Effectiveness of A Levonorgestrel-Releasing Intrauterine System Versus Hysteroscopic Treatment for Abnormal Uterine Bleeding in Women with Cesarean Scar Defects: A Systematic Review and Meta-Analysis
Abstract
:1. Introduction
2. Materials and Methods
2.1. Search Strategy, Eligibility of Studies, and Protocol Registration
- Population: Women undergoing treatment for symptomatic isthmocele.
- Intervention: Insertion of a levonorgestrel-releasing intrauterine system for symptomatic treatment.
- Comparator: Application of hysteroscopy using a resectoscope for symptomatic treatment.
- Outcomes: Postoperative outcomes at follow-up intervals of ≤3 months, 6 months, 9 months, and 12 months (effectiveness rate, total bleeding days per cycle, reduced spotting days per cycle, amenorrhea rate).
2.2. Literature Search and Data Extraction
2.3. Definitions and Predetermined Outcomes
2.4. Quality Assessment
2.5. Statistical Analysis
3. Results
3.1. Study Selection and Characteristics
3.2. Outcomes
4. Discussion
4.1. Principal Findings
4.2. Comparison with Existing Literature
4.3. Clinical Implications
4.4. Strengths and Limitations of the Study
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Year; Author | Study Design | Country | Study Period | Patient No. | Inclusion Criteria | Exclusion Criteria |
---|---|---|---|---|---|---|
2021; He et al. [22] | PCS | China | April 2018– April 2019 | 36 vs. 38 | Patients aged between 20 and 45 years, diagnosed with a niche with postmenstrual spotting of at least 2 days, who considered to undergo a hysteroscopic niche resection or to receive a LNG-IUD (52 mg). | Fertility wish within 1 year, irregular menstrual cycle before the last cesarean delivery, IUD present, length of uterine cavity < 6 cm or >10 cm, coagulopathy, current exogenous hormone treatment, and other gynecological conditions that could cause prolonged bleeding such as leiomyoma, endometrial hyperplasia, ovarian endometriosis, and pregnancy. Moreover, patients had received hysteroscopic resection or LNG-IUD before intervention. |
2023; Zhang et al. [24] | RCT | China | September 2019– January 2022 | 102 vs. 104 | Women with postmenstrual spotting after CD, with a niche in the anterior wall of the LUS of at least 2 mm in depth and a residual myometrium of at least 2.2 mm on MRI, aged 18 to 48 years, and without a desire to conceive within 1 year. | Contraindications or unwillingness for either hysteroscopic niche resection or LNG-IUD placement; positive pregnancy test; current use of an intrauterine device; contraindications to general or local anesthesia; a history of coagulation disorder or high risk for anticoagulant use; malignancy, endometrial polyp, atypical endometrial cells, cervical dysplasia, or hydrosalpinx that may communicate with the uterus; presence of adenomyosis, submucosal leiomyoma, or leiomyoma causing uterine cavity length 9 cm assessed by transvaginal ultrasound or MRI; endocrine disorders resulting in changes in the menstrual cycle; and menstrual cycle disorders (>35 days or intercycle variation of 2 weeks). |
2024; Huang et al. [23] | RS | Taiwan | April 2013– November 2021 | 33 vs. 26 | Patients diagnosed with niche by hysteroscopy who received either resectoscopic remodeling procedures or LNG-IUD insertion for intermenstrual bleeding treatment. | Patients with pelvic inflammatory disease, vaginitis, cervical infection, submucosal myoma, or other endometrial lesions. |
2021; He et al. [22] | 2023; Zhang et al. [24] | 2024; Huang et al. [23] | p-Value | |
---|---|---|---|---|
Patients’ Characteristics | ||||
Age (years) | 34.9 ± 4.1 vs. 34.4 ± 4.1 a | 36.4 ± 3.9 vs. 36.8 ± 4.5 a | 41.7 ± 5.2 vs. 39.5 ± 4.4 a | 0.52 |
Gravidity | 3 ± 1.54 vs. 2 ± 1.54 a | 2.3 ± 0.75 vs. 2.3 ± 0.75 a | NRD | 0.37 |
Parity | 1.7 ± 0.8 vs. 1.3 ± 0.8 a | 1.7 ± 0.8 vs. 1.7 ± 0.8 a | 2.1 ± 0.6 vs. 2.5 ± 0.7 a | 0.98 |
Number of CS | 1.3 ± 0.8 vs. 1.3 ± 0.8 a | 1.7 ± 0.8 vs. 1.7 ± 0.8 b | 2.0 ± 0.6 vs. 2.1 ± 0.8 a | 0.81 |
Time since last CS (years) | NRD | 5.9 ± 4.2 vs. 6.2 ± 4.2 a | 6.85 ± 8.95 vs. 2.63 ± 4.6 a | 0.46 |
Uterine and Isthmocele Characteristics | ||||
Retroflexion rate (%) | 19/36 (53%) vs. 16/38 (42%) | 25/102 (24.5%) vs. 22/104 (21.2%) | 11/33 (33.3%) vs. 4/27 (15.4%) | 0.12 |
RMT (mm) | 3 ± 1.5 vs. 4.7 ± 2.3 a | 3.8 ± 1.5 vs. 3.8 ± 1.5 a | 4.3 ± 1.95 vs. 6.1 ± 1.96 a | 0.10 |
