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Timing of insertion affects expulsion in patients using the levonorgestrel 52 mg intrauterine system for noncontraceptive indications

  • Author Footnotes
    1 Dr. Harris's Present address:Kaiser Permanente Hawaii- Waipio Medical Office, 94-1480 Moaniani St., Waipahu, HI 96797.
    Sara Harris
    Footnotes
    1 Dr. Harris's Present address:Kaiser Permanente Hawaii- Waipio Medical Office, 94-1480 Moaniani St., Waipahu, HI 96797.
    Affiliations
    University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology, and Women's Health, Honolulu, HI, United States
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  • Bliss Kaneshiro
    Affiliations
    University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology, and Women's Health, Honolulu, HI, United States
    Search for articles by this author
  • Hyeong Jun Ahn
    Affiliations
    University of Hawaii, John A. Burns School of Medicine, Office of Biostatistics & Quantitative Health Sciences, Honolulu, HI, United States
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  • Lynne Saito-Tom
    Correspondence
    Corresponding author.
    Affiliations
    University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology, and Women's Health, Honolulu, HI, United States
    Search for articles by this author
  • Author Footnotes
    1 Dr. Harris's Present address:Kaiser Permanente Hawaii- Waipio Medical Office, 94-1480 Moaniani St., Waipahu, HI 96797.

      Abstract

      Objective

      To evaluate levonorgestrel 52 mg intrauterine system (IUS) expulsion risk by menstrual cycle day of insertion (days 1–8 vs days 9 and beyond) in women using the IUS for noncontraceptive indications.

      Study design

      We performed a retrospective cohort study of patients with a levonorgestrel IUS inserted for the management of noncontraceptive, gynecologic conditions at Kaiser Permanente-Hawaii between January 2009 and December 2010. We used multivariable logistic regression models to estimate the likelihood of IUS expulsion adjusting for demographic and clinical factors and a Kaplan-Meier curve for survival analysis.

      Results

      Of 176 patients identified, insertion occurred in 42 patients in cycle days 1 to 8 and 87 patients after day 8. Patient follow-up within the Kaiser system ranged from 1 to 71 months. Thirty-nine (22%) patients experienced expulsion, 16 (38%) and 15 (17%) for the 2 timing groups, respectively. Expulsion was more likely if the IUS placement occurred during the menstrual cycle days 1 to 8 (adjusted odds ratio 3.57 [95% confidence interval 1.13, 11.31]), which was consistent with the Kaplan-Meier analysis (p = 0.008).

      Conclusion

      Levonorgestrel IUS expulsion among women using the IUS for noncontraceptive indications occurred more frequently if insertion occurred during the first eight days of the menstrual cycle.

      Implications

      In women planning to use the levonorgestrel IUS to treat gynecologic conditions such as abnormal uterine bleeding, dysmenorrhea, and endometrial hyperplasia, providers should consider waiting until after cycle day 8 to perform insertion.

