Presented by – D.Parth.K, P.Shiva.P, N.Mranalee Scientific Supervisor – Asst. Prof. Lavrinenko.Elena.Borisovna Stavropol 2017 The effects of the levono- rgestrel intrauterine system (Mirena coil) on endometrial morphology

Background The Mirena coil is a levonorgestrel releasing intrauterine device that is in widespread use in the UK and elsewhere. It is a progestogen containing device and is currently licensed for periods of treatment of five years. Given the expansion in the clinical indications for Mirena coil usage we have reviewed the endometrial morphology in a large series of patients treated with this device

Background The Mirena coil is a highly effective contraceptive and, compared with other intrauterine devices, reduces menstrual bleeding. The Mirena coil is also licensed for the management of idiopathic menorrhagia. Previous studies have shown that Mirena coil to compare well with endometrial resection for the management of menorrhagia.

Background The system has also been used to deliver progestogen for endometrial protection in postmenopausal hormone replacement regimens. It has also been suggested that the Mirena coil can be used to prevent endometrial hyperplastic changes in patients taking tamoxifen or oestrogen as the only hormone replacement therapy. Despite its widespread use, our impression is that the effects of the Mirena coil on endometrial morphology are not well known, especially among general pathologists.

Background These morphological features have been briefly alluded to previously. However, given the expansion in the clinical indications for Mirena coil usage we have reviewed the endometrial morphology in a large series of patients treated with this device.

Objective The effects of the levonorgestrel intrauterine system (Mirena coil) on endometrial morphology.

MATERIALS AND METHODS Patients (n = 75) were retrieved from the files of the departments of pathology,. All available histological sections were reviewed by the authors, two of whom are gynaecological pathologists. The duration of coil placement was not known in these patients.

RESULTS Clinical findings The age of the patients ranged between 25 and 5 8 years, with a mean of 42. Eighteen patients u nderwent hysterectomy, one had a transcervical re section of the endometrium, and in 56 patients th ere was an endometrial curettage or pipelle biopsy. Usually the indication for hysterectomy or e ndometrial sampling was irregular vaginal bleeding.

RESULTSRESULTS Four patients had a history of endometrial h yperplasia (three simple hyperplasia and one at ypical hyperplasia) diagnosed on previous e ndometrial sampling. In these cases, the Mirena coil had been inserted after the diagnosis of endometrial hyperplasia.

RESULTSRESULTS Pathological findings Morphological featurNumber of cases Decidualisation of stroma72 (96%) Atrophy of glands65 (87%) Stromal inflammatory cell infiltrate59 (79%) Stromal inflammatory cell infiltrate, including plas ma cells 20 (27%) Surface papillary formations38 (51%) Stromal myxoid change29 (39%) Stromal haemosiderin deposition24 (32%) Glandular metaplasia7 (9%) Stromal necrosis5 (7%) Reactive atypia in surface glands3 (4%) Stromal calcifications1 (1%) Endometrial morphological features associated with Mirena coil

RESULTSRESULTS In 72 of 75 cases there was decidualisation of the stroma, 65 of 75 samples contained atrophic small tubular endometrial glands (in occasional cases there was focal weak secretory activity of some glands).

RESULTSRESULTS 59 of 75 samples there was a stromal inflammatory cell i nfiltrate, usually with a mixture of lymphocytes, n eutrophils, histiocytes, and eosinophils. In 20 of these cases, plasma cells were identified. The stromal decidualisation and glandular atrophy generally involved the whole of the superficial endometrium but not the endometrial basalis.

RESULTSRESULTS The surface had a localised undulating papillary pattern in 38 of 75 cases (best seen in hysterectomy specimens where the endometrium was present in its entirety).

RESULTSRESULTS Foci of stromal myxoid change were present in 29 of 75 cases. Twenty four of 75 cases contained small amounts of haemosiderin pigment within the stroma, in two cases there was stromal necrosis, and in one case there were stromal calcifications.

RESULTSRESULTS In three cases there was significant reactive a typia of the surface endometrial glands and in s even cases focal glandular metaplastic changes ( hobnail, clear cell, or ciliated) were present. Stromal granulomas were not seen. Of the four patients with a history of endometrial hyperplasia, the three with simple hyperplasia showed no evidence of persisting hyperplasia and the other showed a small focus of persisting atypical hyperplasia.

RESULTSRESULTS Coexisting pathology in the hysterectomy specimens included leiomyomas in eight cases and adenomyosis in one. There was one case of cervical intraepithelial n eoplasia (CIN) I and one of CIN III. In one case there was cervical microglandular hyperplasia (MGH) associated with focal decidualisation of the cervical stroma.

CONCLUSIONCONCLUSION In conclusion, our study describes the endometrial morphological features associated with the Mirena coil, a progestogen containing device. Pathologists should be aware of these features because this device is increasingly being used as a contraceptive and for the management of abnormal uterine bleeding.