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MRCOG PART 2 SBAs and EMQs

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ESSAY 145 - MIRENA

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		Posted by Sarwat F. Mon Feb 7, 2005 07:26 am
Levonorgestrel releasing intrauterine system contains 52mg Levonorgestrel around the stem of the intrauterine device which is released at the rate of 20mcg / day. It is licensed for contraception for 5 years. It provides effective contraception with an efficacy of 0.3 per 100 women years. It is associated with quick return of fertility on discontinuation of the method as after removal, endometrial morphology returns to normal with menstruation within 30 days. It can not however be used for emergency contraception Besides contraception it has many other non-contraceptive uses and benefits which include use for dysfunctional uterine bleeding and menorrhagia. It is now also licensed as a treatment for \"idiopathic menorrhagia. It is associated with reduction in menstrual blood loss of up to 97% after 12 months of use. This also helps in improving anemia with an increase in serum ferritin and hemoglobin concentrations. Among women using this method, amenorrhoea rate at 1 year is found to be 35%. It is also used for dysmenorrohea as well as for premenstrual tension. Dysmenorrohea is relieved in 80 percent cases with use of LNGIUS. It is also used as progesterone opposition in oestrogen therapy for example estradiol implants and high dose estradiol skin patchesfor PMS. There is some evidence that it can provide symptomatic improvement for endometriosis, however further research is needed before its acceptance for use in endometriosis. Preliminary data suggest that it might also be useful for the management of endometrial hyperplasia in women who do not wish to undergo surgical procedures however clear guigelines are still awaited on this subject. Another advantage of mirena is that it is associated with low rate of ectopic pregnancy as compared to copper IUD users and sexually active women not using contraception. This helps in reassuring women regarding risk of ectopic pregnancy. It provides protection against pelvic inflammatory disease by causing thickening of cervical mucus, inactivation of the endometrium and reduced bleeding. It can provide progestogenic arm for oestrogen replacement therapy in HRT. This enables women to use estrogen only preparations for menopausal symptoms having LNGIUS inserted for endometrial protection. There is some evidence that the incidence of uterine fibroids and their growth is reduced with use of mirena. As compared to hysterectomy and medical treatment of menorrhagia it is cost-effective as well as it is not associated with anaesthetic and surgical complications of operative procedure. Studies are being conducted to establish its effectiveness in preventing and treating endometrial hyperplasia induced by tamoxifen. It is however associated with certain disadvantages which include difficulties with insertion especially in nulliparous women and cervical dilatation may be required under para-cervical block or analgesic medicines. It also needs detailed counseling regarding breakthrough bleeding and amenorrohea as it takes 3 months for endometrial atrophy and women may experience some irregular bleeding during this period. Therefore good counselling is required prior to insertion. On the other hand some women may regard amenorrohea associated with LNGIUS as abnormal and they should be told beforehand regarding its occurrence. Few women experience progestogenic side effects including headache, nausea, bloating, breast tenderness, mood changes, oily skin, acne however they are short lived and usually subside after few months. LNGIUS is also associated with increased incidence of functional ovarian cysts compared to copper IUD users. Another unwanted effect is expulsion which commonly occurs during first month following insertion. There are certain conditions in which use of Mirena is contraindicated which include Pregnancy, Undiagnosed genital tract bleeding, Severe distortion of the uterine cavity, Valvular heart disease, Liver disease and Sensitivity to levonorgestrel. History of ovarian cysts and thrombo-embolic disease are relative contra-indications for the use of LNGIUS
		Posted by Sonali G. Tue Feb 8, 2005 06:46 am
