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BMJ 2004; 328 doi: (Published 13 May 2004) Cite this as: BMJ 2004;328:1199

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Mirena IUS , a novel therapeutic alternative to hysterectomy for menorrhagia

We read the article by Gavin Yamey with interest and agree that in
most cases , estimation of menstrual blood loss is subjective to the
patient and 60% of such women actually do not classify as having excessive
menstrual blood loss.

We emphasize the strict use of evidence based guidelines published by
the Royal College of Obstetrics and Gynaecology on their website while
evaluating women presenting with menorrhagia.This not only helps avoid
over investigations but also addresses other issues as fertility and
contraceptive desires. Of course in primary care setting tranexamic acid
and NSAID's are the first line drugs which help decrease menstrual blood
loss by over 50%. Only in refractory cases like non responders or women
with multiple fibroids and adenomyosis, does surgery provide a definitive

A suitable alternative before considering hysterectomy is a trial of
the progestogen releasing intra uterine device Mirena, which has been
found to have long term 5 year satisfaction rates comparable to
hysterectomy and with over 90% reduction in monthly menstrual blood loss.
In addition it has advantages of long term contraception with failure
rates equalling sterilization. There is recent evidence that even in women
with fibroids , Mirena helps reduce the monthly blood loss. It is already
on the market, and is now being used by 300,000 women in 14 European and
Asian Countries. The levonorgestrel-releasing intrauterine system (LNG-
IUS), as it is called, combines the best features of hormonal
contraceptives and IUDs, and adds a few advantages of its own. The LNG-IUS
was co-developed and tested by the Population Council and its
International Committee for Contraception Research.

By causing suppression of endometrial growth, LNG-IUS causes marked
reduction in the amount of monthly menstrual blood loss (MBL). Initially
device tends to increase the number of days of bleeding as spotting. But
after few months of use both amount and duration of bleeding decrease.
After one year, 20% women are completely amenorrhoeic and overall 90%
reduction in MBL occurs. This compares with 30% reduction with NSAIDs, 50%
reduction with OCs and fibrinolytic inhibitors and 2% reduction with
placebo and D & C. This is also accompanied by reduction in
dysmenorrhoea, increase in body iron reserves and decreased cost of
menstrual hygiene. In a systematic cochrane review, LNG-IUS was found more
effective than cyclical nor-ethistrone as treatment for heavy menstrual

Mirena has been found as a good alternative to TCRE or hysterectomy
in women with perimenopausal DUB. In two studies, system was offered to
women awaiting hysterectomy or TCRE due to menorrhagia(2,3). Eighty
percent and 64% of women respectively cancelled their decision to undergo
surgery. Further more problem of contraception in this age group is also
met with by the use of this device. Even women with endometrial
hyperplasia have been successfully treated with this system(4,5)

Not only women with DUB, Mirena has even been found effective in
decreased HMB secondary to uterine fibroids. In a study by Starczewski A
et al, insertion of LNG-IUS decrease the intensity of menstrual bleeding
secondary to fibroids(6). Similarly in another study, insertion of this
device decrease development of uterine enlargements compared with Cu IUD

In view of above studies , we strongly recommend the use of Mirena
IUS before offering hysterectomy as last resort for treatment of

Sincerely yours

1. Lethaby AE, Cooke I, Rees M. Progesterone/progestogen releasing
intrauterine systems versus either placebo or any other medication for
heavy menstrual bleeding (Cochrane Review). The Cochrane Library, Issue 2,
2002. Oxford : Update Software Ltd.

2. Barrington JW, Bowen-Simpkins P. The levonorgestrel intrauterine
system in the management of menorrhagia. Br. J Obstet Gynaecol 1997; 104 :

3. Lahteenamaki P, Haukkarnaa M, Puolakka J, et al. Open randomised
study of use of levonorgestrel releasing intrauterine system as
alternative to hysterectomy. Br Med J 1998; 316 : 1122-6.

4. Perino A, Quartararo P, Catinella E, et al. Treatment of
endometrial hyperplasia with levonorgestrel releasing intrauterine
devices. Acta Eur Fertil 1987; 18 : 137-40.

5. Scarselli G, Tantini C, Colafranceschi M, et al. Levonorgestrel-
Nova T and precancerous lesions of the endometrium. Eur J Gynaecol Oncol
1988; 9 : 284-6.

6. Starczewski A. Intrauterine therapy with levonorgestrel relesing
IUD of women with hypermenorrhea secondary to uterine fibroids. Ginekol
Pol 2000; 71 : 1221-5

7. Sivin I, Stern J. Health during prolonged use of levonorgestrel 20
mg/d and the copper TCu 380 Ag intrauterine contraceptive devices. Fertil
Steril 1994; 61 : 70-7.

Competing interests:
None declared

Competing interests: No competing interests

14 May 2004
Umber Agarwal
Specialist registrar Obs and Gynae
Rodin Adam , Bernhardt LW, Broadbent M, Bajekal Nitu, Pundir Jyotsna, Singh Ruchira, Chaudhry Pooja
Barnet General Hospital EN5 3HD