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Progesteronlu RİA : Kime ? Prof.Dr.Umur Çolgar THE LEVONORGESTREL INTRAUTERINE DEVICE Steroid...
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Transcript of Progesteronlu RİA : Kime ? Prof.Dr.Umur Çolgar THE LEVONORGESTREL INTRAUTERINE DEVICE Steroid...
Progesteronlu RİA : Kime ?
Prof.Dr.Umur Çolgar
THE LEVONORGESTREL INTRAUTERINE DEVICE
Steroid reservoir: Levonorgestrel 52mg Silicone rate-limiting membrane
T frame
Removal threads
32 mm
Mirena®: Levonorgestrel release 20 µg/24 hours
THE LEVONORGESTREL INTRAUTERINE SYSTEM
Mirena®
Levonorgestrel Intrauterine System
Multiple modes of action
Main: Prevention of
endometrial proliferation Thickening of utero-
cervical fluidMinor: Occasional prevention of
ovulation Foreign body reaction in
endometrium
Which Patient ?
Desire for contraceptionMenorrhagiaHRT programme for
perimenopausal and menopausal women
Barcelona1 7
Effects of LNG-IUD
Suppression of IGF-1 by abandoned production of IGFBP-1 causes inhibition of the IGF-1-mediated estrogen effects.Inhibition of angiogenesis.Hamptom et al Human Reprod. 20, 2653, 2005
Levonorgestrel concentration in plasma, fat myometrium, endometrial and oviduct tissues
Tissue LNG-IUS Oral**
Plasma(pg/ml) 202 559
Fat tissue * 1.23 4.41
Myometrium * 2.43 1.4
Endometrium* 808 3.5
Oviduct * 1.8 1.7
*ng/g wet weight** Oral administration of levonorgestrel
Clinical Endocrinology ,Nilsson et al 1982
LEVONORGESTREL IUS
Proliferative Secretory Inactive
Courtesy Dr E-M Rutanen, Helsinki
SEVERE PELVIC INFLAMMATION
12.5% risk of tubal infertility with first attack
33% risk with second attack
Weström 1980
Return to Fertility
No delay
Ovulation occurs within 2 weeks
& menstruation within 23 days
Rates of conception post removal
are normal
Definition
Regular heavy bleedingfrom a secretory endometriumexceeding 80 ml per cycle
Patient Selection for Menorrhagia Treatment
Organic factors should be diagnosed
Pathologies of the endometrium should be examined
Causes of menorrhagiaIdiopathic (no obvious cause)Fibroidsendometriosis / adenomyosisgenital infectionsendometrial polypshyperplasiamalignancycoagulation or endocrine
disordersmedications
Efficacy of Mirena® in menorrhagia
Mirena effectively reduces menstrual blood loss (MBL)
0
50
100
150
200
Beforeinsertion
3 6 12
Months of Mirena use
Med
ian
MB
L (m
L)
Andersson and Rybo. Br J Obstet Gynaecol. 1990; 97: 690-4
* * *
* p<0.001
─86%─97%─91%
% Reduction
(80mL MBL = menorrhagia)
Mirena® compared with flurbiprofen, and tranexamic acid
Mirena® is significantly more effective than flurbiprofen or tranexamic acid in reducing menstrual blood loss
-95.8
-20.7
-44.4
-100-90-80-70-60-50-40-30-20-10
0
Mirena Flurbiprofen
(FL)Tranexamicacid (TA)
Per
cent
age
chan
ge fr
om
base
line
in M
BL
Milsom et al. Am J Obstet Gynecol 1991; 164: 879-83
***
**
*
* P<0.05 (FL vs TA)
**P<0.01 (Mirena vs TA)
***P<0.001 (Mirena vs FL)
Mirena® compared with endometrial ablation/resection
Mirena has comparable efficacy with endometrial resection in reducing menstrual blood loss
Crosignani et al. Obstet Gynecol 1997; 90: 257-63
184.8203.2
38.823.5
0
50
100
150
200
250
Mirena Endometrialresection
Mea
n bl
eedi
ng s
core
Baseline
12 months
79% 89
%
LNG-IUS therapeutic effect on Fibroid uterus
The local direct endometrial suppression is the principal mechanism explaining the effect of the LNG-IUS on menstrual blood loss in cases of leiomyoma.
Single intramural fibroid less than 5 cm or multiple intramural fibroids < 3 cm in diameter and < 5 in number.
Submucousal extension less than 30% and not causing major distortion of uterine cavity.