The aim of any intrauterine hormone delivery system is to deliver a small predictable amount of hormone in the uterine Cavity. LNG IUS contains 52mgs of Levonorgesterol. It has varied use in gynaecology. It is an effective form of contraception lasting its effect for 5 years. Its effacy is comparable to the Sterlisation. It is particularly helpful in patients complaining of menorrhagia and demanding contraception. But its insertion needs expertise. It cannot be used as post coital contraception. It is particularly used and licensed for treatment of menorrhagia. Its efficacy has been compared with other medical and surgical treatments of menorrhagia. Reduction in blood flow after 12 months of use is between 80-95% while with tranexemic acid it is 50%, with mefenemic acid 25%, with GNRHa 75%. Endometrial ablation procedures have success rate between 86-98%. Overall satisfaction rate is lesser than hysterectomy but it is a cost effective option and a option in patients who are unfit for surgery. But Mirena IUS can cause intermittent spotting and discharge for first 3-6 months which can be distressing for patient. So preinsertion counselling is very important. Mirena IUS has been shown to provide symptomatic relief from fibroids causing menorrhagia and dysmenorrhoea. It has also been shown to reduce the incidence of fibroids on long term use. It reduces the pain, bleeding and dysparunea caused by endometriosis. And is also associated with resolution of rectovaginal endometriosis. It reduces the bleeding associated with adenomyosis. The new small frameless LNG IUS may be useful in irregular cavities. In premenstrual syndrome (PMS) it can be used as progestrogenic support in patients using estradiol patch for PMS (to reduce endometrial hyperplasia by unopposed oestrogen). It s advantage over oral progesterone is that it doesn?t cause major systemic side effects. It has been used for treatment of endometrial hyperpasia and to prevent endometrial hyperplasia during unopposed estrogen exposure. There has been studies proving its efficacy in preventing tamoxifen induced hyperplasia also. It can also be used in treatment of stage I grade I endometrial cancer in surgically unfit patients. LNG IUS can be used as progestrone arm of hormone replacement therapy in post menopausal women, thus minimising systemic side effects. Low dose LNG IUS (releasing 10ug LNG) is under research. Risk of pelvic inflammatory disease (PID) is reduced by use of mirena in comparison to copper IUCD. It doesn?t reduce the chances of acquiring infection but it reduces the development of PID. But it should not be used in active PID / acute infection. Its use is associated with reduced risk of ectopic pregnancy as compared to non-users. Thus mirena IUS has varies use in gynaecology but it has drawbacks like its insertion needs training, it can be associated with side effects like bloating, headaches, weight gain. It is also associated with development of simple ovarian cyst (0.1%) which usually subsides on its own. Intermittent spotting and discharge is the main reason for its discontinuation (20% rate). Adequate preinsertion counselling is important in such patients.
		Posted by Nibedita R. Tue Feb 8, 2005 07:45 am
LNG-IUS contains 52 mg levonorgestrel, releases 20 mcg into the uterine cavity each day and licensed for use as contraceptive for 5 years. Its contraceptive efficacy is comparable with Cu-T 380(failure rate less than 1/100 women over 5 years); additionally it reduces menstrual loss (90%) and dysmenorrhoea. Systemic progesterone concentration is lowered thus minimizes dose related progestrogenic side effects like headache, bloating, acne, breast tenderness. Data from RCT suggest that women using LNG-IUS are less likely to have pelvic inflammatory disease and ectopic pregnancy compared to IUD. But this is not a cost effective method of contraception and cannot be use as postcoital contraception. LNG-IUS is very effective treatment option for idiopathic menorrhagia. This is much more effective than oral medications for menorrhagia with 97% reduction of blood loss after 1year of use and 35% amenorrhoea rate with increasing serum ferritin and haemoglobin concentration. LNG-IUS is a simple, cheap and effective method of treatment for DUB and can be alternative to both hysterectomy and endometrial ablation, with advantage of preservation of fertility. Data suggest that it reduces the number of surgeries required for DUB. While considering cost effectiveness, LNG-IUS costs ?75-100 per unit compared to ?4000 for hysterectomy. It is estimated that 1:40 hysterectomies for DUB has to be prevented for IUS to be considered as cost effective treatment. When used in uterine fibroid, a reduction of fibroid size as well as blood loss after 6 months of use has been shown. There is evidence to suggest a decrease in incidence and fibroid related surgery in LNG-IUS users. It also relieves dysmenorrhoea (80%) and blood loss associated with endometriosis and adenomyosis. However, there is insufficient evidence to support the use of LNG-IUS routinely for women with pain in the absence of menorrhagia. There is insufficient evidence till date to support that LNG-IUS alone is effective in the treatment of premenstrual syndrome. Mirena can provide