Experiences of the use of the levonorgestrel intrauterine device for heavy menstrual bleeding: Device discontinuation rates and reasons for discontinuation among users at a regional hospital in the Western Cape - A seven-year review

Abstract

Background. Medical management for heavy menstrual bleeding (HMB) in low- and middle-income countries is limited. The National Institute for Health and Care Excellence recommends the levonorgestrel intrauterine device (LNG-IUD) as first-line management for HMB. However, since 2019, South Africa’s (SA) Essential Medicines List (EML) guidelines have listed it as the last medical treatment option in the public health sector. An economic analysis conducted from a payer’s perspective found the LNG-IUD dominant at 5 years and more cost-effective at 1 year than other medical treatment options. However, it would no longer be dominant if the 5-year discontinuation rate exceeded 40%. Assumptions about continuation rates of the LNG-IUD for HMB were made, as no local SA data are available. Objectives. To assess the discontinuation rate of the LNG-IUD for HMB after 1 year and explore the reasons for discontinuation. Methods. This was a retrospective, folder-based study of patients who received the LNG-IUD for HMB at Tygerberg Hospital, Cape Town, SA between 2014 and 2020. Results. The hospital records of all women who received the LNG-IUD were reviewed. Incomplete records, duplications or prescriptions for contraception were excluded. Complete records were available for 100 patients, of whom 68 reported symptom improvement after 1 year and continued use. Thirty-two patients discontinued use, of whom eight experienced spontaneous expulsions and 24 requested removals. Reasons for discontinuation included ongoing symptoms (n=18), adverse effects (n=4) and the desire for fertility (n=2). Fourteen of the 24 patients who requested removal had a hysterectomy. The study showed a 68% continuation rate for the LNG-IUD, which is lower than in higher-income countries (82 - 88%). This rate is considered sufficient to endorse the affordability of LNG-IUD for HMB over 5 years. Conclusion. Offering LNG-IUD as the primary treatment may potentially improve the continuation rate. Further research is needed to assess the feasibility of recommending LNG-IUD as the first-line treatment in national policy, following patient discussion.