Uterine length less than 10cm
Hysteroscopy, endometrial biopsy
liquid base cytology
Transvaginal ultrasound
Criteria of selection
ESH classification
X
XX
ESH Submucous Myoma Classification
TypeIntramural Extension
0 None
I < 50%
II > 50%
European Society for Hysteroscopy Classification
Changes in Uterine and Leimyoma Volume
Baseline(n=67)
3 months (n=56)
6 months (n=56)
12 months (n=61)
Uterine volume (mL)
138±72 131±68p<0.01
125±58 p<0.01
122±73p<0.01
Total leiomyoma volume (mL)
30±29 27±34p=0.10
19±21 p<0.001
19±21 p<0.001
Barcelona 2 23
Barcelona 2 26
Suvanto-Luukkonen et al Acta Obstet. Gynecol. Scand. 77, 758, 1998
Barcelona 2 27
Anderson et al Obstet. Gynecol. 79, 963, 1992
28
Mirena® combined with 2 mg oral estradiol valerate in postmenopausal women
At 6 and 12 month endometrial histology was nonproliferative.
The thickness of the endometrium was 3.6 mm.Conclusion: Mirena® protects against endometrial
hyperplasia. In most of the women it induces amenorrhea.
Varila et al Fert. Steril. 76,969,2001
Barcelona 2 29
Percutaneous gel (1.5 mgE2 daily) and Mirena®
1. Spotting was frequent during the first 6 month and declined thereafter.
2. At 1 one year 80 % of the women were amenorrheic
3. Endometrium morphology showed epithelial atrophy accompanied by decidual reaction of the stroma.
Suvanto-Luukkonen, Kauppila Fert. Steril. 72, 161, 1999
30
Levonorgestrel-IUD Mirena® with oral conjugated estrogens in perimenopausal women
n=82
Length of treatment
(month)
Nonproliverative endometrium
(%)
Propotion of amenorrhea
(%)
12 98,6 % 54,4
24 98,6 %
36 95,5 %
48 96,8 %
60 95,2 % 92,7
No endometrial hyperplasia was detected throughout the period of 60 month.
Hampton et al Human Reprod. 20, 2653, 2005
LNG-IUD in ERT-users1 Year Follow-Up
Raudaskoski et al. BritJ Obstet Gynaecol 2002;109:136
168 postmenopausal women in 4 Finish Menopause ClinicsAll did get oral 2mg E2-valeriate daily Randomised:
LNG-IUD 10 microgram per dayLNG-IUD 20 microgram per dayCyclic MPA: 5mg/day 14/30
Endometrial protectionAtrophia in both LNG-IUD18/47 had endometrial proliferation in MPA group
Serum lipid profileTotal cholesterol decreased in all 3 groupsHDL increased in MPA and LNG-IUD 10 micrograms per day
InsertionEasy: 70% for smaller versus 46% for larger (Mirena)Difficult: 4% for smaller versus 21% for larger (Mirena)
LNG-IUD – Beyond Contraception
Down regulation of ER/PRIncrease in apoptosis and decreased proliferationEndometrial glandular atrophy in 87%Endometrial stromal decidualisation in 96%Stromal inflammatory cell infiltrate in 79%Insuline-like growth factor 1 (IGF1-BP)Increase in impedance to blood flow to uterine a.Endometrial angiogenic growth factorsMany locally acting mediators of breakthrough
beeding: Interleukin-8, Cyclooxygenase-2
Barcelona1 33
Varma et al Obstet. Gynecol. in press
MIRENA and Endometriosis
StudyStudy size
Duration ResultsLNG IUS vs control
Vercellini et al (2003)
20 LNG IUS
20 surgery
only
12 months
10% vs 45% recurrence of dysmenorrhea
75% vs 50% satisfied with the treatment
Barcelona1 35
Petta et al Human Reprod. 20, 1993-1998, 2004
The nulliparous modern woman
Appropriate method NICE
Possible less PID Investment in fertility
◦ Less menorrhagia◦ Less dysmenorrhea
Switch off/Switch on contraception
Fit and forgetHigher continuation in 80%
compared to 73% for COC Suhonen, Contraception 2004;69:407
38
Meme Kanseri İnsidansı/100.000
Yaş Grupları 30-34 35-39 40-44 45-49 50-54
Mirena 27,2 74,0 120,3 203,6 258,5
Kontrol 25,5 49,2 122,4 232,5 272,6
BackmanT. ObstetGynecol 106:813,2005
40
Varma et al Obstet. Gynecol. in press