the progesterone arm of HRT when used in conjunction with oral or transdermal oestrogen, this limits the systemic side effects of oral progesterone and increases compliance to treatment. RCT suggest that this is effective in providing endometral protection from unopposed oestrogenic stimulation for perimenopausal and postmenopausal women along with around 60-80% amenorrhoea rate after 12 months of use. However, this makes diagnosis of menopause difficult. Current advice is that HRT use should be restricted for short-term treatment of vasomotor symptoms, because on long-term use it increases risk of cardiovascular disease and breast cancer. LNG is unlikely to be effective to protect the endometrium when used for short-term, unless the women are already using it. Report suggests that LNG-IUS may be effective in the treatment of endometrial hyperplasia. When using for simple or atypical endometrial hyperplasia normal endometrium has been seen after 12 months of insertion. However, its use solely for endometrial hyperplasia is not licensed in UK. Tamoxifen causes unopposed oestrogenic stimulation when used to treat breast cancer. The effectiveness of LNG-IUS in prevention of hyperplasia due to tamoxifen is under trial. Disadvantages include difficulties with insertion, especially in nulliparous women, which may require cervical dilatation under paracervical block or GA. Women should be counselled adequately regarding the irregular bleeding pattern in the following few months after insertion and also the possibility of amenorrhoea when used for long term (about 12 months) which may be confused with pregnancy. She should also be told about the possibilities of expulsion of the device during the first month following insertion and that the possible hormonal symptoms would gradually settle down. There is increased incidence of functional ovarian cysts (3 fold) and the possible risk of perforation (1 in 1000) during insertion.
		Posted by velam K. Tue Feb 8, 2005 08:37 am
Mirena IUS is used a variety of gynaecology conditions as outlined below. It contains 52mg of levonorgestrel and 20 microgram is released every 24 hour. Mirena is licensed for the treatment of menorrhagia in UK. It is shown to reduce the amount of blood loss in about 80% -90% of patients.It reduces the incidence of anaemia in these patients. It also improves their quality of life. It also helps them to avoid hysterectomy and its associated morbidity like thromboembolism, injury to other viscera, haemorrhage and infection. It is cost effective for the NHS compared to hysterectomy. But the main disadvantage is the irregular bleeding associated with mirena in the initial months and patients should be counselled adequately. Mirena is proven to be an effective contraceptive for 5 years after insertion. Its efficacy is comparable to tubal sterilisation. The main advantage is it is reversible. It is coital independent and the patient compliance is good. It is shown to reduce the incidence of ectopic pregnancy(0.02%) compared to 1.2% in patients not using any contraception. It is thought to reduce the incidence of PID because of its effect on cervical mucus, but this has been challenged by a recent published review. There is an increased risk during the first week after insertion because of uterine instrumentation. So patients need to be screened for chlamydia before insertion and treated appropriately. It can be used in the treatment of simple endometrial hyperplasia. It is shown to be of benefit in treatment of endometriosis. It is also of some use in dysmenorrhoea. It can be used as the progesterone supplement in HRT. But since the publication of WHI trial both patients and clinicians are apprehensive about their usage. This is because of the side effects like incidence of stroke,myocardial infarction,breast cancer. It can also be used as progesterone supplement in patients being treated with estrogen for PMS. It is shown to reduce the incidence of fibroids. But it is not of use in treating menoorhagia in patient with multiple fibroid because of risk of expulsion. The patient should be counselled about the amennorrhoea associated with its use, because some patients may be perceive this as abnormal. There is a risk of perforation of uterus during insertion but the rate is minimal.(1 in 1000). There may be a difficulty in insertion particularly for nulliparous patients . They may need paracervical block or insertion under GA. There is a small risk of expulsion in the initial few months after insertion. There is a slightly increased risk of functional ovarian cysts. Somepatients complain of progestogenic side effects like breast tenderness, bloatedness. Overall the benefits of mirena outweigh the risks associated with it. Every patient should be assessed on an individual basis for its use.
