Endometriosis is the presence of endometrial tissue outside the uterus, usually in the pelvis, that can lead to infertility and pelvic pain. It is managed with surgery, hormonal medications, or a combination of both. The progestogen levonorgestrel is one such hormonal medication. The aim of this review was to assess whether the use of a hormone-releasing intrauterine device was beneficial for managing associated painful symptoms and for preventing recurrence of endometriosis following surgery. Although preliminary findings are encouraging, at this stage there is only limited evidence from three randomised trials of a beneficial role with the use of the LNG-IUD in reducing the recurrence of painful periods following surgery for endometriosis. The strength of the evidence was graded as moderate reflecting our belief that future evidence will most likely not change these findings.
There is limited but consistent evidence showing that postoperative LNG-IUD use reduces the recurrence of painful periods in women with endometriosis. Further well-designed RCTs are needed to confirm these findings.
Various options exist for treating endometriosis, including surgical, medical, such as ovarian suppression, or a combination of these strategies. Surgical treatment of endometriosis aims to remove visible areas of endometriosis. The aim of medical therapy is to inhibit growth of endometriotic implants by induction of a hypo-estrogenic state. Treatment with a hormone-releasing intrauterine device, using levonorgestrel (LNG-IUD), has also been suggested.
To determine whether postoperative LNG-IUD insertion in women with endometriosis improves pain and reduces recurrence of symptoms compared with no postoperative treatment, postoperative insertion of a placebo, or postoperative therapy.
The following databases were searched from inception to June 2012: Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, CINAHL, and the World Health Organization (WHO) International Clinical Trials Registry Platform. EMBASE was searched from 2010 to June 2012. The citation lists of relevant publications, review articles, abstracts of scientific meetings, and included studies were also searched.
Trials were included if they compared women undergoing surgical treatment for endometriosis with uterine preservation and then randomised within three months to LNG-IUD insertion versus no postoperative treatment, placebo (inert IUD), or other treatment. Diagnostic laparoscopy alone was not considered suitable treatment.
Two review authors independently selected studies for inclusion and extracted data to allow for an intention-to-treat analysis. For dichotomous data, the risk ratio (RR) and 95% confidence interval (CI) were calculated using the Mantel-Haenszel random-effects method. For continuous data, the mean difference (MD) and 95% CI were calculated using the inverse variance random-effects method.
Three randomised controlled trials were included. In two trials, there was a statistically significant reduction in the recurrence of painful periods in the LNG-IUD group compared with expectant management (RR 0.22, 95% CI 0.08 to 0.60, 95 women, I2 = 0%, moderate strength of evidence). The proportion of women who were satisfied with their treatment was also higher in the LNG-IUD group but did not reach statistical significance (RR 1.21, 95% CI 0.80 to 1.82, 95 women, I2 = 0%). The number of women reporting a change in menstruation was significantly higher in the LNG-IUD group (RR 37.80, 95% CI 5.40 to 264.60, 95 women, I2 = 0%) but the number of women not completing the allocated treatment did not differ between groups (RR 0.66, 95% CI 0.08 to 5.25, I2 = 43%).
In one trial, women receiving LNG-IUD noted lower pain scores compared with women receiving gonadotrophin-releasing hormone agonists (MD -0.16, 95% CI -2.02 to 1.70, 40 women) but this did not reach statistical significance.