BACKGROUND AND PURPOSE:

• Niche-related postmenstrual spotting and chronic pelvic pain can occur after cesarean delivery
• Both the 52-mg levonorgestrel IUD (LNG IUD) and hysteroscopic niche resection have been shown to improve symptoms
• Zhang et al. (AJOG, 2023) compare the effectiveness of the 52-mg LNG IUD with hysteroscopic niche resection in reducing niche-related postmenstrual spotting

METHODS:

• Randomized, open-label, controlled trial
• Participants
  • Women with symptoms of postmenstrual spotting after cesarean delivery
  • Niche depth of ≥2 mm and residual myometrium of ≥2.2 mm on MRI
  • Not planning to conceive within the next year
• Intervention
  • 52-mg LNG IUD
  • Hysteroscopic niche resection
• Study design
  • Efficacy and safety were assessed using intention-to-treat analysis
• Primary outcome
  • Reduction in postmenstrual spotting at 6 months after randomization
    • Defined as percentage of women with a reduction of at least 50% in spotting days relative to baseline

RESULTS:

• IUD: 104 participants | Hysteroscopic niche resection: 104
• At 6-month follow-up: No difference in the number of women who achieved a 50% reduction in spotting
  • IUD: 78.4% | Niche resection: 73.1%
  • Relative Risk (RR) 1.07 (95% CI, 0.92 to 1.25) | P=0.370
• Spotting decreased over time (Ptrend=0.001)
  • There was a stronger reduction observed in the IUD group (P=0.001)
  • There was a significant interaction between time and treatment (P=0.007)
• ≥9 months: A more significant reduction in spotting was observed in the IUD group
  • 9 months
    • IUD: 89.2% | Niche resection: 72.1%
    • RR 1.24 (95% CI, 1.08 to 1.42)
  • 12 months
    • IUD: 80.2% | Niche resection: 70.2%
    • RR 1.29 (95% CI, 1.12 to 1.48)
• IUD group had significantly
  • Fewer postmenstrual spotting days at ≥6 months (P<0.001)
  • Fewer total bleeding days at ≥6 months (P<0.001)
  • Less pelvic pain at ≥3 months (P<0.01)
• No intervention-related complications were reported in any group
• Side-effects
  • Hormone-related side effects: 10.8%
  • Spontaneous partial expulsion in IUD group: 2.0%
• There were 3 unintended pregnancies in the niche resection group

CONCLUSION:

• For women with niche-related postmenstrual spotting, there was no difference in spotting reduction at 6 months with levonorgestrel IUD vs hysteroscopic niche resection but by 9 months the IUD was better at reducing spotting
• Pelvic pain was also improved in the IUD group as early as 3 months from intervention
• The authors state

On the basis of these results, we recommend LNG-IUS as the first-line therapy for women with niche-related gynecologic symptoms and without an active desire to become pregnant

Learn More – Primary Sources:

Comparing levonorgestrel intrauterine system with hysteroscopic niche resection in women with postmenstrual spotting related to a niche in the uterine cesarean scar: a randomized, open-label, controlled trial

Related ObG Topics:

Double or Single Layer Closure for Best Cesarean-Section Outcomes?

Does the 52-mg Levonorgestrel IUD Improve Symptoms for Those with Heavy Menstrual Bleeding? 

RCT Results: Levonorgestrel IUD vs Endometrial Ablation for Heavy Menstrual Bleeding

Cochrane Review 2020: Are Progestogen-Releasing IUDs Effective for Managing Heavy Menstrual Bleeding?