The effect of a hysteroscopic niche resection compared with Levonorgestrel-releasing intrauterine device on postmenstrual spotting in patients with a symptomatic niche in the uterine cesarean scar: A prospective cohort study

Objective: To compare the effect of a hysteroscopic niche resection with a Levonorgestrel-releasing intrauterine device (LNG-IUD, 52 mg) on postmenstrual spotting duration in patients with a symptomatic niche in the uterine cesarean scar. Study design: This prospective cohort study was conducted at the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, China. Patients with postmenstrual spotting symptomatic niches were allocated to hysteroscopy group or LNG-IUD group based on the shared medical decision-making approach, and were followed up for 1 year after treatment. Main outcome measures: The primary outcome was reduced postmenstrual spotting days at 6th month after treatment. Secondary outcomes were effectiveness rate (proportion of patients with spotting days reduced by at least 50% from baseline), menstrual characteristics, menstruation satisfaction, direct medical costs, complications and side effects. Results: 78 out of the 82 eligible patients were included, 36 patients in both group finished 1-year follow-up. Reduced spotting days at the 6th month was 7 days in LNG-IUD group, significantly higher than 5 days in hysteroscopy group, P = 0.004; The effectiveness rate increased over time within 1 year after the insertion of LNG-IUD (63.89%, 83.33%, 88.89%, 88.89%, P for trend = 0.006), while no trend change was observed in hysteroscopy group (71.05%, 71.05%, 66.67%, 61.11%, P for trend = 0.77). The mean direct medical costs were 817[785,856] $ in the hysteroscopy group and 243[239,255] $ in the LNG-IUD group (p＜0.001). 2 patients removed IUD and 2 patients reported weight gain of more than 5 kg and breast distended pain in LNG-IUD group; 2 patients got pregnant in hysteroscopy group. No serious complications were observed in both groups. Conclusions: LNG-IUD is more effective in the treatment of postmenstrual spotting from the 6th month onwards than a hysteroscopic niche resection in patients with a symptomatic niche at lower direct costs.