The role of FIGO-PALM pathologies in heavy menstrual bleeding resistant to levonorgestrel-releasing intrauterine system (Mirena®) treatment

Abstract

Objectives: To evaluate of the indications requiring surgical treatment after Levonorgestrel-Releasing Intrauterine System (LNG-IUS) (Mirena®) treatment due to heavy menstrual bleeding.

Methods: This retrospectively designed study was created with 72 patients who applied to the university hospital gynecology outpatient clinics between January 2018 and April 2019 and were diagnosed with heavy menstrual bleeding and received LNG IUS (Mirena®) for treatment.

Results: Surgery was not performed in 60 (83.33%) patients who had heavy menstrual bleeding and underlying organic pathology (FIGO-PALM group) These patients were treated with LNG-IUS. However, in 12 (16.67%) patients, LNG-IUS was removed and surgery was performed due to resistance to treatment within an average of 10.2 ± 8.0 months. There was no difference between the groups in terms of age, gravida, parity, body mass index and endometrial thickness p > 0.05 for all parameters), but the mean hemoglobin value in the surgical group was found to be significantly lower than the group without it (8.9 ± 1.2 g/dL vs 11 ± 1.6 g/dL, p = 0.03) In the surgical group, the median diameters of leiomyoma and myoma compressing the endometrium were found to be significantly higher (44 mm vs 34 mm, p = 0.03 and 42 mm vs 33 mm, p = 0.04; respectively).

Conclusions: LNG-IUS (Mirena®) is a popular and effective treatment option for heavy menstrual bleeding. The necessity of surgical treatment due to resistance to LNG-IUS revealed that the underlying organic pathologies in these patients should be determined precisely and effective treatment options should be carefully selected before LNG-IUS is inserted.

Keywords

• FIGO-PALM-COEIN
• heavy menstrual bleeding
• levonorgestrel-releasing intrauterine system

References

1. 1. NICE. Heavy menstrual bleeding: Assessment and management. National Institute of Health and Care Excellence; 2021. Available from: https://www.nice.org.uk/guidance/ng88/resources/heavy-menstrual-bleeding-assessment-and-management-pdf-1837701412549
2. 2. Sriprasert I, Pakrashi T, Kimble T, Archer DF. Heavy menstrual bleeding diagnosis and medical management. Contracept Reprod Med 2017;2:20.
3. 3. Salih MM, Adnan E, Mousa ET. The effectiveness of levonorgestrel-releasing intrauterine system on hemoglobin and serum ferritin in women with heavy menstrual bleeding. Biochem Cell Arch 2020;20:5681-5.
4. 4. Chodankar R, Critchley HO. Abnormal uterine bleeding (including PALM COEIN classification). Obstet Gynaecol Reprod Med 2019;29:98-104.
5. 5. Sabre A, Serventi L, Nuritdinova D, Schiattarella A, Sisti G. Abnormal uterine bleeding types according to the PALM-COEIN FIGO classification in a medically underserved American community. J Turk Ger Gynecol Assoc 2021;22:91-6.
6. 6. Davis E, Sparzak PB. Abnormal Uterine Bleeding. In: StatPearls [Internet] Treasure Island (FL): Stat Pearls Publishing; 2021.
7. 7. Sirkeci F, Moss J, Belli AM, McPherson K, Daniels J, Manyonda I, et al. FEMME Trial Collaborative Group. Effects on heavy menstrual bleeding and pregnancy of uterine artery embolization (UAE) or myomectomy for women with uterine fibroids wishing to avoid hysterectomy: The FEMME randomized controlled trial. Int J Gynaecol Obstet 2023;160:492-501.
8. 8. Mansour D, Hofmann A, Gemzell-Danielsson K. A review of clinical guidelines on the management of iron deficiency and iron-deficiency anemia in women with heavy menstrual bleeding. Adv Ther 2021;38:201-25.

