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Randomized clinical trial of a levonorgestrel-releasing intrauterine system and a depot GnRH analogue for the treatment of chronic pelvic pain in women with endometriosis
Abstract
BACKGROUND: The objective of this multicentre randomized, controlled clinical trial was to compare the efficacy of a levonorgestrel-releasing intrauterine system (LNG-IUS) and a depot-GnRH-analogue in the control of endometriosis-related pain over a period of six months. METHODS: Eighty-two women, 18 to 40 years of age (mean 30 years), with endometriosis, dysmenorrhoea and/or CPP, were randomized using a computer-generated system of sealed envelopes into either LNG-IUS (n = 39) or GnRH analogue (n = 43) treatment groups at three university centres. Daily scores of endometriosis-associated CPP were evaluated using the Visual Analogue Scale (VAS), daily bleeding score was calculated from bleeding calendars, and improvement in quality of life was evaluated using the Psychological General Well-Being Index Questionnaire (PGWBI). The pain score diary was based on the VAS in which women recorded the occurrence and intensity of pain on a daily basis. A monthly score was calculated from the result of the sum of the daily scores divided by the number of days in each observation period. RESULTS: CPP decreased significantly from the first month throughout the six months of therapy with both forms of treatment and there was no difference between the groups (P > 0.999). In both treatment groups, women with stage III and IV endometriosis showed a more rapid improvement in the VAS pain score than women with stage I and II of the disease (P < 0.002). LNG-IUS users had a higher bleeding score than GnRH-analogue users at all time points of observation with 34% and 71% of patients in the LNG-IUS and GnRH-analogue groups, respectively, reporting no bleeding during the first treatment month, and 70% and 98% reporting no bleeding during the sixth month. No difference was observed between groups with reference to improvement in quality of life. CONCLUSIONS: Both, the LNG-IUS and the GnRH-analogue were effective in the treatment of CPP-associated endometriosis, although no differences were observed between the two treatments. Among the additional advantages of the LNG-IUS is the fact that it does not provoke hypoestrogenism and that it requires only one medical intervention for its introduction every 5 years. This device could therefore become the treatment of choice for CPP-associated endometriosis in women who do not wish to conceive.
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“At the end of the study, the 13% ( n = 5) of patients in the LNG-IUS group and the 14% ( n = 6) in the GnRHa group failed to reach a VAS pain score of less than three.”
From Oral and depot progestin therapy for endometriosis: towards a personalized medicine (2017) · cites this paper as [80]
In the citing paper
“In both treatment groups, the subgroup of patients that achieved the more rapid improvement in VAS score was the one of patients with stage III and IV of the disease.”
From Oral and depot progestin therapy for endometriosis: towards a personalized medicine (2017) · cites this paper as [80]
In the citing paper
“In particular, a Brazilian multicenter trial [80] compared the efficacy of the LNG-IUS and a depot GnRHa in 82 women with symptomatic endometriosis. At 6-months follow-up both treatments appeared to be similarly effective for endometriosis-related chronic pelvic pain, with a six-points decrease from baseline in VAS pain score in both study groups.”
From Oral and depot progestin therapy for endometriosis: towards a personalized medicine (2017) · cites this paper as [80]
In the citing paper
“Progestins were positively associated with HRQoL in women with endometriosis [20,21,23-25,27,29,30].”
From Health-related quality of life in women with endometriosis: a systematic review (2012) · cites this paper as [23]
In the citing paper
“Moreover, six months of therapy with progestins seemed equivalent to that of GnRHa in improving HRQoL and reducing pain, according to six RCTs [20,23-25,27,29].”
From Health-related quality of life in women with endometriosis: a systematic review (2012) · cites this paper as [23]
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“for dysmenorrhea- or endometriosis-related pain [18].”
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“Of note, SOGC points out that LNG-IUS and COCs are also beneficial for treating dysmenorrhoea and chronic pelvic pain due to endometriosis in nonpregnant reproductive-aged women, based on a randomised controlled trial of 82 women [61].”
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“…83 women, both LNG-IUS (20 µg/day) and LEU (3.75 mg every 3 months) significantly improved pain symptoms over 6 months, with no significant difference between them; however, faster pain relief was observed in women with advanced stage disease compared to those with mild stage disease [61].”
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“In addition to hysterectomy or bilateral oophorectomy, hormonal treatments resulting in the absence of menstrual bleeding, such as continuous use of COCs or the LNG-IUS, were associated with a reduced risk of recurrence.”
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“Progestins are often used, with their selection according to their different side effects, especially the irreversible or highly prevalent ones (8-10).”
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“Sample size Based on previously published studies using AI [3, 4, 12, 13] or LNG-IUD [9], in the research project-protocol of the clinical trial ENDOMET-IA-DIULNG08 (EudraCT No.”
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“At 36 months, 59% of women were still using the LNG-IUS and 82% of these users reported a lower VAS score compared with GnRHa.”
