Clinical implications
Both therapies have proven to be effective in the reduction of spotting
in
women with postmenstrual spotting of at least 2 days and a niche in the
uterine CS scar, without signs of endometrial atypia and without a
desire to become pregnant within one year. However, the LNG-IUD is
superior from 6 months onwards in the reduction of spotting and with
substantially lower direct medical costs. In women without a wish to
conceive the LNG-IUD has the additional advantage that is also has a
contraceptive effect. Based on our data LNG-IUD should be offered in
this population as a first line treatment. However, LNG-IUD is not an
option in women with an active desire to become pregnant.
After LNG-IUD insertion, the effect improves in time during the first
year. It is important to provide this information to patients before
insertion to prevent premature removal of the LNG-IUD or unneeded
additional therapies during the first months after insertion. In the
hysteroscopic niche resection group the optimal effect is already
achieved after 3 months. Our results indicate that if spotting does not
improve substantially at three months after hysteroscopic niche
resection, there is no need to wait much longer before considering
additional treatments. In our study 2 patients received an additional
LNG-IUD with good results.
Another advantage of the LNG-IUD is that its application is independent
of the TRM, while a hysteroscopoic niche resection in general is applied
in women with a TRM > than 2.5 mm in order to prevent any
bladder injury.11, 16, 28-30 The additional advantage
of an LNG-IUD over a hysteroscopic niche resection is that it is easy to
insert, does not require surgical instruments or operating room
facilities. Hysteroscopic correction operation demands a longer learning
curve for the surgeons, and its’ safety and efficacy are more likely to
be affected by the surgeon’s proficiency. Moreover, it is in generally
performed under general anesthesia requiring a longer recovery.
Also, even after clear instructions and counseling of our patients
almost 1/3 of the patients in the LNG-IUD group were concerned about
their ovarian function due to the change of their menstrual pattern and
requested initially for removal of their LNG-IUD. This removal could be
prevented by repeated health education. This underlines the importance
of clear and repeated health education in women considering a LNG-IUD in
order to improve compliance and to reduce negative experiences or
thoughts.