intrauterine methods of getting the progesterone, and looking at 1-, 2-, and 5-year follow-up for endometrial hyperplasia or uterine cancer.”
Despite limited research, Wise emphasized that the levonorgestrel IUD remains a strong option for many women. “It’s a really good option for women to use, because we know that it’s going to have all these additional benefits that you may not get with some of the other oral or transdermal progesterone,” she said. “About 80% of women will not have any bleeding or spotting at all at one year.”
She added that the device is particularly useful for women transitioning from perimenopause to menopause who already have an IUD in place. “They might start getting hot flashes, and then it’s easy to just keep it in, so you’ve got that progesterone protection already, and then you just add in the estrogen,” she said. “That’s a really nice option.”
Wise reports no relevant disclosures.
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