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.