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Levonorgestrel releasing IUS (Mirena

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... /2001 Duration of pregnancy up to 8 weeks Analysis of efficacy, learning curve and future contraception 29% chose IUS/IUD for future contraception 16% ... – PowerPoint PPT presentation

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Title: Levonorgestrel releasing IUS (Mirena


1
Levonorgestrel releasing IUS (Mirena) after
abortion
  • S.Rogovskaya, MD,PhD
  • The Research Center of Obstetrics, Gynecology and
    Perinatology,
  • Russian Academy of Medical Science,
  • Moscow, Russia

2
Abortion and gynecological morbidity
The higher the number of abortions The higher
the risk of gynecological diseases
Abortion number 0 2 -3 6 -7
Risk of gynecological morbidity 3 -4 18 -20 100
Abortion rates in RF
(MH RF)
N.Nikiforovsky et.al, 2000
3
Special demands for contraception after abortion
  • Long-term
  • Reversible
  • Effective
  • Safe
  • Easy to use

4
Reasons to initiate contraception immediately
after abortion
  • The return of fertility after a first trimester
    abortion is very rapid
  • For women, who usually do not visit a doctor and
    might not come to a control visit after abortion
    - an optimal opportunity to initiate
    contraception is immediately after the procedure

5
Contraception after abortion (tipical use)
Method Pearl index
COP 1-3
Injection 0,3 1,0
Implants 0,2-1,0
IUD 0,1 3,9
Barrier 5 25
Sterilization 0,2 1,0
Natural 10-30
V. Prilepskaya, 1998
6
Intrauterine levonorgestrel - releasing system
was developed to combine contraceptive and
therapeutic properties of hormonal agents with
advantages of intrauterine devices
  • Long lasting
  • Active progestin
  • Antiestrogenic effect
  • Antiproliferative action on endometrium
  • No metabolic effect
  • Therapeutic properties

7
Advantages of LNG IUS
  • Lighter periods
  • Reduces dysmenorrhea
  • Beneficial effects on adenomyosis
  • and leiomyomas
  • Effective treatment in menorrhagia
  • Decreases the need for hysterectomies
  • Protection from endometrium
  • hyperplasia during hormonal therapy (HRT)
  • Intrauterine release of 20µg LNG/d
  • Approved for 5 years
  • Pearl-index 0.1

Maia et al, GynEndocr 2005 Grigorieva et al,
FertilSteril 2003 Hurskainen et al, JAMA 2004
8
Various aspects of LNG-IUS were studied in
Research Center of Obstetrics, Gynaecology and
Perinatology for 8 years
  • Two studies were carried out within
  • framework of WHO and FHI.
  • Published 1 monograph, 30 articles in domestic
    and foreign magazines, 16 reports at
    congresses, conferences and symposia.
  • Detailed survey in 1126 women.

V. Prilepskaya, L.Ostreykova, A.Tagieva, 2005
9
LNG-IUS in women with diabetes
  • The continuation rates per 100 women with
    diabetes mellitus type I
  • 86.7 (95 CI, 68.8-100)
  • The small amounts of levonorgestrel absorbed
    systemically from LNG-IUS do not impair glucose
    metabolism

S.Rogovskaya et al, The American College of
Obstetricians and Gynecologists 2005
10
Glycosylated haemoglobin at baseline and
follow-up by treatment group
S.Rogovskaya et al, 2005
11
Mirena-IUS after surgical abortion the first
study
  • Immediate postabortal insertion of a
    LNG-releasing IUS compared with Cu-IUD
  • n 60
  • Both devices well tolerated
  • LNG-IUS - regular cycles in 75 at 1 year
  • Cu-IUD - regular cycles in all
  • Continuation rate 75 at 1 year

Heikkilä et al., Contraception, 1982 26245-59
12
12-month multicenter trial comparing Mirena and
Nova T
  • Alltogether 2758 women
  • 1821 in Mirena group
  • 937 in NovaT group
  • 440 (16) postabortal insertions
  • immediately after abortion or in 2 weeks

Luukkainen et al 1987
13
Cumulative 12-month events per 100 women

Event NovaT Mirena NovaT Mirena
Pregnancy 0.8 0.1 2.1 0
Expulsion 3.0 2.8 8.3 6.8
Mestrual/pain 7.5 9.0 7.7 7.9
Hormonal 0.1 2.6 0 1.7
Other medical 1.9 2.3 9.2 7.1
Personal 2.8 2.5 1.8 2.7
Continuation 83.9 80.8 71.3 73.8
Menstrual Interval
Postabortion
Luukkainen et al 1987
14
Results of 12-month study
  • Pregnancies
  • Mirena group 0
  • NovaT group 2.1 / 100 women
  • Expulsion rate higher in postabortion insertions
  • NovaT 3.0 vs 8.3
  • Mirena 2.8 vs 6.8
  • Removals for other medical reasons
  • Most usual in postabortal NovaT group (9.2/100)
  • Removals for hormonal reasons
  • Most usual in menstrual interval Mirena group
    (2.6 / 100)