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“There was no significant difference between LNG-IUS and GnRH-a (leuprorelin) in reducing endometriosis- and/or adenomyosis-related pain during the 6 months’ treatment (78).”
BackgroundThe possibility of treatment with dienogest 2 mg in patients with genital endometriosis
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Self-citationTreatment of Endometriosis-Associated Pain with Elagolix, an Oral GnRH Antagonist
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Endometriose Aspectos clínicos do diagnóstico ao tratamento
Silva, J. C. R. E., Valério, F. P., Herren, H., Troncon, J. K., Garcia, R. B., & Poli‐Neto, O. B. (2021) · Femina · doi:10.61622/0100-7254493202101 · Cited by 14
“Associada à melhora clínica, observou-se também a diminuição dos valores séricos de CA125, marcador tumoral utilizado na prática clínica para o acompanhamento da endometriose.(42) Os COCs são a primeira escolha de tratamento clínico em muitos centros.”
Pohl, O., Baron, K. T., Riggs, M. M., French, J., Garcia, R., & Gotteland, J. (2021) · British Journal of Clinical Pharmacology · doi:10.1111/bcp.15171 · Cited by 12
“Gonadotropin-releasing hormone (GnRH) agonists offer another hormonal therapeutic approach for treatment of endometriosis, often used in patients with severe disease who are no longer responding to oral contraceptives.(6,7) GnRH agonists, however, can cause an initial surge of follicle-stimulating hormone, luteinizing…”
BackgroundBulun, S. E. (2019) · Elsevier eBooks · doi:10.1016/b978-0-323-47912-7.00025-1 · Cited by 14
Endométriose et douleurs pelvipérinéales chroniques
Roman, H., Bourdel, N., Rigaud, J., Delavierre, D., Labat, J.-J., & Sibert, L. (2010) · The French Journal of Urology · doi:10.1016/j.purol.2010.08.007 · Cited by 13
Managing drug-resistant essential menorrhagia without hysterectomy
Hurskainen, R. (2006) · Best Practice & Research Clinical Obstetrics & Gynaecology · doi:10.1016/j.bpobgyn.2006.03.003 · Cited by 14
Is There a Role for Use of Levonorgestrel Intrauterine System in Women with Chronic Pelvic Pain?
Anpalagan, A., & Condous, G. S. (2008) · Journal of Minimally Invasive Gynecology · doi:10.1016/j.jmig.2008.07.008 · Cited by 14
Manetta, L. A., Martins, W. P., Silva, J. C. R. E., Silva, A. C. J. D. S. R. E., Nogueira, A. A., & Ferriani, R. A. (2008) · Ultrasound in Medicine & Biology · doi:10.1016/j.ultrasmedbio.2008.04.013 · Cited by 14
Self-citationHarada, T., Ota, I., Kitawaki, J., Momoeda, M., Maeda, N., Akira, S., Umeyama, M., Sunaya, T., & Hirano, K. (2022) · Contraception · doi:10.1016/j.contraception.2022.08.006 · Cited by 12
Wang, J., Deng, K., Li, L., Dai, Y., & Sun, X. (2022) · Frontiers in Global Women s Health · doi:10.3389/fgwh.2022.1013921 · Cited by 13
“We could not draw any conclusions according to available data because few studies (18, 28, 74, 75, 83) have reported on quality of life and the scales they adopted differed.”
BackgroundMethodResultInfluentialRosenberger, D. C., Mennicken, E., Schmieg, I., Medkour, T., Péchard, M., Sachau, J., Fuchtmann, F., Birch, J. V., Schnabel, K., Vincent, K., et al. (2024) · Pain · doi:10.1097/j.pain.0000000000003290 · Cited by 13
National consensus on management patients with endometriosis
Запорожан, В. М., Татарчук, Т. Ф., & Володимирович, К. В. (2015) · Reproductive Endocrinology · doi:10.18370/2309-4117.2015.24.7-12 · Cited by 12
The Double Engines and Single Checkpoint Theory of Endometriosis
Hsu, C.-F., Khine, A. A., Huang, H.-S., & Chu, T.-Y. (2022) · Biomedicines · doi:10.3390/biomedicines10061403 · Cited by 12
“Clinical studies have shown that although Mirena worked equally effective as GnRHa in relieving endometriosis-associated pain [112], it was not as effective in preventing the recurrence of ovarian endometrioma [25].”
BackgroundWildemeersch, D. A., Andrade, A. T. L., & Goldstuck, N. D. (2016) · Clinical Medicine Insights Reproductive Health · doi:10.4137/cmrh.s40087 · Cited by 12
Watanabe, Z., Nishigori, H., Tanoue, K., Tanaka, K., Iwama, N., Satoh, M., Murakami, T., Nishigori, T., Mizuno, S., Sakurai, K., et al. (2018) · Journal of Affective Disorders · doi:10.1016/j.jad.2018.11.061 · Cited by 12
Copper IUD and LNG IUS compared with tubal occlusion
Mansour, D. (2007) · Contraception · doi:10.1016/j.contraception.2006.12.021 · Cited by 12
“pain/menstrual symptoms found in users over a 6-month period [24,25]”
BackgroundIs endometriosis due to evolutionary maladaptation?