      Keywords

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      References

        • Rodriguez M.B.
        • Lethaby A.
        • Jordan V.
        Progestogen-releasing intrauterine systems for heavy menstrual bleeding.
        Cochrane Database Syst Rev. 2020; 6CD002126
        • Carvalho N.
        • Margatho D.
        • Cursino K.
        • Benetti-Pinto C.
        • Bahamondes L.
        Control of endometriosis-associated pain with etonorgestrel-releasing contraceptive implant and 52-mg levonorgestrel-releasing intrauterine system: randomized clinical trial.
        Fertil Steril. 2018; 110: 1129-1135
        • Varma R.
        • Sinha D.
        • Gupta J.K.
        Non-contraceptive users of levonorgestrel-releasing hormone system (LNG-IUS)- a systematic enquiry and overview.
        Eur J Obstet Gynecol Reprod Biol. 2006; 125: 9-28
        • Bahamondes L.
        • de Andrade K.C.
        • Leon-Martins O.
        • Petta C.
        Levonorgestrel-releasing intrauterine system (Mirena) as a therapy for endometrial hyperplasia and carcinoma.
        Acta Obstet Gynecol Scand. 2003; 82: 580-582
        • Vilos G.A.
        • Marks J.
        • Tureanu V.
        • Abu-Rafea B.
        • Vilos A.G.
        The levonorgestrel intrauterine system is an effective treatment in selected obese women with abnormal uterine bleeding.
        J Minim Invasive Gynecol. 2011; 18: 75-80
        • Magalhaes J.
        • Aldrighi J.M.
        • de Lima G.R.
        Uterine volume and menstrual patterns in users of the levonorgestrel-releasing intrauterine system with idiopathic menorrhagia or menorrhagia due to leiomyomas.
        Contraception. 2007; 75: 193-198
        • Hidalgo M.
        • Bahamondes L.
        • Perrotti M.
        • Diaz J.
        • Dantas-Monteiro C.
        • Petta C.
        Bleeding patterns and clinical performance of the levonorgestrel-releasing intrauterine system (Mirena) up to two years.
        Contraception. 2002; 65: 129-132
        • Heikinheimo O.
        • Gemzell-Danielsson K.
        Emerging indications for the levonorgestrel-releasing intrauterine system (LNG-IUS).
        Acta Obstet Gynecol Scand. 2012; 91: 3-9
        • Westhoff C.L.
        • Keder L.M.
        • Gangestad A.
        • Teal S.B.
        • Olariu A.I.
        • Creinin M.D.
        Six-year contraceptive efficacy and continued safety of a levonorgestrel 52 mg intrauterine system.
        Contraception. 2020; 101: 159-161
        • Mawet M.
        • Nollevaux F.
        • Nizet D.
        • Wijzen F.
        • Gordenne V.
        • Tasev N.
        • et al.
        Impact of new levonorgestrel intrauterine system, Levosert®, on heavy menstrual bleeding: results of a one-year randomized controlled trial.
        Eur J Contracept Reprod Health Care. 2014; 19: 169-179
        • Kaunitz A.M.
        • Bissonnette F.
        • Monteiro I.
        • Lukkari-Lax E.
        • Musyers C.
        • Jensen J.T.
        Levonorgestrel-releasing intrauterine system or medroxyprogesterone for heavy menstrual bleeding.
        Obstet Gynecol. 2010; 116: 625-632
        • Youm J.
        • Lee J.G.
        • Kim S.K.
        • Kim H.
        • Jee B.C.
        Factors affecting the spontaneous expulsion of the levonorgestrel-releasing intrauterine system.
        Int J Gynaecol Obstet. 2014; 126: 165-169
        • Braaten K.P.
        • Goldberg A.B.
        Malpositioned IUDs: When you should intervene (and when you should not).
        OBG Manag. 2012; 24: 38-46
        • Munro M.G.
        • Critchley H.O.
        • Fraser I.S.
        • FIGO Menstrual Disorders Committee
        The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions.
        Int J Gynaecol Obstet. 2018; 143: 393-408
        • Busfield R.A.
        • Farquhar C.M.
        • Sowter M.C.
        • Lethaby A.
        • Sprecher M.
        • Sadler L.C.
        • et al.
        A randomized trail comparing the levonorgestrel intrauterine system and thermal balloon ablation for heavy menstrual bleeding.
        BJOG. 2006; 113: 257-263
        • Gupta J.K.
