Endometrial vascular changes and bleeding disturbances with long-acting progestins

Unscheduled disturbances of bleeding with long-acting progestogen-only methods continue to be a major social inconvenience, and the most common reason for premature discontinuation of use. The patterns of bleeding with different methods are now well characterised, but in spite of a substantial amount of recent research we still do not clearly understand the actual mechanisms underlying these disturbances. The major changes occur locally within the endometrium, although these are influenced substantially by different dosages and regimens of contraceptive steroids. Hysteroscopic studies have demonstrated major changes in the extent of superficial endometrial vascularization, disturbances in superficial vascular morphology, and increased endometrial vascular and epithelial fragility in progestogen-only users. There may also be alterations in endometrial perfusion and vasomotion. Laboratory studies of cellular and molecular mechanisms have shown changes in vascular basement membranes, pericytes, migratory leukocytes, cellular architecture, cell adhesion molecules, and intercellular matrix breakdown systems, such as matrix metalloproteinases. It appears that continuous exposure to progestogen, in the presence of low to moderate levels of estrogen, results in an endometrium that histologically demonstrates 'suppressed secretory' changes, associated with disturbed angiogenesis, and a tendency to release molecules capable of causing focal endometrial epithelial and endothelial damage and bleeding.