Use of progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding

Cochrane: This Cochrane review has evaluated whether the levonorgestrel–releasing intrauterine system (LNG IUS) reduces heavy menstrual bleeding and whether it is safe and acceptable. Heavy or excessive menstrual bleeding is a common problem in women before they reach the menopause. Women who feel that their menstrual bleeding is excessive will have reduced quality of life and are likely to seek medical help.
A wide variety of treatments, of variable effectiveness, are available for women with heavy bleeding. These include oral tablets, such as non steroidal anti-inflammatory drugs, anti-fibrinolytic drugs, the contraceptive pill and drugs containing progestogen. Surgery, either hysterectomy (removal of the womb) or endometrial ablation (removal of the inner lining of the womb) are also commonly used, often when drug treatments are ineffective. A less invasive alternative to these options is the progestogen-releasing intrauterine system, a device placed inside the womb, which regularly delivers small amounts of progestogen and can also be used for contraception.

This review contains 21 RCTs conducted up to July 2014 that included 2082 participants with heavy menstrual bleeding. Evidence obtained is current to January 2015.

Almost all the studies assessed the effects of the LNG IUS and conclusions refer only to this device. The LNG IUS was more effective in reducing heavy menstrual bleeding and improving quality of life than oral medication. Satisfaction with treatment was not assessed in enough trials to know whether this was better with LNG IUS. The evidence suggested that the LNG IUS and techniques used to remove the inner lining of the womb were similarly effective at reducing heavy menstrual bleeding and improving quality of life and satisfaction and the two treatments had similar failure rates. The LNG IUS caused higher rates of some side effects, such as breast tenderness, bloating, weight gain and ovarian cysts, but this did not seem to cause women to stop taking their treatment. The LNG IUS was not as effective as hysterectomy in reducing menstrual blood loss but improvements in quality of life were similar. Although many women trying the LNG IUS eventually went on to have a hysterectomy for their heavy menstrual bleeding, the LNG IUS appeared to have lower overall costs than either endometrial ablation or hysterectomy.

Many of the trials in this review were small (<100 participants) and some were at high risk of bias. Ratings for the overall quality of the evidence for each comparison ranged from very low to high. Limitations in the evidence included inadequate reporting of study methods and inconsistency. One large trial compared the LNG IUS with hysterectomy over a 10-year period and a number of other trials made assessments two years after starting treatment, so we have some information on the long-term effects of treatments. Future research needs to measure satisfaction.

The levonorgestrel-releasing intrauterine device (LNG IUS) is more effective than oral medication as a treatment for heavy menstrual bleeding (HMB). It is associated with a greater reduction in HMB, improved quality of life and appears to be more acceptable long term but is associated with more minor adverse effects than oral therapy.
When compared to endometrial ablation, it is not clear whether the LNG IUS offers any benefits with regard to reduced HMB and satisfaction rates and quality of life measures were similar. Some minor adverse effects were more common with the LNG IUS but it appeared to be more cost effective than endometrial ablation techniques.
The LNG IUS was less effective than hysterectomy in reducing HMB. Both treatments improved quality of life but the LNG IUS appeared more cost effective than hysterectomy for up to 10 years after treatment.