Mümüşoğlu, S., & Hsueh, A. J. W. (2023) · Reproductive BioMedicine Online · doi:10.1016/j.rbmo.2023.103695 · Cited by 12
Modern trends in the treatment of endometriosis
Adamyan, L. V., Arslanyan, K. N., Kharchenko, E. I., & Логинова, О. Н. (2019) · Russian Journal of Human Reproduction · doi:10.17116/repro20192506158 · Cited by 10
Engemise, S. L., Willets, J. M., Emembolu, J. O., & Konje, J. C. (2011) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2011.09.007 · Cited by 10
“Mirena (LNG-IUS) which delivers the progestogen levonorgestrel (LNG) into the uterine cavity at a steady rate of 20 mg/day has been shown in several pilot studies to be effective in symptom control in women with minimal to moderate endometriosis [14–17].”
BackgroundKim, H. Y., Song, S. Y., Jung, S. H., Song, H. J., Lee, M., Lee, K. H., Jung, Y. W., & Yoo, H. J. (2022) · Medicine · doi:10.1097/md.0000000000029023 · Cited by 12
“The LNG-IUS (Mirena, Bayer Ag, Turku, Finland) is an intrauterine device that can steadily release levonorgestrel at a rate of 20mg/day directly into the uterine cavity for 5 years.([9]) Many clinical studies have demonstrated the efficacy of LNG-IUS as a first-line treatment([5,10]) and a maintenance therapy after su…”
BackgroundThe current place of progestins in the treatment of endometriosis
Schweppe, K.-W. (2012) · Expert Review of Obstetrics & Gynecology · doi:10.1586/eog.11.71 · Cited by 9
Paterson, H., Miller, D., & Devenish, C. J. (2009) · Australian and New Zealand Journal of Obstetrics and Gynaecology · doi:10.1111/j.1479-828x.2009.00973.x · Cited by 9
C-reactive protein of serum and peritoneal fluid in endometriosis.
Kianpour, M., Nematbakhsh, M., & Ahmadi, S. M. (2012) · Europe PMC (PubMed Central) · Cited by 9
Pharmacologic treatment of the ovarian endometrioma
Benagiano, G., Guo, S., Bianchi, P., Puttemans, P., Gordts, S., Petraglia, F., & Brosens, I. A. (2016) · Expert Opinion on Pharmacotherapy · doi:10.1080/14656566.2016.1229305 · Cited by 9
“[47] compared the efficacy of Mirena with that of a depot”
ResultYuan, P., Chen, B., Huang, Y., & Xin, X. (2012) · Human Reproduction · doi:10.1093/humrep/des142 · Cited by 9
Zhu, S., Wu, Y., Gu, Z., Zhang, J., Jia, S., Shi, J., Dai, Y., Leng, J., & Li, X.-Y. (2020) · Archives of Gynecology and Obstetrics · doi:10.1007/s00404-020-05843-5 · Cited by 8
Management of endometriosis‐related pelvic pain
Hoo, W., Hardcastle, R., & Louden, K. A. (2017) · The Obstetrician & Gynaecologist · doi:10.1111/tog.12375 · Cited by 8
Metadata
- Authors
- Petta, C. A., Ferriani, R. A., Abrao, M. S., Hassan, D., Rosa e Silva, J. C., Podgaec, S., & Bahamondes, L.
- Affiliations
- Universidade Estadual de Campinas (UNICAMP) (BR)
- Corresponding author
- Petta, Carlos A.
- Venue
- Human Reproduction
- Publisher
- Oxford University Press (OUP)
- Published
- 2005-03-24
- Volume
- 20
- Issue
- 7
- Pages
- 1993-1998
- ISSN
- 0268-1161 (ISSN-L)
- 1460-2350
- OpenAlex
- W2123134517
- Cited by
- 363
- References
- 34
- Citations by year
- 2026: 6 · 2025: 5 · 2024: 5 · 2023: 5 · 2022: 22 · 2021: 16 · 2020: 12 · 2019: 12 · 2018: 18 · 2017: 16 · 2016: 19 · 2015: 22 · 2014: 20 · 2013: 17 · 2012: 19
- FWCI
- 25.58
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Human Reproduction (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Menstrual Health and Disorders
- Health Sciences › Medicine › Obstetrics and Gynecology › Ectopic Pregnancy Diagnosis and Management
- Keywords
- endometriosis, chronic pelvic pain, levonorgestrel-releasing intrauterine system, dysmenorrhea, endometriosis-associated pain, hemorrhage, quality of life, endometriosis stage, estrogen deficiency, treatment efficacy comparison, psychological well-being
- MeSH terms
- Adolescent, Adult, Delayed-Action Preparations, Endometriosis, Female, Humans, Intrauterine Devices, Medicated, Gonadotropin-Releasing Hormone, Leuprolide, Levonorgestrel, Pelvic Pain
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