Pre-treatment with Mifepristone before Mirena insertion helps optimize the bleeding pattern

Pretreatment with low dose Mifepristone significantly improves the bleeding pattern following the insertion of the levonorgestrel-releasing intrauterine system with a 52 mg reservoir (LNG-IUS 52 mg, Mirena®) report the results of randomized control trial published in Journal of Human Reproduction.

The LNG-IUS is one of the most cost-effective contraceptive method currently available, but many women discontinue its use because of irregular bleeding/spotting during the initial three months following its placement. It is estimated that about 25–62% of women experience irregular vaginal bleeding during the first 3-6 months causing them to discontinue the contraceptive.

With continued use after 3-6 months, the irregular bleeding and spotting are reduced, and more than half the women experience amenorrhea at the end of 1 year.

The Swedish researchers recruited 68 eligible women attending the Karolinska University Hospital from November 2009-2013 for this prospective, randomized, double-blind, placebo-controlled trial (European Union Clinical Trials Register–2009-009014-40). Fifty-eight women met the eligibility criteria and were randomized to receive 50 mg mifepristone as single oral dose or placebo for two months before and three days following the insertion of LNG-IUS.

The LNG-IUS insertion was timed at the end of two 28 days menstrual cycle. All women were asked to systemically note the daily bleeding and spotting (B/S) or adverse effects for two months of mifepristone treatment and six months following the insertion of LNG-IUS.

The study participants underwent routine physical and gynecological examination, required laboratory tests including pelvic ultrasound, tests for chlamydia infection, breast biopsy, endometrial biopsy and pap test at baseline and during follow-up.

After statistical analysis, researchers noted significant lower B/S in the mifepristone group (−17.8% points, P < 0.001) in the first month following the LNG-IUS insertion. However, no significant difference was observed in both groups in the subsequent months.

This European study is the first study investigating the effect of prophylactic use of progesterone receptor modulators to reduce the B/S associated with post-LNG-IUS insertion. Other studies have investigated mifepristone for therapeutic purposes.

Based on the study results, researchers are optimistic that other modified treatment protocols of mifepristone with different duration and dose could be explored in further studies. Studies could also be planned with other progesterone receptor modulators to address the issue of B/S immediately after LNG-IUS insertion.

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ACOG updates its recommendations for treatment of Dysmenorrhea and Endometriosis in the Adolescent

The American College of Obstetrics and Gynecology (ACOG) has issued new guidance on diagnosing and relieving dysmenorrhea in adolescents, published in December issue of Journal Obstetrics and Gynecology.

Obstetrician and gynecologists frequently come across adolescents with dysmenorrhea in their practice due to high prevalence ranging between 50% to 90%. It is also responsible for recurrent short-term school absenteeism and reduced quality of life.

Most of the adolescents suffering from dysmenorrhea have primary dysmenorrhea–– painful menstruation in the absence of pelvic pathology.

If the physician suspects it to be primary dysmenorrhea, no pelvic examination or ultrasound is indicated in the initial evaluation. The patient should be put on empirical therapy after a careful history and physical examination.

If the patient does not respond to empirical therapy with NSAIDs and hormonal treatment in 3-6 months, she should be investigated for secondary causes or irregular treatments.

The most common cause of secondary dysmenorrhea is endometriosis, the other being obstructive anomaly of the reproductive tract (hymenal, vaginal, or Mullerian), uterine fibroids and polyps, adenomyosis, cervical stenosis, and adhesions.

Patients who do not respond to treatment for primary dysmenorrhea should be investigated for secondary causes which include pelvic examination and pelvic ultrasound. If pathology is detected, treatment of the cause is warranted.

If no pathology is seen, suspect endometriosis and consider a diagnostic laparoscopy. About 75% of adolescents and young adults with dysmenorrhea who do not respond to NSAIDs and hormonal therapy have endometriosis as the primary pathology. 

Endometriotic lesions present a different appearance in adolescents as compared to a young woman and are typically transparent or red and are challenging to diagnose.   

If a young woman is diagnosed with endometriosis, treatment consists of biopsy of the lesions along with destruction, ablation, or excision of the visible lesions at the time of initial laparoscopy. The patient should also be started on suppressive medical therapy to prevent further endometrial proliferation.

Consideration should be given to placing a levonorgestrel-releasing intrauterine system (LNG-IUS) at the of diagnostic laparoscopy to minimize the pain of insertion later. 

If patients do not respond to conservative surgical therapy and suppressive hormonal therapy, they often benefit from at least six months of gonadotropin-releasing hormone (GnRH) agonist therapy with add-back medicine.

NSAIDs are the principal medications used for pain relief in endometriosis, and there is no role of long-term opioids in the management of endometriosis, besides being used by a specialized pain management team.

ACOG committee opinion No. 760

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