        • Daniels J.P.
        • Middleton L.J.
        • Pattison H.M.
        • Prileszky G.
        • Roberts T.E.
        • et al.
        A randomized controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia: the ECLIPSE trial.
        Health Technol Assess. 2015; 19 (i-118)
        • Shaw R.W.
        • Symonds I.M.
        • Tamizian O.
        • Chaplain J.
        • Mukhopadhyay S.
        Randomised comparative trail of thermal balloon ablation and levonorgestrel intrauterine system in patients with idiopathic menorrhagia.
        Aust NZ J Obstet Gynaecol. 2007; 47: 335-340
        • Rauramo I.
        • Elo I.
        • Istre O.
        Long-term treatment of menorrhagia with levonorgestrel intrauterine system versus endometrial resection.
        Obstet Gynecol. 2004; 104: 1314-1321
        • Shaw V.
        • Vandal A.C.
        • Coomarasamy C.
        • Ekeroma A.J.
        The effectiveness of the levonorgestrel intrauterine system in obese women with heavy menstrual bleeding.
        Aust NZ J Obstet Gynaecol. 2016; 56: 619-623
        • Chen B.A.
        • Eisenberg D.L.
        • Schreiber C.A.
        • Turok D.K.
        • Olariu A.I.
        • Creinin M.D.
        Bleeding changes after levonorgestrel 52-mg intrauterine system insertion for contraception in women with self-reported heavy menstrual bleeding.
        Am J Obstet Gynecol. 2020 Apr; 222: S888.e1-S888.e6
        • Kriplani A.
        • Awasthi D.
        • Kulshrestha V.
        • Agarwal N.
        Efficacy of the levonorgestrel-releasing intrauterine system in uterine leiomyoma.
        Int J Gynaecol Obstet. 2012; 116: 35-38
        • White M.K.
        • Ory H.W.
        • Rooks J.B.
        • Rochat R.W.
        Intrauterine device termination rates and the menstrual cycle day of insertion.
        Obstet Gynecol. 1980; 55: 220-224
        • Kaunitz A.M.
        • Inki P.
        The levonorgestrel-releasing intrauterine system in heavy menstrual bleeding: a benefit-risk review.
        Drugs. 2012; 72: 193-215
        • Akinla O.
        • Luukkainen T.
        • Timonen H.
        Important factors in the use-effectiveness of the copper-T-200 IUD.
        Contraception. 1975; 19: 449-454
      1. Mirena (Levonorgestrel-releasing intrauterine system).
        Bayer, Whippany, NJ2014
        • Edelman D.A.
        • Zipper J.
        • Rivera M.
        • Medel M.
        Timing of the IUD insertion.
        Contraception. 1979; 19: 449-454
        • Eisenberg D.L.
        • Schreiber C.A.
        • Turok D.K.
        • Teal S.B.
        • Westhoff C.L.
        • Creinin M.D.
        Three-year efficacy and safety of a new 52-mg levonorgestrel-releasing intrauterine system.
        Contraception. 2015; 92: 10-16
        • Madden T.
        • McNicholas C.
        • Zhao Q.
        • Secura G.M.
        • Eisenberg D.L.
        • Peipert J.F.
        Association of age and parity with intrauterine device expulsion.
        Obstet Gynecol. 2014; 124: 718-726
        • Bahamondes M.V.
        • Monteiro I.
        • Canteiro R.
        • Fernandes Ados S.
        • Bahamondes L.
        Length of the endometrial cavity and intrauterine contraceptive device expulsion.
        Int J Gynaecol Obstet. 2011; 113: 50-53
        • Kaislasuo J.
        • Heikinheimo O.
        • Lahteenmaki P.
        • Suhonen S.
        Menstrual characteristics and ultrasonographic uterine cavity measurements predict bleeding and pain in nulligravid women using intrauterine contraception.
        Hum Reprod. 2015; 30: 1580-1588
        • de Kroon C.D.
        • van Houwelingen J.C.
        • Trimbos J.B.
        • Jansen F.W.
        The value of transvaginal ultrasound to monitor the position of an intrauterine device after insertion. A technology assessment study.
        Hum Reprod. 2003; 18: 2323-2327
        • Benacerraf B.R.
        • Shipp T.D.
        • Bromley B.
        Three-dimensional ultrasound detection of abnormally located intrauterine contraceptive devices which are a source of pelvic pain and abnormal bleeding.
        Ultrasound Obstet Gynecol. 2009; 34: 110-115