Clinical outcomes of three hysteroscopic levonorgestrel-releasing intrauterine system placement methods in the management of adenomyosis: a retrospective cohort study

Abstract

Abstract Background The levonorgestrel-releasing intrauterine system (LNG-IUS) is effective for adenomyosis, yet expulsion frequently limits its clinical application. This study aimed to compare clinical outcomes of three hysteroscopic LNG-IUS placement techniques for adenomyosis. Methods This retrospective cohort recruited 131 adenomyosis patients (non-suture fixation n = 32, suture fixation n = 23, conventional placement n = 76) at Fujian Maternity and Child Health Hospital from October 2024 to October 2025. The primary outcome was LNG-IUS expulsion or displacement. Follow-up assessments were performed at baseline, 1 month and 6 months after placement for uterine volume, endometrial thickness, hemoglobin, carbohydrate antigen 125, dysmenorrhea and menstrual blood loss. Intraoperative parameters and postoperative adverse events were recorded. Between-group comparisons used ANOVA or Kruskal-Wallis tests; within-group changes used repeated-measures ANOVA or the Friedman test, with Bonferroni correction for multiple comparisons. Subgroup analysis was stratified by uterine cavity depth (cut-off 9.0 cm). Propensity-score matching (1:1:1), generalized estimating equations (GEE) and Cox regression were applied for data analyses. Results Expulsion or displacement rates at 1 and 6 months were 0% in both fixation groups versus 19.74% and 27.63% in the conventional group ( P < 0.01). All groups achieved significant improvements in clinical parameters ( P < 0.001). For patients with uterine cavity depth > 9.0 cm, fixation techniques yielded lower expulsion or displacement rates and superior 6-month clinical improvements versus conventional placement; comparable efficacy was observed among all groups for depth ≤ 9.0 cm. Operation time was shorter for non-suture fixation and conventional placement than suture fixation ( P < 0.001), whereas intraoperative blood loss and adverse reactions were similar ( P > 0.05). In the PSM-matched cohort ( n = 23 per group), expulsion-displacement remained 0% in fixation groups vs. 69.56% conventional. GEE analysis in the matched cohort further revealed significant group × time interactions across the longitudinal clinical outcomes ( P < 0.05). Cox regression identified uterine volume > 150 cm³ as the only independent risk factor (HR = 8.822, 95% CI 3. 172–24. 530, P < 0.001). Conclusions All three methods effectively improve clinical outcomes in adenomyosis patients. For patients with cavity depth > 9.0 cm, hysteroscopic fixation methods were associated with significantly lower observed expulsion rates compared with conventional placement. Non-suture fixation has practical merits of shorter operative time and lower technical requirements. Further prospective studies are required for external validation.

The authors' abstract, as published at the source. BMC Women s Health, 2026 · DOI ↗