Health: Contraceptive with a surprise side-effect: IUDs could reduce hysterectomies, says Cathy Read

WOULD a man readily seek the advice of his family doctor for a common problem if he knew that a vital part of his reproductive tract might ultimately be removed? Women certainly do. The common problem is menorrhagia, the medical term for heavy periods. The remedy is, usually, hysterectomy, the 'gold standard' treatment for this complaint for more than 30 years. It is a major operation with a complication rate of nearly 50 per cent. This is, arguably, a primitive solution.

At last a number of new treatments are coming through. Surgeons are evaluating endometrial ablation, a minor operation that strips away the lining of the womb. But the latest development is an alternative to surgery in the unlikely guise of an intrauterine device.

It has been developed by the Population Council, a research body based in New York, working with Professor Tapani Luukkainen and his colleagues at the University of Helsinki in Finland. Unlike other IUDs, it releases a contraceptive hormone from a silicone capsule located on its stem. The hormone, levonorgestrel (LNG), is a type of progestogen that is used in some brands of the Pill and mini-Pill. The hormone sets the new device apart from other IUDs. 'Forget everything you ever heard about IUDs, this one is different,' says Professor John Guillebaud, director of the Margaret Pyke Centre for family planning in Soho, London, which is also conducting a trial of the device as hormone replacement therapy.

The commonly used copper- releasing IUDs tend to increase bleeding. The new IUD, called LNG-20, is unlike other IUDs in its ability to reduce menstrual bleeding. This surprising effect turned up in contraceptive trials.

The LNG-20 is so-called because it releases 20 micrograms of levonorgestrel per 24 hours, compared with 30 micrograms of levonorgestrel in some mini-

Pills. 'When this effect was confirmed, we deliberately started using it in patients who wanted treatment for heavy periods,' says John Newton, consultant in obstetrics and gynaecology at Birmingham Maternity Hospital. Professor Newton's unit has been involved with contraceptive trials of the LNG-20 for the World Health Organisation and is one year into a three-year trial to compare the device with surgical treatments for menorrhagia.

Several large long-term clinical studies suggest the LNG-20 is also as effective as the combined oral contraceptive pill in preventing pregnancy. (The Pill failure rate is 0.5 per 100 couples per year compared to an IUD rate of 2.5.) Its main action is to suppress the lining of the womb, which regenerates each month to cause a period. It also thickens cervical mucus and prevents sperm from penetrating the womb. The effect on the womb lining also explains why menstrual blood loss is reduced. Studies in Sweden and the UK suggest that in women with an average monthly blood loss of more than 80ml (most women lose 20ml-60ml each month) the loss is reduced to about 10ml after six months' treatment with the LNG-20.

Naomi Hampton, a research registrar at the Margaret Pyke Centre, says more than 70 women attending the clinic are using the LNG-20 for heavy periods. 'The vast majority of women seem satisfied. There's a dramatic reduction in blood loss and some don't have any periods at all. It's also quite good at relieving period pain,' she says.

The LNG-20 can be inserted as an outpatient procedure and does not require anaesthetic. Women who use it also have automatic contraception. In contrast, those who have endometrial ablation, a relatively new surgical technique that destroys the womb lining, need to continue with another contraceptive. The LNG-20 is also reversible, unlike hysterectomy or endometrial ablation.

The effect on periods is not the only surprise the LNG-20 has thrown at family planners. Standard IUDs increase the risk of pelvic inflammatory disease and ectopic pregnancy. Studies of the LNG-20 in Finland have shown that even in young women the risk of either complication is extremely low.

The LNG-20 is believed to have a two-fold effect in protecting against pelvic inflammatory disease. Thick cervical mucus prevents bacteria and the sperm on which they sometimes hitch a ride from swimming through the cervix, and the thinned womb lining provides a hostile environment for the invaders.

The LNG-20 is by no means the answer for everyone with menorrhagia. Some women suffer hormonal side-effects such as acne, mood changes and breast tension. Other women do not want their periods to stop altogether or cannot cope with the irregular spots of blood that may occur in the early months of treatment with LNG-20. Nevertheless it improves what has been, until recently, a poor choice. At present the LNG-20 is not available on general prescription here but can be obtained on a named-patient basis.

Further information is available from Margaret Pyke Centre, 15 Bateman Buildings, Soho Square, London W1V 6JB.