		Posted by narmin B. Tue Feb 8, 2005 11:22 am
Levonorgestrel-releasing intrauterine device, known as Mirena coil, is a progesterone releasing coil which releases 20 micrograms progesterone per day. It has various uses in gynaecological practice. Mirena coil is a very effective contraceptive method. It cause atrophic endometrium and reduces cervical mucus production. It is licensed for contraceptive use for a period of 5 years. Its failure rate is comparable to sterilisation failure and is about one in 200 women.Also it reduces the rate of ectopic pregnancy and pelvic inflammatory diseases. However due to its large diameter insertion can be difficult especially in nuuliparous women. Local or general anaesthesia may be required for insertion. Perforation of the uterus and failure to insert the coil can happen and these should be discussed with the patient beforehand. Another disadvantage is its cost, as each coil costs about 70 to 100 pounds. Amenorrhoea which is one the effects of the coil may be considered as an undesirable effect by some women. Mirena coil is associated with formation of functional ovarian cysts. For these reasons it is not the first line of contraceptive method. It should be noticed that Mirena coil can not be used as an emergency contraception. Another important role for Mirena coil is in the treatment of menorrhegia. Where medical treatment is ineffective or refused by the patient, insertion of Mirena coil should be offered. It reduces blood loss significantly and leads to amenorrhoea after 12 months in about 50% of women. It is a very useful method especially in older women with menorrhagia who also need contraception. It reduces considerably the number of women who need surgical methods such as transcervical resection of endometrium and hysterectomy for traeatment of menorrhagia.Its disadvantage is irregular bleeding for firs 4-5 months after insertion which is the main cause of its removal. Mirena coil can be used in women with dysmenorrhoea and premenstrual tension. However in these conditions, Mirena coil is not as effective as menorrhagia and this should be discussed with patient. Also amenorrhoea may be an unwanted side effect in some women. In women with a fibroid uterus, Mirena coil could reduce the amount of bleeding. However its effect on reducing the size of the fibroid has not been proved. Due to distortion of the uterine cavity by fibroid, insertion of the coil can be difficult. There is inadequate evidence about the beneficial effect of Mirena coil on adenomysis. Another role for Mirena coil is its use as progesterone arm of hormone replacement therapy (HRT). Systemic side effects of progesterone such as weight gain, breast tenderness and depressions are the main reason for discontinuing HRT. Insertion of Mirena coil while provide the required progesterone, it has no systemic side effects. The disadvantage of this method is difficulty in diagnosis of menopause due to the amenorrhoea which is caused by Mirena coil. In this situation measurement of FSH LH level can be helpful. Endometrial hyperplasia is another condition which Mirena coil can be used. In the presence of simple or complex forms of endometrial hyperplasia Mirena coil insertion is useful as it releases progesterone which leads to regression of the hyperplastic endometrium. Since atypical hyperplasia can progress to endometrial carcinoma in 30-40 % of women, Mirena coil should be avoided as a treatment modality.
