Levonorgestrel intrauterine system vs hysteroscopic niche resection for postmenstrual spotting: a 3-year randomized...

Previous findings demonstrated that both the 52-mg levonorgestrel intrauterine system and hysteroscopic niche resection significantly reduced niche-related postmenstrual spotting, with more than 70% of patients achieving ≥50% reduction at 6 months and levonorgestrel intrauterine system showing superior efficacy beyond 9 months.

This study evaluates the long-term effectiveness of both treatments in reducing niche-related postmenstrual spotting over 36 months.

This 3-year follow-up stems from a single-center randomized trial. Women experiencing postmenstrual spotting after cesarean delivery, with magnetic resonance imaging-confirmed niche depth ≥2.0 mm and residual myometrium ≥2.2 mm, and without plans to conceive within 1 year, were randomized to receive either the 52-mg levonorgestrel intrauterine system or hysteroscopic niche resection. Main outcome of this long-term follow-up was the proportion of women achieving ≥50% reduction in spotting from baseline at 36 months. Secondary outcomes, including menstrual patterns, spotting discomfort, chronic pelvic pain, and satisfaction with treatment, were assessed at 18, 24, 30, and 36 months.

A total of 208 women were randomized (104 in each group), with 93 (89.4%) in the levonorgestrel intrauterine system group and 89 (85.6%) in the hysteroscopic niche resection group completing the 3-year follow-up. At 36 months, 98.9% of women in the levonorgestrel intrauterine system group and 51.7% in the hysteroscopic group achieved a 50% reduction in spotting (relative risk, 1.91 [95% confidence interval, 1.56-2.34]; P<.001). Spotting decreased progressively over time in the levonorgestrel intrauterine system group through 36 months (P_trend=0.001), whereas the hysteroscopic group showed reduction only until 24 months (P=.007), followed by a slight increase. A significant time-treatment interaction was observed (P=.007), with levonorgestrel intrauterine system demonstrating superior spotting reduction from 24 months onward. Additionally, the levonorgestrel intrauterine system group had fewer postmenstrual spotting days, total bleeding days (P<.001), and less pelvic pain (P<.010) from 6 months onward, with the difference widening over time. During the follow-up, 20 women in the levonorgestrel intrauterine system group reported hormone-related side effects, and 2 experienced partial expulsions. In the hysteroscopic group, 5 pregnancies were reported (3 unintended and 2 planned).

Over 36 months, the 52-mg levonorgestrel intrauterine system was superior to hysteroscopic niche resection for reducing postmenstrual spotting, pelvic pain, and discomfort, while also offering contraceptive benefits in women with symptomatic niche. We recommend levonorgestrel intrauterine system as a first-line treatment for niche-related spotting in reproductive-age women with no fertility desire for at least the next year.