Margarete Hidalgo

Bleeding patterns and clinical performance of the levonorgestrel-releasing intrauterine system (Mirena) up to two years.

The objectives of this study were to evaluate the bleeding patterns and clinical performance during the first 2 years of use of an intrauterine system releasing 20 microg/day of levonorgestrel (LNG-IUS, Mirena). Two-hundred-fifty-six women accepted use of Mirena from April 1998 through September 1998. The gross cumulative discontinuation rate due to pregnancy and expulsion were significantly higher in women who used the device because of heavy bleeding. There was one pregnancy at the 15th month of use after an inadvertent expulsion of the device. The continuation rate was 66.2 at the end of the second year. Forty-four percent of women reported amenorrhea at the 6th month of use. This rate maintained stability at 50% after 12 and 24 months of use. Spotting was present in 25% of the users at 6 months, decreasing to 8% and 11% at 18 and 24 months, respectively. Oligomenorrhea was described by one-quarter of women and was similar at each observation period. Removals due to menstrual bleeding problems were concentrated in the first 6 months of use and mostly due to amenorrhea or menorrhagia. In conclusion, LNG-IUS showed a high contraceptive efficacy and a good continuation rate up to 2 years. In addition, a reduction of blood loss was observed a few months after insertion.

Ease of insertion and clinical performance of the levonorgestrel-releasing intrauterine system in nulligravidas

BACKGROUND Despite the high contraceptive efficacy and the additional noncontraceptive benefits of the levonorgestrel-releasing intrauterine system (LNG-IUS), concerns persist with respect to its use in nulligravidas. The objective of this study was to evaluate the ease of insertion and clinical performance of the LNG-IUS in nulligravida women up to 1 year after insertion. METHODS Two cohorts were formed after LNG-IUS insertion, one consisting of 159 nulligravidas and the other of 477 parous women. Each nulligravida women was paired with three parous women who had an LNG-IUS inserted on the same day. Insertion was classified as easy or difficult, and when classified as difficult, the use of Hegar dilators and/or misoprostol and insertion failure were additional factors recorded. RESULTS In almost 80% of cases, no difficulty was encountered during insertion, and dilators and misoprostol were seldom required; however, when necessary, dilator use was almost threefold higher in nulligravida women. Insertion failed in one nulligravida women and in two parous women. Contraception was the most common reason for insertion, although some of the women received the LNG-IUS for both contraceptive and therapeutic purposes, including heavy menstrual bleeding, hematologic diseases, warfarin use, endometriosis-associated pain and following kidney or liver transplantation. The clinical performance of the device showed zero pregnancy rate, expulsion rates of ∼4/100 women-year and 1-year continuation rate of over 90% in both groups. CONCLUSIONS The LNG-IUS is suitable for use by nulligravidas. It is simple to insert, and its clinical performance in nulligravidas is similar to that found in parous women.

Management of missing strings in users of intrauterine contraceptives.

BACKGROUND A common question among health care professionals is how to manage nonvisible strings in users of intrauterine contraceptives (IUCs) at repeat follow-up visits. This study assessed the position of the IUCs in women who consulted repeatedly with nonvisible IUC strings. STUDY DESIGN The medical records of the clinic were reviewed to identify new acceptors and switchers who had an IUC inserted between 1990 and 2009. All women were identified whose IUC string could not be visualized at the external os of the cervix by the health care professional at any given follow-up visit, even after attempting a standard maneuver of sweeping the strings from the cervical canal using a cervical brush or trying to visualize the strings in the cervical canal using colposcopy. Data were also retrieved on the use of ultrasonography and/or pelvic X-ray to assess IUC position, as well as data from any subsequent visits at which the IUC strings were nonvisible. RESULTS The medical charts of 14,935 patients using an IUC were reviewed, and 750 women (5.0%) presenting for the first time with missing IUC strings at any follow-up visit were identified. Ultrasound scans showed the IUC to be in situ in 735 cases (98.0%), while 9 women (1.2%) had expelled the device and, in 5 cases (0.7%), the device was found in the pelvis following uterine perforation. IUC strings were missing on a second occasion in 297 cases. The device was found to be in situ in 295 cases (99.3%) and had been expelled in 2 (0.7%). At subsequent consultations, (between 1 and 18 years after the first consultation), strings were missing in 113, 55, 19 and 5 cases. In 111 (98.2%), 54 (98.2%), 18 (94.7%) and 5 (100%) of these cases, respectively, the IUC was found to be in situ, while in the remaining cases, the device had been expelled. CONCLUSIONS Missing IUC strings are an uncommon finding, and ultrasonography confirmed that the device was in situ in the majority of these cases. For women with persistent missing IUC strings after one ultrasound scan that has verified appropriate intrauterine position, given the 2.4% likelihood that expulsion may have occurred at the time of subsequent visits, repeating the ultrasound (if available) should be considered for at least one (and possibly two) additional womens visit.