Length (mm) | 6 ± 1.54 vs. 5 ± 1.54 a | 7.5 ± 2.7 vs. 7.5 ± 3.5 a | NRD | 0.29 |
Width (mm) | 11.7 ± 3.1 vs. 11.3 ± 3.85 a | 15.4 ± 4.8 vs. 14.4 ± 4.3 a | NRD | 0.12 |
Depth (mm) | 6 ± 1.5 vs. 4.7 ± 2.3 a | 6.2 ± 1.6 vs. 5.1 ± 1.6 a | NRD | <0.001 |
Study | Type | Tool | Bias Arising from the Randomization Process | Bias in Selection of Participants into the Study | Bias in Classification of Interventions | Bias Due to Confounding | Bias Due to Deviations from Intended Interventions | Bias Due to Missing Data | Bias in Measurement of Outcomes | Bias in Selection of the Reported Result | Overall Risk of Bias |
---|---|---|---|---|---|---|---|---|---|---|---|
2021; He et al. [22] | Non-RCT | ROBINS-I | X | Low Risk | Low Risk | Moderate Risk | Low Risk | Low Risk | Low Risk | Low Risk | Moderate |
2023; Zhang et al. [24] | RCT | RoB-2 | Low Risk | X | X | X | Low Risk | Low Risk | Low Risk | Low Risk | Low |
2024; Huang et al. [23] | Non-RCT | ROBINS-I | X | Moderate Risk | Moderate Risk | Moderate Risk | Low Risk | Moderate Risk | Moderate Risk | Moderate Risk | Moderate |
Outcome | Number of Studies | Sample Size | Meta-Analytic Model | Pooled Outcome (MD, OR, Pooled Weighted Rate) | 95% CI | p-Value | I2 |
---|---|---|---|---|---|---|---|
≤3 Months Follow-up | |||||||
Effectiveness Rate | 3 studies | 170 vs. 169 | REM | (OR) 1.31 | 0.64 to 2.69 | 0.45 | 48% |
Reduced Spotting Days per Cycle | 3 studies | 170 vs. 169 | REM | (MD) −0.40 | −1.50 to 0.70 | 0.48 | 0% |
Total Bleeding Days per Cycle | 3 studies | 170 vs. 169 | REM | (MD) −0.78 | −2.33 to 0.78 | 0.33 | 0% |
Post-treatment Satisfaction (five-point Likert Scale) | 2 studies | 137 vs. 142 | REM | (MD) 0.25 | −0.61 to 1.11 | 0.57 | 71% |
6 Months Follow-up | |||||||
Post-treatment Satisfaction (5-point Likert scale) | 2 studies | 137 vs. 141 | FEM | (MD) 0.37 | 0.09 to 0.66 | 0.009 | 0% |
9 Months Follow-up | |||||||
Effectiveness Rate | 2 studies | 123 vs. 99 | FEM | (OR) 3.72 | 1.88 to 7.35 | 0.0002 | 0% |
Reduced Spotting Days per Cycle | 2 studies | 136 vs. 138 | FEM | (MD) 2.23 | 1.34 to 3.12 | <0.00001 | 0% |
Total Bleeding Days per Cycle | 2 studies | 136 vs. 138 | FEM | (MD) −4.83 | −5.80 to −3.86 | <0.00001 | 0% |
Post-treatment Satisfaction (5-point Likert Scale) | 2 studies | 136 vs. 138 | REM | (MD) 0.59 | 0.24 to 0.94 | 0.0009 | 28% |
12 Months Follow-up | |||||||
Post-treatment Satisfaction (5-point Likert Scale) | 2 studies | 136 vs. 138 | REM | (MD) 0.59 | 0.24 to 0.94 | 0.0009 | 28% |
Amenorrhea Rate | 3 studies | 171 | FEM | 47.4% | 46.5 to 48.3 | - | 0% |
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Douligeris, A.; Kathopoulis, N.; Kypriotis, K.; Zacharakis, D.; Prodromidou, A.; Mortaki, A.; Chatzipapas, I.; Grigoriadis, T.; Protopapas, A. Effectiveness of A Levonorgestrel-Releasing Intrauterine System Versus Hysteroscopic Treatment for Abnormal Uterine Bleeding in Women with Cesarean Scar Defects: A Systematic Review and Meta-Analysis. J. Pers. Med. 2025, 15, 117. https://doi.org/10.3390/jpm15030117
Douligeris A, Kathopoulis N, Kypriotis K, Zacharakis D, Prodromidou A, Mortaki A, Chatzipapas I, Grigoriadis T, Protopapas A. Effectiveness of A Levonorgestrel-Releasing Intrauterine System Versus Hysteroscopic Treatment for Abnormal Uterine Bleeding in Women with Cesarean Scar Defects: A Systematic Review and Meta-Analysis. Journal of Personalized Medicine. 2025; 15(3):117. https://doi.org/10.3390/jpm15030117
Chicago/Turabian StyleDouligeris, Athanasios, Nikolaos Kathopoulis, Konstantinos Kypriotis, Dimitrios Zacharakis, Anastasia Prodromidou, Anastasia Mortaki, Ioannis Chatzipapas, Themos Grigoriadis, and Athanasios Protopapas. 2025. "Effectiveness of A Levonorgestrel-Releasing Intrauterine System Versus Hysteroscopic Treatment for Abnormal Uterine Bleeding in Women with Cesarean Scar Defects: A Systematic Review and Meta-Analysis" Journal of Personalized Medicine 15, no. 3: 117. https://doi.org/10.3390/jpm15030117
APA StyleDouligeris, A., Kathopoulis, N., Kypriotis, K., Zacharakis, D., Prodromidou, A., Mortaki, A., Chatzipapas, I., Grigoriadis, T., & Protopapas, A. (2025). Effectiveness of A Levonorgestrel-Releasing Intrauterine System Versus Hysteroscopic Treatment for Abnormal Uterine Bleeding in Women with Cesarean Scar Defects: A Systematic Review and Meta-Analysis. Journal of Personalized Medicine, 15(3), 117. https://doi.org/10.3390/jpm15030117