Abnormal uterine bleeding (AUB) is not only a health concern, but can have a significant impact on quality of life for the up to 30 percent of women affected by AUB at some point during their lives.
The Samuel A. Cosgrove Memorial Lecture, “Medication Superheroes Take on the Mighty IUD for Treatment of AUB,” on Saturday morning featured a pair of experts who discussed the efficacy of the levonorgestrel-releasing intrauterine device (LNG-IUD) for treating abnormal uterine bleeding as compared to the medical therapies commonly used to treat AUB, particularly combined oral contraceptives.
“This is an important discussion because abnormal uterine bleeding, which is defined as menstrual flow outside of the normal volume, duration, regularity, or frequency, accounts for about 33 percent of gynecologic outpatient visits and about 70 percent of consults that come in for patients who have perimenopausal or postmenopausal issues,” said Michael A. Thomas, MD, chief of the division of reproductive endocrinology and infertility at the University of Cincinnati College of Medicine.
Dr. Thomas, who was a member of the research team that developed the LNG-IUD (brand name Mirena), believes it is a safe and effective AUB treatment option for most women, noting that studies have shown the IUD to be superior to medical therapies at reducing the total volume of bleeding.
“The LNG-IUD has been shown to be more effective at controlling bleeding than placebo, hormonal agents, and NSAIDs,” Dr. Thomas said. “Additionally, compared to oral therapies, LNG-IUD users are more likely to continue use at two years.”
Dr. Thomas said the LNG-IUD also offers other beneficial therapeutic effects, such as increasing hemoglobin levels and iron stores, reducing dysmenorrhea, and mitigating tamoxifen-induced endometrial effects. AUB patients who use the IUD, he noted, can also avoid the potential side effects associated with oral therapies.
“Patients sometimes have progestin-related problems, such as mood changes, nausea or bloating, which they may not have with the IUD because very little of the medication gets into the peripheral blood stream,” Dr. Thomas said. “The advantage of this type of local device that is inside the uterus is that it actually has a direct effect, as opposed to taking something by mouth.”
While Kristen A. Matteson, MD, MPH, does not dispute the research studies that have demonstrated the effectiveness of the IUD, she said they have mainly focused on measuring the total amount of blood loss as the sole outcome without taking into account patients’ varying preferences and expectations of how they want their symptom to change in response to treatment. Dr. Matteson is director of the division of research for the department of obstetrics and gynecology at The Warren Alpert Medical School of Brown University and Women & Infants Hospital in Rhode Island.
“The leading reason women discontinue use once they’ve already gotten the IUD, for example, is they don’t like the irregular bleeding pattern associated with it,” Dr. Matteson said. “And while the medical treatments we have may not reduce the amount of blood loss as much as the IUD, all result in predictable and lighter bleeding episodes, which I would argue is more important to many patients than just quantified amounts of blood loss that they have per cycle.”
Ultimately, she said, it is a quality of life issue, and the IUD may be the right choice for some women, but cautions against looking at it as a “one-size-fits-all” treatment for women with AUB. She believes there is a “disconnect” between research on heavy menstrual bleeding, clinical care, and patient-centered care delivery, pointing to studies that have shown, from the woman’s point of view, objective reduction in mean blood loss is a poor indicator of treatment effectiveness for heavy menstrual bleeding.
“Each individual patient has a treatment option that is best for her, and that best option likely varies from woman to woman. It’s fabulous that we have the IUD as an option, but it is equally fabulous that we have awesome effective medical options like combined hormonal contraceptives, oral progestins and tranexamic acid,” Dr. Matteson said. “Women suffering from heavy menstrual bleeding deserve shared decision-making and a patient-centered approach. Physicians, other health care providers, and health systems owe women the chance to be active participants in their own medical care and decision making related to treatment of heavy menstrual bleeding.”