Luukkainen et al 1987
15
Postabortal contraception with the Mirena,
Norplant, and traditional methods
  • Turkey
  • 50 women in each group
  • Pregnancy lt 10 weeks
  • Insertion of Mirena or Norplant implants was done
    immediately after the evacuation
  • of the uterus
  • 12 month follow-up

Ortayli et al 2001
16
Postabortal contraception with the Mirena,
Norplant, and traditional methods
  • Pregnancies
  • Mirena 0, Norplant 0, traditional method rate
    8/100
  • Continuation rates at 12 months
  • 96 for Norplant and 90 for Mirena
  • Expulsions
  • 2 in Mirena group
  • Bleeding and spotting
  • After 5th week no difference between the groups
    in bleeding

Ortayli et al, 2001
17
Postabortal contraception with the Mirena,
Norplant, and traditional methods
  • Satisfaction with the methods
  • Most of the users of hormonal methods were
    satisfied with their method
  • Easy to use
  • Safe
  • Effective
  • The Mirena users appreciated the reduced
    menstrual bleeding

Ortayli et al 2001
18
Randomized comparison of LNG and Cu-releasing
IUSs immediately after abortion - a 5-year
follow-up
  • Multicenter study in Denmark, Finland, Hungary,
    Norway and Sweden
  • Surgical abortion of pregnancies up to 12 weeks
  • Randomized for Mirena (305 patients) or
  • Nova-T (133 patients)
  • IUS inserted immediately after curettage

Pakarinen et al., Contraception 2003 68 31-34
19
LNG vs Cu-IUSs after abortion
  • Reasons for discontinuation (/100 women)
  • 1 year 5 years p
  • Cu LNG-IUS Cu LNG-IUS
  • Pregnancy 2 0 9.5 0.8 lt0.0005
  • Expulsion 8.6 7.1 15.4 10.5 ns
  • Bleeding 7.7 5.8 22.6 13.7 ns
  • Amenorrhea 0 1.6 0 2.1 ns
  • Pain 1 2 10.8 5.5 ns
  • Hormonal 0 2 3.9 15.9 lt0.01

Pakarinen et al., Contraception 2003 68 31-34
20
Reasons for discontinuation
  • 2 pregnancies in Mirena group
  • - (Occurred during the 4th year)
  • The first pregnancy was terminated by curettage
    and no IUS was found
  • The second pregnancy was after an unnoticed
    expulsion
  • The incidence of expulsions, bleeding problems,
    pain and pelvic inflammatory disease (PID)
  • Not significantly different between the groups
    but tended to be lower in the Mirena group

Pakarinen et al., Contraception 2003 68 31-34
21
Reasons for discontinuation
  • Planning pregnancy
  • 11.5 for NovaT and 17.7 for Mirena
  • High figures show the importance of a reversible
    method
  • Amenorrhea
  • Terminations occurred during the use of Mirena
  • The cumulative gross rate was low, 2.1 at 5 years
  • Bleeding disorders
  • Tended to be lower in Mirena group
  • Hormonal reasons higher with the Mirena than
    NovaT

Pakarinen et al., Contraception 2003 68 31-34
22
Mirena-IUS following medical abortion at Womens
Hospital, University of Helsinki
  • 417 women chose medical abortion between
    VIII/2000 and VIII/2001
  • Duration of pregnancy up to 8 weeks
  • Analysis of efficacy, learning curve and future
    contraception
  • 29 chose IUS/IUD for future contraception
  • 16 (n65) Mirena
  • 13 (n53) Cu-IUD
  • 55 of the IUDs inserted at the control visit at
    3 weeks following mifepristone
  • 25 inserted at later occasion at the clinic
  • Insertions without complications

Suhonen et al., Contraception 2003 67 223-7
23
LNG-IUS after abortion in RC OGP, Moscow
  • N37
  • 12 months follow-up
  • Effective (no pregnancies)
  • Safe, no serious adverse effects
  • Most reasons for discontinuation bleeding,
    spotting
  • Continuation rate 82

V.Prilepskaya, A.Kuzemin, 2004
24
Mirena-IUS after abortion summary
  • Mirena-IUS is highly effective for postabortal
    contraception (Pregnancy rates low, IP0.1-0.2)
  • Mirena-IUS can be safely inserted
  • at the time of 1st trimester surgical abortion or
  • 2-3 weeks after medical abortion
  • High rate of discontinuation of Mirena due to
    wish for pregnancy - emphasises the importance of
    reversibility of contraception

25
Mirena-IUS after abortion summary
  • Counselling and insertion technique are important
    (expulsions increased)
  • Easy method for women
  • Effective immediately after insertion, long-term
    5 yrs
  • No daily remembering
  • Offers added health benefits
  • Reduction of menstrual bleeding
  • Better iron balance and prevention of anaemia
  • Reduces dysmenorrhea, smaller risk of bleeding
    due to adenomyosis and leiomyomas
  • Effective in menorrhagia

26
Mirena method of contraception after abortion
  • Effective
  • Safe
  • Reversible
  • 5 years
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