Pain at insertion of the levonorgestrel-releasing intrauterine system in nulligravida and parous women with and without cesarean section

BACKGROUND Despite the high contraceptive effectiveness and noncontraceptive benefits of the levonorgestrel-releasing intrauterine system (LNG-IUS) in nulligravidas, there are still concerns related to the use of this device. Pain at insertion is one of the limitations to the increased use of intrauterine contraceptives. The aim of the study was to evaluate the ease of insertion and occurrence of pain at insertion of the LNG-IUS in nulligravidas (women who never became pregnant) compared to parous women with and without cesarean section (c-section). We also assessed the difficulty at insertion in each group. METHODS Three groups of new acceptors of the LNG-IUS were studied: one with 23 nulligravida women, one with 28 parous women who had undergone at least one c-section and one with 23 parous women who had no previous c-section. Pain at insertion was evaluated by using a pain visual analogue score (VAS). The ease of insertion was defined as easy or difficult by health care providers (HCPs) and classified according to the cause of difficulty: tight cervix, anatomically distorted uterus or pain. RESULTS Almost all women reported pain at insertion, regardless of parity and form of delivery. The mean VAS was 6.6 for nulligravida women, 5.2 for parous women with c-section and 5.9 for parous women with no c-section. Although 93% of the women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS again if needed. The most common difficulties were a tight cervix in nulligravidas, an anatomically distorted uterus in parous women with c-section and pain in parous women without c-section. There was no failure of insertion in any group. HCPs reported that it was easier to perform insertion in parous women who had undergone only vaginal deliveries than nulligravid women or parous women with a prior c-section. CONCLUSIONS Although almost all women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS if needed. This attitude reflects high satisfaction with the LNG-IUS. The type of difficulty at insertion was related to parity and type of delivery. The LNG-IUS was able to be inserted in all women; however, it was easier to do in parous women without c-section than nulligravid women or those with a prior C-section.

Users' Perspectives on Bleeding Patterns after Two Years of Levonorgestrel-Releasing Intrauterine System Use

The demand for intrauterine devices (IUDs) has increased over recent years because they represent one of the most cost-effective reversible methods of contraception.[1] However, IUD use still causes concern for women, especially those with heavy menstrual bleeding, because of the risk of anaemia.[2] Hormone-medicated IUDs, such as the 20 μg/day levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena®1, Leiras Oy, Turku, Finland), are associated with a reduction in the amount of blood loss during the menstrual period. Because of this property, the LNG-IUS has been used for the treatment of menorrhagia.[3,4] From 50–70% of women using LNG-IUS became amenorrhoeic after 1 year of use in one study.[5] However, modification of the menstrual pattern, including amenorrhoea, is one of the leading causes of discontinuation among women using the device for contraception.[6,7] The perception of what is ‘normal’ menstrual bleeding differs widely between different populations, and is influenced by sociocultural aspects and by the counselling women receive. The perception of menstrual patterns in LNG-IUS users varies among different populations. However, these differences could, in part, result from the woman’s interpretation, the service provider’s opinion regarding bleeding patterns, or the system of evaluation. Hence, when a new contraceptive method that is associated with changes in menstrual patterns, like the LNG-IUS, is introduced it is important to inform the potential user what changes she may expect to experience in her bleeding pattern. It is probable that this counselling would directly influence the continuation rate. The objective of this study was to evaluate the perspectives of users of the LNG-IUS in Campinas, Brazil, after 1 year of use, regarding bleeding patterns and their opinion on whether amenorrhoea induced by the device has health consequences.

A comparison of the performance of endometrial biopsy with the Pipelle® by nurses and physicians

1 Gordon-Watson C, Shaw W: Case of axial torsion of tibromyomatus uterus. J Obstet Gynecol 33: 419, 1926. Page SW, Blunt VAW; Acute axial torsion of the tibromyomatous uterus. Aust NZ J Obstet Gynaecol 8: 99, 1968. Mackenzie LL, Nimelman A: Torsion of the uterus. Am J Obstet Gynecol 39: 883, 1940. Black EFE, McFarlane CJ: Torsion of the uterus causing infarction of a fibromyoma. Am J Obstet Gynecol 77: 5 13, 1959.