		Posted by Iman B. Tue Feb 8, 2005 11:56 am
Mirena is an intrauterine levonorgesterel releasing system (LNG-IUS) which is licenced for contraceptive use. As a contraceptive it has a low pregnancy rate(Pearl Index 0.16) and cumulative pregnancy rate of 0.3 for the first three years. It is an effective long term contraception and should be offered to all those seeking sterilisation. Non contraceptive benefits include its use for treatment of menorrhagia, which is cost effective compared to hysterectomy or medical treatment of menorrhagia. In the first few months there is an irregular bleed but this subsides with amenorrhoea in majority of cases within the first year. with appropriate counselling this side effect is usually accepted by most women.It is useful as an adjunct to oestrogen therapy, in the treatment of premenstrual tension syndrome, some women however experience some progesterogenic effects on first using the mirena they should know that these effects rarely last beyond the first few months. It decreases the pelvic congestion associated with secondary dysmenorrhoea and a decrease in the occurence of pelvic inflammatory disease. Of course as with any intrauterine device an umbrella of antibiotics should be given following insertion to decrease the incidence of infection(which is increased in the first three weeks post insertion). Decrease in ectopic pregnancy rates (0.02) compared to 0.25 in Nova T users and 1.5 in noncontraceptive users. It may also be used as the progesterogenic arm in HRT, and to counter the oestrogenic action in cases of endometrial hyperplasia. There is an increase in the number of functional ovarian cysts. There is also slight increase in difficulty of insertion, especially with nulliparas, where local anesthesia may be needed. , and an increased expulsion rate in the first month of insertion, this decreases with more experienced operators.
		Posted by uma M. Tue Feb 8, 2005 12:16 pm
Lug-Ius (MIRENA) is a progesterone containing Intruterine devise system which is effective for contraception with many noncontraceptive uses. LNG-IUS is a T -shaped devise with a plastic frame containing 52 mg of levonorgestrol,releasing at a constant rate of 20 mcg/day via a rate limiting membrane.It acts mainly by local action on the Endometrium.It renders endometrium attrophic with no effect on HPO axis, 75%continue to ovulate.Serum levels of drug is lower than as with oral /subdermal administration,with wide individual variation. Cochrane review has showed that it is as effective as Cu-T 380 A as a contraceptive agent with a failure rate of <1/100 women /year. So it stands to be an effective reversible long term contraceptive choice,licensed for 5 yr duration.Ther is no delay in return of fertility after removal.Risk of ectopic is low,similar to cu-T380A.Risk of PID is also less.It cannot be used as post coital contraceptive. LUG-IUS has been shown to be effective in reducing menstrual loss in women with menorrhagia due it\'s effect on endometrium.92%REDUCTION IN menstrual blood loss by 6 months, 97% by 12 months has been observed with it\'s use.50-60% of users will become amenorrhoeic/hypomenorrhoeic at 1 year.RCOG recomends it\'s use for menorrhagia in primary &secondary care.Use is more effective than oral treatment with progesterones..It\'s use avoids hysterectomy and prroduce similar satisfaction rates to TCRE. In women with fibroids use of lng-ius has shown to reduse menstrual blood loss,fibroid volume after 6M of use.How ever in presense of distorted uterine cavity in should not be inserted. Dysmenorrhoea _80% reduction in dysmenorrhoea has been reported in addition to redection in menstrual blood loss .How ever there is insuficient evidence to use it in women with only pain in the absense of heavy periods. It has a role to protect endometrium from hyperplasia and possible carcinoma .For Women on HRT lng-ius can be used as progesterone arm to prevent effects of estrogen on endometrium. It is also used with same effect in users of tamoxifen for ca.breast.Women with PMS where estogen implants ars used to treat ,lng-ius is used to protect the endometrium.But lng-ius as sole treatnent has no role in PMS. It is not without limitations. Wide stem , not tolerable for nulli while inserting ,at times require analgesia for insertion.Irregular bleeding for 3-6 months arter insertion is main draw back.Amenorrhoea is main reason for discontinuation of lng-ius. A thorough preinsertion counselling would reduce discotinuation due to this reason.Risk of perforation is <1/1000 insertions.Increase in incidense of ovarian cysts in noted -3 fold. Few side pregesterone side effects like acne,headache,breast tenderness ,are occasionally reported by ing-ius users. However it is not significantly different from CU containing IUD users. No effect on bone mineral density. It is associated with low cost compared to hysterectomy.to BE COST EFFECTIVE 1:40 HYsterectomies need to be prevented for menorrhagia.
