Correspondence

Levonorgestrel-Releasing Intrauterine Device for the Treatment of Menometrorrhagia in a Woman on Hemodialysis

N Engl J Med 1999; 341:541August 12, 1999

Article

To the Editor:

A 25-year-old nulliparous woman was admitted to our hospital for recurrent menometrorrhagia and secondary anemia. She had received a renal transplant for infantile polycystic kidney associated with congenital hepatic fibrosis that was complicated by hepatitis C, but for two years she had been undergoing hemodialysis for chronic renal insufficiency after numerous episodes of transplant rejection. Since starting dialysis, she had had frequent episodes of menometrorrhagia, which was treated with oral progestins with partial success.

At admission, the patient's hematocrit was 17.4 percent, and the hemoglobin concentration was 5.9 g per deciliter. Transvaginal ultrasonography showed a dyshomogeneous endometrium, 12 mm thick, but no myometrial or adnexal abnormalities. The patient then received a blood transfusion and underwent hysteroscopy and diagnostic curettage, followed by the immediate insertion of a levonorgestrel-releasing intrauterine device. Histologic examination showed only the presence of endometrial decidualization attributable to the previous progestin treatment.

During the first two months after the insertion of the levonorgestrel-releasing intrauterine device, the patient had spotting and then amenorrhea, which, two years later, still persists, with only sporadic episodes of mild bleeding. Her condition was complicated by recurrent pyelonephritis of the transplanted kidney, which necessitated its removal. At present the patient is undergoing hemodialysis, with a hemoglobin concentration of 10 g per deciliter, and is waiting for a combined kidney and liver transplant. She is being treated with interferon and ribavirin for her liver disease.

Menometrorrhagia is frequent in women of reproductive age undergoing hemodialysis, and its occurrence may lead to anemia.1 It can be treated with progestins or gonadotropin-releasing hormone agonists, although these approaches are not always effective and may be associated with important side effects.2 The levonorgestrel-releasing intrauterine device causes prompt and marked endometrial atrophy owing to elevated progestin concentrations at the surface of the endometrium, without major systemic side effects.3 This safety and efficacy profile, together with its notable safety as a contraceptive, makes the levonorgestrel-releasing intrauterine device a reasonable option for young women on hemodialysis who have menstrual disorders.

Luigi Fedele, M.D.
Linda Gammaro, M.D.
Università di Verona, 37134 Verona, Italy

Stefano Bianchi, M.D.
Università di Milano, 20122 Milan, Italy

3 References

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   Kawashima R, Douchi T, Oki T, Yoshinaga M, Nagata Y. Menstrual disorders in patients undergoing chronic hemodialysis. J Obstet Gynaecol Res 1998;24:367-373
   CrossRef | Medline

2. 2

   Buhler K. GnRH analogues: safety aspects. In: Lunenfeld B, Insler V, eds. GnRH analogues: state of the art 1996. Lancashire, England: Parthenon Publishing, 1996:139-48.
   

3. 3

   Fedele L, Bianchi S, Raffaelli R, Portuese A, Dorta M. Treatment of adenomyosis-associated menorrhagia with a levonorgestrel-releasing intrauterine device. Fertil Steril 1997;68:426-429
   CrossRef | Web of Science | Medline