Levonorgestrel device beats niche resection

A 52-mg levonorgestrel intrauterine system provided better 3-year relief than hysteroscopic niche resection.
*Randomized controlled trial; Level 2 (OCEBM).

Citation

Yan L, Zhu C, Xia W, et al. American Journal of Obstetrics & Gynecology. 2026;234:390-399. doi:10.1016/j.ajog.2025.09.011

Background

Cesarean scar niches can cause prolonged spotting after periods, pelvic pain, and lower quality of life. Surgery is used, but longer-term comparison with a hormone-releasing intrauterine device was needed.

Patients

208 women with postmenstrual spotting after cesarean delivery, imaging-confirmed niche depth at least 2 mm, and remaining uterine muscle at least 2.2 mm. Women planning pregnancy within 1 year or with thinner remaining muscle were not studied.

Intervention

52-mg levonorgestrel intrauterine system.

Control

Hysteroscopic niche resection, an accepted surgical treatment.

Outcome

Primary: at least 50% reduction in spotting days. Secondary: bleeding days, pelvic pain, spotting discomfort score (0–10), and satisfaction score (1–5).

Follow-up Period

36 months.

Results

36-month outcome Levonorgestrel system Resection Significant effect
≥50% spotting reduction (primary) 98.9% 51.7% RR 1.91 (95% CI, 1.56–2.34); NNT 3
Spotting days per cycle 0 6 Fewer with levonorgestrel system
Total bleeding days per cycle 0 10 Fewer with levonorgestrel system
Pelvic pain 3.2% 21.3% NNT 6
Spotting discomfort score 0 2 Lower with levonorgestrel system

RR: relative risk; CI: confidence interval; NNT: number needed to treat.

Analyses were intention-to-treat; per-protocol findings were similar. Hormone-related side effects occurred in 20 levonorgestrel users; 2 partial expulsions were reported.

Limitations

Single-center, open-label trial at a specialized hospital. Results may not apply to women seeking near-term pregnancy, those with very thin remaining uterine muscle, or large niches. Other causes of abnormal bleeding were not fully evaluated.

Funding

Chinese public academic/government grants; no industry funding or reported conflicts.

Clinical Application

Offer levonorgestrel intrauterine system first-line for symptomatic niche spotting when pregnancy is not desired within 1 year.