9. 9. van Dijk MM, van Hanegem N, de Lange ME, Timmermans A. Treatment of women with an endometrial polyp and heavy menstrual bleeding: a levonorgestrel-releasing intrauterine device or hysteroscopic polypectomy? J Minim Invasive Gynecol 2015;22:1153-62.
10. 10. Beelen P, van den Brink MJ, Herman MC, Geomini PMAJ, Dekker JH, Duijnhoven RG, et al. Levonorgestrel-releasing intrauterine system versus endometrial ablation for heavy menstrual bleeding. Am J Obstet Gynecol 2021;224:187.e1-10.
11. 11. Kitawaki J, Akira S, Harada T, Maeda N, Momoeda M, Ota I, et al. Bleeding patterns of women with heavy menstrual bleeding or dysmenorrhoea using the levonorgestrel-releasing intrauterine system: results from a real-world observational study in Japan (J-MIRAI). Eur J Contracept Reprod Health Care 2022;27:300-7.
12. 12. El-Balat A, DeWilde RL, Schmeil I, Tahmasbi-Rad M, Bogdanyova S, Fathi A et al. Modern myoma treatment in the last 20 years: a review of the literature. Biomed Res Int 2018;2018:4593875.
13. 13. Krentel H, De Wilde RL. Prevalence of adenomyosis in women undergoing hysterectomy for abnormal uterine bleeding, pelvic pain or uterine prolapse - A retrospective cohort study. Ann Med Surg (Lond) 2022;78:103809.
14. 14. Wildemeersch D, Schacht E. Treatment of menorrhagia with a novel 'frameless' intrauterine levonorgestrel-releasing drug delivery system: a pilot study. Eur J Contracept Reprod Health Care 2001;6:93-101.
15. 15. Irvine GA, Campbell-Brown MB, Lumsden MA, Heikkilä A, Walker JJ, Cameron IT. Randomised comparative trial of the levonorgestrel intrauterine system and norethisterone for treatment of idiopathic menorrhagia. Br J Obstet Gynaecol 1998;105:592-8.
16. 16. Durga BC. Levonorgestrel Intrauterine System (MIRENA): initial experience in the management of abnormal uterine bleeding. Nepal Med Coll J 2022;20:74-6.
17. 17. Henry C, Ekeroma A, Dowell A, Filoche S. 'The horror stories put me off!': exploring women's acceptability of the Levonorgestrel IntraUterine System (LNG-IUS) for endometrial protection. J Prim Health Care 2021;13:55-62.
18. 18. Günay T, Tüfekçi C, İlter E, Akyol H, Öcal A. [The effect of levonorgestrel releasing intrauterine device (Mirena®) in the treatment of simple endometrial hyperplasia and menorrhagia. Turk Klin J Gynecol Obst 2007;17:7-13. [Article in Turkish]
19. 19. Mathew SM, David A. Does timing of levonorgestrel insertion in women with abnormal uterine bleeding affect its expulsion and bleeding pattern? A follow-up study. J Obstet Gynaecol India 2023;73:160-5.
20. 20. Chowdary P, Maher P, Ma T, Newman M, Ellett L, Readman E. The role of the Mirena intrauterine device in the management of endometrial polyps: a pilot study. J Minim Invasive Gynecol 2019;26:1297-302.
21. 21. Ni P, Wu M, Guan H, Yuan Y, Zhang L, Zhang F. et al. Etiology distribution of abnormal uterine bleeding according to FIGO classification system: a combined study of ultrasound and histopathology. J Obstet Gynaecol Res 2022;48:1913-20.
22. 22. Chaturvedi M, Margam S, Azad S. Organic causes of abnormal uterine b leeding: a clinic-pathological study based on PALM category of FIGO classification. Indian J Pathol Oncol 2017;4:247-53.
23. 23. Chapron C, Vannuccini S, Santulli P, Abrão MS, Carmona F, Fraser IS. et al. Diagnosing adenomyosis: an integrated clinical and imaging approach. Hum Reprod Update 2020;26:392-411.