Levonorgestrel‐releasing intrauterine device (LNG‐IUD) for symptomatic endometriosis following surgery

BACKGROUND: Various options exist for treating endometriosis, including surgical treatment, ovarian suppression therapy, or a combination of these strategies. Surgical treatment of endometriosis aims to remove visible areas of endometriosis and restore anatomy by division of adhesions. The aim of medical therapy is to inhibit growth of endometriotic implants by suppression of ovarian steroids and induction of a hypo-estrogenic state. Postoperative treatment with a hormone-releasing intrauterine device, using levonorgestrel (an LNG-IUD), has been suggested. OBJECTIVES: To determine if postoperative use of an LNG-IUD in women with endometriosis improves pain symptoms associated with menstruation and reduces recurrence compared with no treatment, postoperative insertion of a placebo, or postoperative systemic therapy. SEARCH METHODS: The following databases were searched: (1) Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register of controlled trials; (2) Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 1); (3) MEDLINE (1966 to Feb 2009); (4) EMBASE (1980 to Feb 2009); and (5) National Research Register (NRR). The citation lists of relevant publications, review articles, abstracts of scientific meetings, and included studies were also searched. SELECTION CRITERIA: Trials were included if they compared women undergoing any type of surgical treatment for endometriosis with uterine preservation and then randomised to LNG-IUD insertion within three months versus no treatment, placebo (inert IUD), or systemic treatment. Diagnostic laparoscopy alone was not considered to be surgical treatment. DATA COLLECTION AND ANALYSIS: Two review authors (AM Abou-Setta, HG Al-Inany) independently selected studies for inclusion and extracted data to allow for an intention-to-treat analysis. For dichotomous data, the odds ratio (OR) and 95% confidence interval (CI) were calculated using the Mantel-Haenszel fixed-effect method. MAIN RESULTS: In one small randomised controlled trial there was a statistically significant reduction in the recurrence of painful periods in the LNG-IUD group compared with the control group receiving expectant management (OR 0.14, 95% CI 0.02 to 0.75). The proportion of women who were satisfied with their treatment was also higher in the LNG-IUD group compared with the control group but this difference did not reach statistical significance (OR 3.00, 95% CI 0.79 to 11.44). AUTHORS' CONCLUSIONS: Limited evidence from one small study has shown that postoperative use of the LNG-IUD reduces the recurrence of painful periods in women who have had surgery for endometriosis. There is a need for further, well-designed RCTs of this approach.