Levonorgestrel-releasing intrauterine system versus medical therapy for menorrhagia: a systematic review and meta-analysis

Abstract

Background: The aim of this study was to compare the effects of the levonorgestrel-releasing intrauterine system (LNG-IUS) with conventional medical treatment in reducing heavy menstrual bleeding.

Material and methods: Relevant studies were identified by a search of MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and clinical trials registries (from inception to April 2014). Randomized controlled trials comparing the LNG-IUS with conventional medical treatment (mefenamic acid, tranexamic acid, norethindrone, medroxyprogesterone acetate injection, or combined oral contraceptive pills) in patients with menorrhagia were included.

Results: Eight randomized controlled trials that included 1170 women (LNG-IUS, n=562; conventional medical treatment, n=608) met inclusion criteria. The LNG-IUS was superior to conventional medical treatment in reducing menstrual blood loss (as measured by the alkaline hematin method or estimated by pictorial bleeding assessment chart scores). More women were satisfied with the LNG-IUS than with the use of conventional medical treatment (odds ratio [OR] 5.19, 95% confidence interval [CI] 2.73-9.86). Compared with conventional medical treatment, the LNG-IUS was associated with a lower rate of discontinuation (14.6% vs. 28.9%, OR 0.39, 95% CI 0.20-0.74) and fewer treatment failures (9.2% vs. 31.0%, OR 0.18, 95% CI 0.10-0.34). Furthermore, quality of life assessment favored LNG-IUS over conventional medical treatment, although use of various measurements limited our ability to pool the data for more powerful evidence. Serious adverse events were statistically comparable between treatments.

Conclusions: The LNG-IUS was the more effective first choice for management of menorrhagia compared with conventional medical treatment. Long-term, randomized trials are required to further investigate patient-based outcomes and evaluate the cost-effectiveness of the LNG-IUS and other medical treatments.

Figure 1

Flow diagram of included studies. RCT, randomized controlled trials.

Figure 2

Quality assessment of included randomized controlled trials using the Cochrane Handbook for Systematic Reviews and Interventions.

Figure 3

Pooled analysis of reduction of pictorial bleeding assessment chart (PBAC) scores. CI, confidence interval; IV, Inverse Variance method; LNG-IUS, levonorgestrel-releasing intrauterine system; MPA, medroxyprogesterone acetate; SD, standard deviation.

Figure 4

Comparison of the levonorgestrel-releasing intrauterine system with medical therapy regarding rate of satisfaction. Surrogates were used for 3 studies (asterisk) not reporting level of satisfaction (Endrikat et al. 2009, Lähteenmäki et al. 1998, Reid et al. 2005). CI, confidence interval; LNG-IUS, levonorgestrel-releasing intrauterine system; M-H, Mantel-Haenszel method; MPA, medroxyprogesterone acetate.

Figure 5

Pooled analysis of rate of discontinuation across studies. CI, confidence interval; LNG-IUS, levonorgestrel-releasing intrauterine system; M-H, Mantel-Haenszel method.

Figure 6

Pooled analysis of treatment failures across studies. CI, confidence interval; LNG-IUS, levonorgestrel-releasing intrauterine system; M-H, Mantel-Haenszel method; MPA, medroxyprogesterone acetate.

Figure 7

Pooled analysis of serious adverse events. CI, confidence interval; LNG-IUS, levonorgestrel-releasing intrauterine system; M-H, Mantel-Haenszel method.