Insertion of the levonorgestrel intrauterine system (LNG-IUS) in post-menopausal women

Insertion of the levonorgestrel intrauterine system (LNG-IUS) in

post-menopausal women

T. Masters (3), R.E. D’Souza (1), W. Bounds (2), J. Guillebaud (2)

Margaret Pyke Memorial Trust Research Unit, Department of Obstetrics and

Gynaecology, University College London, UK (1); Retired from Margaret Pyke

Memorial Trust Research Unit (2); Formerly Margaret Pyke Memorial Trust Research

Unit, now Brook (Avon), Bristol, UK (3)

Objective: There is growing evidence to support intrauterine

progestagen delivery in HRT and this can be achieved with the LNG-IUS (Mirena®

– Schering). However, clinicians may be concerned that insertion of the LNG-IUS

in the post-menopausal state might be difficult. We present information on the

insertion procedures of a cohort of post-menopausal women who had an LNG-IUS


Design & Methods: One hundred and ten women aged between 45 and 60

years with confirmed post-menopausal status had an attempted fitting of the

LNG-IUS within an open randomized comparative trial of the LNG-IUS plus oral

oestrogen versus a combined oral sequential preparation. These insertion data

were secondary outcome measures within the study, which took place at a research

unit in central London. Intervention: Those with no previous HRT use (n=72) used

estriol cream 0.1% vaginally for one week prior to the insertion. There was no

wash-out period for current HRT users (n=38). The procedure was performed on a

flat examination couch by one of four experienced clinicians. Pre-insertion oral

analgesia and paracervical block (with 10ml 1% lidocaine) was used, unless the

woman declined either. The IUS inserter used was the old 2-handed version. The

clinician assessed the insertion as ‘easy’ or ‘difficult’ and the woman

assessed the pain of insertion as ‘none’, ‘mild’, ‘moderate’ or ‘severe’.

Results: In only one woman was insertion not achieved (the procedure

was abandoned because the uterine cavity felt abnormally small on sounding). The

clinician rated the insertion procedure as ‘easy’ in 66 (60%) and ‘difficult’

in 43 (40%). Ninety three women (85%) had a paracervical block and 43 (39%) had

cervical dilatation. 17 (16%), 66 (61%), 21 (19%) and 5 (5%) described no, mild,

moderate or severe pain, respectively. In five women the LNG-IUS was

inadvertently removed during removal of the applicator (n= 3), speculum (n= 1)

or whilst cutting the threads (n= 1). All immediately had a subsequent

straightforward reinsertion. In one case ultrasound assessment was required to

establish uterine position prior to insertion.

Conclusions: There was a low level of problems during insertion of the

IUS within this group of postmenopausal women. Clinicians experienced in IUS

insertion and familiar with local anaesthetic techniques and cervical dilation

are unlikely to encounter excessive problems during IUS insertion for

post-menopausal women.

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