title: Endometrial protection from tamoxifen-stimulated changes by a levonorgestrel-releasing intrauterine system: a randomised controlled trial.
abstract: BACKGROUND
  Tamoxifen is currently the most commonly used adjuvant treatment for breast cancer, however, it frequently causes episodes of unscheduled uterine bleeding, which could be associated with proliferative changes of the endometrium, or even endometrial cancer. We aimed to assess whether a levonorgestrel intrauterine system could modulate the uterine responses to tamoxifen. We also aimed to assess women's tolerance of the screening procedures, the insertion, removal, and potential side-effects of the device.
  
  
  METHODS
  We did a randomised controlled trial, in which postmenopausal women who had had at least 1 year of adjuvant tamoxifen treatment and who were undergoing regular follow-up for breast cancer were randomly assigned to either endometrial surveillance alone, or endometrial surveillance before and after insertion of the levonorgestrel intrauterine system for 12 months. We assessed tolerance of the surveillance procedures and the device with visual analogue scales.
  
  
  RESULTS
  Baseline assessment showed only benign uterine changes in all women (n=122). Hysteroscopic assessment indicated a uniform decidual response (confirmed histologically in 40 of 41 cases) in all women fitted with the intrauterine system; there were no new polyps in these women and 13% had fewer fibroids than in controls. Both screening procedures and device were well tolerated. There was an excess of bleeding in the women fitted with intrauterine systems but this resolved to a baseline similar to those receiving surveillance only.
  
  
  CONCLUSIONS
  The levonorgestrel-releasing intrauterine system had a protective action against the uterine effects of tamoxifen. The effectiveness of this device in preventing uterine changes in the endometrium needs to be assessed in the context of decreasing the need for repeated investigations of postmenopausal bleeding in women taking tamoxifen.
authors.affiliation: Department of Obstetrics and Gynaecology, University of Leicester, UK. fjegl@le.ac.uk
authors.forename: F J
authors.initials: FJ
authors.lastname: Gardner
authors.forename: J C
authors.initials: JC
authors.lastname: Konje
authors.forename: K R
authors.initials: KR
authors.lastname: Abrams
authors.forename: L J
authors.initials: LJ
authors.lastname: Brown
authors.forename: S
authors.initials: S
authors.lastname: Khanna
authors.forename: F
authors.initials: F
authors.lastname: Al-Azzawi
authors.forename: S C
authors.initials: SC
authors.lastname: Bell
authors.forename: D J
authors.initials: DJ
authors.lastname: Taylor
mesh_terms: D000368:Aged; D018931:Antineoplastic Agents, Hormonal / Q000009:adverse effects* / Q000627:therapeutic use; D001943:Breast Neoplasms / Q000188:drug therapy / Q000473:pathology; D004717:Endometrium / Q000187:drug effects* / Q000473:pathology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007436:Intrauterine Devices, Medicated; D016912:Levonorgestrel / Q000008:administration & dosage*; D008875:Middle Aged; D010352:Patient Dropouts; D017698:Postmenopause; D013629:Tamoxifen / Q000009:adverse effects* / Q000627:therapeutic use; D016896:Treatment Outcome; D014592:Uterine Hemorrhage / Q000139:chemically induced / Q000517:prevention & control
chemical_list: D018931:Antineoplastic Agents, Hormonal; D013629:Tamoxifen; D016912:Levonorgestrel