1 Department of Obstetrics and Gynecology, Hadassah University Hospital and 2 Institute of Hormone Research, Shaare-Zedek Medical Center, 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: intrauterine device/levonorgestrel/perforation/pharmacokinetics/progestagen
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Introduction |
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Case report |
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On laparoscopy, the uterus and the adnexae appeared normal. The perforation site was unidentified. An LNG-IUD was observed encased in mild peritoneal adhesions in the pouch of Douglas and was easily removed. The remainder of the procedure was uneventful and the patient was discharged the following day. Plasma concentrations of LNG and sex hormone binding globulin (SHBG) were measured 1 day prior to the procedure and serially for 24 h following the laparoscopy. Assays for LNG determination were performed at the Steroid Research Laboratory in Helsinki, Finland, following the method described by Johansson et al. (2002)
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Results |
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Discussion |
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Plasma LNG is mainly bound to SHBG (64%) and to albumin (35%). The free fraction of LNG is only 1.3% (Kuhnz et al., 1992). SHBG is a plasma binding protein with high affinity to sex hormones such as testosterone, dihydrotestosterone, estradiol and LNG. A significant correlation was found between concentrations of LNG and SHBG, although a marked inter-individual variation of SHBG levels exists (Xiao et al., 1990
; Jia et al., 1992
; Kuhnz et al., 1992
).
Plasma SHBG levels increased in our patient by 15%, 25 h following LNG-IUS removal. The concentrations of SHBG have been shown to decrease slightly during the use of oral LNG-containing contraceptive mini-pill, but not during the use of LNG-IUS (Pakarinen et al., 1999). LNG released from either subdermal or intrauterine devices is not subjected to a first-pass effect of the liver, unlike LNG administered orally or released i.p. We presume that i.p. localization of LNG-IUS may result in increased hepatic exposure to LNG via the portal system, leading to decreased levels of SHBG.
Although no strong recommendations should be based on case reports, in the infrequent event of uterine perforation by an IUD, there is much to be learnt from each report. The very high level of plasma LNG originating from the i.p. misplaced LNG-IUD dictates a different therapeutic strategy towards its presence and its removal. I.p. LNG-medicated IUD may suppress ovulation, and could still be regarded as an effective contraception. When pregnancy is desired, the therapeutic approach differs from that of a copper IUD. The latter may be left intraperitoneally, especially if asymptomatic. In contrast, a misplaced LNG-IUD should be removed in order to permit ovulation.
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Acknowledgement |
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References |
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Submitted on January 23, 2003; accepted on March 6, 2003.