		Posted by Vaijayanti R. Tue Feb 8, 2005 02:33 pm
The LNG-IUS is a plastic intrauterine device (containing52mg levonorgestrel) which delivers a fixed dose of levonorgestrel (20mcg/24hrs) directly into the uterine cavity. The advantage of direct delivery is that the systemic side effects of progesterone are reduced considerably ( headache, bloating, breast tenderness, depression) while the beneficial efficacy is maintained with a low dose of the hormone.Other advantages include long duration of action (contraceptive for 5 years).Disadvantages inherent to the device ? training required for insertion, ocassionally will need to be done under anesthesia,expulsion, perforation,association with development of functional ovarian cysts,and irregular bleeding in the initial phases followed by amenorrhoea ( which may be inacceptable to some women) The LNG-IUS has a number of uses in gynecology. The first licensed use was for contraception ( duration 5 years).Efficacy is similar to the copper containing T Cu 380A ( less than1/100 women years) and is less likely to be associated with PID or ectopic pregnancy.Additional benefit would be in women with menorrhagia,dysmenorrhoea.However it is not suitable as a postcoital contraceptive and is far more expensive than the copper containing devices.Does not prevent sexuallytransmitted disease. Contraceptive effect in completely reversible within 30 days of discontinuation. This system is very useful in the management of menorrhagia/ DUB ; 95 to 97% reduction in menstrual flow by 1 year of use, with 35% incidence of amenorrhoea.The efficacy has been favourably compare with other methods ? medical management, endometrial ablation and hysterectomy. Fertility is preserved.This is a cost effective compared to the surgical procedures and does not have the associated surgical/ anesthetic risks. A reduction in the severity of secondary dysmenorrhoea has been noted ; inadequate evidence to use primarily for Management of dysmenorrhoea. Protects against pelvic inflamatory disease to some extent ? progestogenic effects on the cervical mucous ( thick, cellular). Continuous use ( atleast 6 months) has been associated with a decrease in the incidence and size of uterine fibroids.May have a similar effect in adenomyosis ? inadequate data. May be combined with estrogen patches for the treatment of the Premenstrual syndrome ? insufficient evidence for primary use. The LNG IUS may also be used for the treatment of endometrial hyperplasia especially in younger women who desire to retain fertility potential. Conversion of atypical to normal endometruim has been demonstrated with 12 months of use.However it is not licensed for this use in the Uk LNG-IUS is used for peri /post menopausal HRT along with oral / transdermal estrogen. Apart from the fact that it is long acting , absence of progestogenic side effects improve compliance.The progestogen is to provide protection against the development of endometrial hyperplasia/ carcinoma. Newer, smaller devices have been specially developed for postmenopausal women ? to overcome the difficulty of insertion into an atrophic uterus ? the MLS releases 10 mcg of lng/day. Prior to insertion, the woman has to undergo extensive counselling ? adequate verbal and written information has to be provided. Contraindications to insertion of the device - hypersensitivity to levonorgestrel, pregnancy, undiagnosed bleed pv, valvular heart disease,acute or recurrent pelvic inflamatory disease,leukemia.
