The levonorgestrel-releasing intrauterine system as an alternative to hysterectomy in peri-menopausal women.

INTRODUCTION: Hysterectomy is one of the most common surgical procedures performed in gynecological practice, and the most common indication for hysterectomy is menorrhagia or excessive menstrual bleeding. Approximately 10-15% of fertile women have menorrhagia, defined as a menstrual blood loss (MBL) of >80 mL. Since operative treatment in the form of a hysterectomy carries a not insignificant risk of morbidity and mortality, various forms of medical treatment have been advocated as initial treatment.

RESULTS: Antifibrinolytic agents, e.g., tranexamic acid (40-50% reduction), prostaglandin synthetase inhibitors (20-25% reduction), oral contraceptives (40-50%) and the intrauterine release of progestin with the levonorgestrel-releasing intrauterine system (LNG-IUS; 86-97% reduction), have all been shown to reduce MBL and to be effective in the treatment of idiopathic menorrhagia. In comparative and noncomparative trials, the greatest reduction in MBL has been achieved with the LNG-IUS. Thus, this system has been proposed as an alternative to hysterectomy in women with menorrhagia. In a randomized controlled trial, the LNG-IUS was compared with hysterectomy. Only 42% of the women randomized to the LNG-IUS system subsequently underwent a hysterectomy during the 5-year observation period, and the total costs (direct and indirect) were 40% lower with the LNG-IUS than with hysterectomy.

CONCLUSION: Despite the strong evidence that medical treatment and, in particular, the LNG-IUS are effective, many hysterectomies and endometrial ablations/resections are performed annually without first evaluating medical treatment.