1 Department of Obstetrics and Gynecology and 2 Department of Pathology, Hadassah University Hospital, Jerusalem, Israel
3 To whom correspondence should be addressed at: Department of Obstetrics and Gynecology, Hadassah University Hospital, Mount Scopus, P.O.B 24035, il-91240, Jerusalem, Israel. e-mail: rkochman{at}hotmail.com
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Abstract |
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Key words: adhesions/intrauterine device/levonorgestrel/perforation
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Introduction |
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Materials and methods |
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Results |
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Histological examination of peritoneal tissue adjacent to LNG-IUS (in case number 4), revealed richly vascularized loose connective tissue with calcifications and mild chronic inflammation admixed with a few foreign body-type giant cells. Aggregates of swollen cells with eosinophilic cytoplasm and vesicular nucleus were found embedded in the tissue. These cells stained with vimentin only and were identified as sub-mesothelial stromal cells of the peritoneal cavity that underwent pseudo-decidual changes (Figure 1). Immuno histochemical staining for estrogen receptor was positive, but staining for progesterone receptor was negative.
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Discussion |
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Levonorgestrel-releasing (20 µg/day) intrauterine system (Mirena) is a relatively new form of contraception. Perforation of the uterus during its insertion has been reported among other IUD types in a Swedish survey (Andersson et al., 1998); however, the abdominal cavity in its presence was not described. The adhesion formation potential of LNG-IUD remained largely unknown. Mirena, similar to copper-bearing IUDs, consists of a plain plastic T-shaped frame. The development of peritoneal adhesions in response to a non-irritating plastic-made foreign body was described by Echenberg and Ledger (1968
). This process involves encasement of the device in delicate peritoneal bands. The plastic skeleton of Mirena carries a cylindric progestogen reservoir that contains 52 mg levonorgestrel and is covered by a polydimethylsiloxane membrane which regulates the release of levonorgestrel. Local release of levonorgestrel by Mirena results in very high tissue concentrations, ranging from 4701500 ng/g wet weight. The endometrial changes seen in the presence of LNG-IUD are: endometrial gland atrophy, stromal decidualization, thickened arterial walls and endometrial capillary thrombosis. An inflammatory reaction involving neutrophils, lymphocytes, plasma cells and macrophages is described (Zhu et al., 1989
), and focal stromal necrosis may also occur (Silverberg et al., 1986
). The local effect of high levonorgestrel concentrations on the peritoneum involves a pseudo-decidual change of swollen cells with rich eosinophilic cytoplasm identified as sub-mesothelial cells by immunohistochemical studies. So far, the pseudo-decidual change, also known as ectopic peritoneal decidua, was described as developing solely in relation to pregnancy, when it was found at sites such as the sub-mesothelial stroma of the uterus, the uterine ligaments, adnexae, appendix and omentum (Clement et al., 1999
). No evidence of tissue necrosis was demonstrated in response to high local levonorgestrel concentrations. A high rate of progesterone receptivity was disclosed when pelvic adhesion tissue was evaluated for sex steroid receptors (Wiczyk et al., 1998
). In our study negative staining for progesterone receptor in the connective tissue in proximity to levonogestrel-medicated IUD could indicate down-regulation of the receptor in reaction to local high levels of the progestogen.
The issue of the effect of progestogens on peritoneal adhesions is controversial. Progesterone has well-established anti-inflammatory and immunosuppressive properties that could play a role in the prevention of peritoneal adhesion formation. Intra-peritoneal instillation of progesterone was shown to prevent the development of adhesions in pelvic surgery (Maurer and Bonaventura, 1983). However, other studies using locally or parenterally administered progestogens failed to support this claim (Blauer and Collins, 1988
; Confino et al., 1988
). Recently, it was argued that pre-operative use of medroxyprogesterone acetate prevents post-operative adhesions development (Ustun et al., 1998
; Sagol et al., 1999
; Baysal, 2001
). Our data demonstrated that high local concentrations of progestins neither affect nor dramatically prevent adhesion formation.
Our results show a lack of difference in the peritoneal cavity appearance in the presence of either a copper-IUD or a LNG-IUS. Although no treatment policy should be based on small case-series reports, in the infrequent event of uterine perforation by IUD, much is to be learnt from each report. Our presented cases, in accordance with what has been previously reported regarding perforating copper-bearing IUDs (Adoni and Ben Chetrit, 1991; Silva and Larson, 2000
; Markovitch et al., 2002
), disclosed only local and delicate peritoneal adhesions in the presence of both copper-bearing IUDs and LNG-IUS. Bands of adhesions that could cause bowel obstruction did not develop. Therefore, the same treatment mode of a suggested laparoscopy for IUD removal for symptomatic, medico-legal or psychological reasons, could fit both copper-bearing and levonorgestrel-medicated IUDs. From the point of view of peritoneal adhesion formation, given the risk associated with laparotomy, it may be safer to leave a perforated LNG-IUS in place than to remove it by laparotomy. However, our advice is based only on our limited experience and further data is needed, probably through a multi-centre study.
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References |
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Submitted on September 13, 2002; resubmitted on December 12, 2002; accepted on January 14, 2003.