		Posted by SWATI M. Wed Feb 9, 2005 12:58 pm
Levonorgestrel ?releasing intra-uterine device(LNGIUS) contains 52mg of levonorgestrel and licenced for 5 years for contraception use.It?s efficacy is similar to Cu T 380.It protects against pelvic infections due to progestogenic effect on cervical mucous. Menorrhagia and dysmenorrhea is less as compared to copper containing devices .But it causes irregular bleeding particularly for 2-3 months after the insertion and amenorrhea in about 1/3rd of the cases which may be unacceptable or increase anxiety regarding pregnancy hence counseling is important.It is associated immediate return of fertility after removal.Insertion is painful due to wide stem particularly in nullipara,needs paracervical block or GA for insertion.It can not be used for emergency contraception and use is associated with increased risk of developing functional cysts than copper devices.It is not cost effective when used for contraception alone but becomes cost effective if used to treat benign condition with contraception. LNGIUS is effective in treatment of dysfunctional uterine bleeding.It decreases blood loss by 97% with 1 year use.It is more effective than a medical treatment.It causes amenorrhoea in 30%(rate is higher in perimenopausal group) and satisfaction rate with use is about 80%.Thus it reduces need for hysterectomy or endometrial ablation and associated surgical and anaesthetic morbidity with these.It is cost effective than these surgical procedures.It provides additional contraception and preserves fertility.The irregular bleeding in initial 2-3 months after insertion may be unacceptable to some women or wish complete amenorrhea .But it is unpredictable in whom it will cause amenorrhoea. Medical treatment is less effective in menorrhagia associated with fibroid uterus but LNGIUS is effective in reducing blood loss .It is not recommended if uterine cavity is distorted.It reduces incidence and growth of fibroids. In adenomyosis it is effective in reducing blood loss with relief of associated dysmenorhoea and thus can reduce need for hysterectomy which is alternative treatment for this condition.It causes symptomatic relief in endometriosis in relieving dysmenorhoea and reduce blood loss. In dysmenorrhoea relief occurs in 80% of women. It can be used to provide progestogenic component of HRT.Systemic side effects of progesterone with oral administration in HRT,such as abdominal bloating,mastalgia,is common cause for discontinuation of HRT which are less with LNGIUS and more acceptable.Systemic side effects do occur but transient and needs conselling. It can be used with estrogenic implants or patches in treatment of premenstrual syndrome to protect endometrium.Symtoms with oral progesterone mimics PMS and may be unacceptable which are less with LNGIUS use. Insertion of LNGIUS needs training.
		Posted by Rani M. Thu Feb 10, 2005 07:08 am
LNG IUS is an intrauterine device which releases 20 micro gm. of levonorgestrel daily, this is absorbed into the basal layers of endometrium. In addition to being an effective contraception it has many non- contraceptive benefits also. It is licensed for use as contraceptive device, failure rate is remarkably low ( pearl index 0.11).In addition pelvic infection which is an associated disadvantage of others IUCD\'s, is not there. Though infection risk is there in first 20 days of insertion.It can also be used in young woman who does not have any children and requests for an intrauterine device.The device is effective for atleast 5 years LND-IUS is also licensed for use in menorrahgia. There is evidence that mean blood loss has reduced by 86% after 3 months of use and by 97% by 12 months.33% may have amenorrhoea. Studies have reported increase in haemoglobin levels.It has been compared with minimally invasive surgeries ( ablation/ resection ) and hysterectomy in different studies. results are comparable and patient satisfaction rates are good. It has the added advantage of preserving fertility and being a reversible method. Menstruation ususally resuts with in 30 days after removal of the device. A potental role of LNG-IUS is in symptomatic relief and possibly regression of small fibroids size.It does reduces the blood loss associated wth fibroid. But it can not be used if there is significant distortion of uterine cavity. LNG IUS can be used while awaiting surgery to build up hemoglobin and reduce blood loss. There is some evidence that LNG IUS may reduce the symptoms as well the size of rectovaginal nodules of endometriosis. Some case reports have reported benefit in woman with adenomyosis & dysmenorrhoea In woman with premenstrual syndrome if estradiol implants or patches are used, LNG=IUS can be used as progestonic component for preventing endometrial hyperplasia. As many woman may not tolerate progestogenic side effects with oral preogesterones ( mood swings, lethargy, headaches, dizziness, mastalgia, bloating etc.)Theses side effects are less with LNG-IUS. It can be used as a component of HRT. compliance is better than oral progesterone .it is especially useful for climactric woman in whom dysfunctional uterine bleeding is common and who require a contraception. Other possible indications are in conjunction with Tamoxifen in breast cancer patients and in the treatment of endometrial hyperplasia. it acts by endometrial suppression, regression of glands, decidualisation of stroma.. Disadvantages are, irregular vaginal bleeding which may be seen in 53% of patients , though this is transient &common in first 2-3 months only but a common reason for discontinuation.The technique of insertion though same as other IUCDs cervical dilatation or analgesia may be required due to the device being thicker.Expulsion may occur during the first months following insertion, rates being higher than Cu containing IUCDs. This can be minimised by inserting at the end of menstruation.Contraindications are similar to other IUCDs and contraindications to progesterone use like liver diseas, severe arteral disease,pregnancy, undiagnosed vaginal bleeding. Therefore adequate counselling of woman is required to achieve high continuation rates. .
		Posted by Iman B. Thu Feb 10, 2005 12:43 pm
Sorry for the trouble, I?ve repeated the essay, would you kindly tell me if I have got it right this time. Thanks a lot. *Levonorgesterel IUS(Mirena) contains 52mg of levonorgesterel, and releases 20ug daily. It is licensed for contraceptive use in the UK. It causes pregnancy rates similar to sterilisation(pearl index,0.16) and pregnancy rates of 0.03/100WY in the first three years. It should be offered as an effective long term alternative to all patients seeking sterilisation. It causes endometrial atrophy with excellent results for those complaining of menorrhagia. There is a 97% decrease in blood loss in the first year, with 35% amenorrhoea rates. Compared to hysterectomy and medical treatment of menorrhagia, it has been found to be cost effective. Endometrial ablation has high success rates, but requires a high level of competence and complications when they do occur are severe, the progress to hysterectomy occurs after 3-4 years in 10-25% of cases, with almost 40% requiring reoperation. Besides this, a contraception will be needed. Mirena can be an effective alternative to patients seeking endometrial ablation for dysfunctional uterine bleeding. It has been found to decrease the symptoms associated with both adenomyosis and fibroids(menorrhagia, and intermenstrual bleeding). A transvaginal scan should be performed first however to exclude severe distortion of the uterine cavity which is a contraindication to its use. Mirena alleviates dysmenorrhoea by decreasing release of endometrial prostaglandins, though exclusion of causes of secondary dysmenorrhoea should come first before offering this option. T may be used as an adjunct to oestrogen therapy for premenstrual syndrome its systemic effects are less than oral progestogens, though mastalgia, bloatedness, mood swings and depression have been reported they usually resolve after the first months. Irrespective of the type of hyperplasia, the inhibitory effect of mirena on the endometrium has been shown to improve cases of endometrial hyperplasia, research is still needed to see of this effect is temporary only with mirena use or permanent. Tamoxifen used for prolonged periods to treat breast cancer may lead to endometrial hyperplasia, polyps or cancer, mirena can effectively counter its agonist action on the endometrium. It may be used as the progesterone arm for hormone replacement therapy with less systemic effects( effect equal to 2 tablets of oral progestogen/week) It decreases the incidence of ectopic pregnancy ten times lower than intrauterine devices(0.02 compared to 0.25 in nova t users and 1.3-1.6 in sexually active noncontraceptive users. PID is decreased due to altered cervical mucus and endometrial atrophy. 1 gm of metronidazole rectally and 100mg bid of doxycycline for one week or 1gm azithromycin single dose should be used to counter any possible ascent of infection on insertion(highest time of infection 20 days post insertion of any intrauterine device) The commonest cause of discontinuation is irregular bleeds, these resolve after a few months but they require good counselling, also the amenorrhoea which may occur since if not properly counselled it may be considered as a side effect. A rise in the number of follicular cysts may occur but these resolve spontaneously and are rarely symptomatic. The mirena has a higher rate of expulsion than other intrauterine devices, the commonest time of expulsion occurring in the first month. This is due to its thicker calibre and proper operator training will improve the expulsion rates, also, insertion towards the end of the menstrual period. Difficulty with insertion is also a small problem which may necessitate cervical dilatation and local (paracervical block)or general anaesthesia.