Hormonal IUD placement during endometrial ablation reduces later hysterectomy risk

Clinical takeaway: Discuss concurrent insertion of a 52-mg levonorgestrel IUD with patients choosing endometrial ablation for heavy menstrual bleeding. Explain the lower likelihood of subsequent hysterectomy alongside potential side effects that may prompt IUD removal.

Endometrial ablation offers an alternative to hysterectomy for heavy menstrual bleeding, but persistent or recurrent symptoms can lead to further surgery. The MIRA2 trial suggests that adding a levonorgestrel-releasing IUD immediately after ablation can help more patients avoid hysterectomy.

The open-label randomized trial enrolled 715 women younger than 60 years who were eligible for endometrial ablation at 34 hospitals in the Netherlands. Participants underwent ablation alone or ablation followed immediately by insertion of a 52-mg levonorgestrel IUD. Median age was 45 years.

Among participants with available two-year data, hysterectomy occurred in 15 of 342 women receiving combined treatment versus 34 of 331 receiving ablation alone—approximately 4% versus 10%. This represented a 57% relative risk reduction, or about six fewer hysterectomies per 100 women treated.

Benefits extended to symptom control. At six months, amenorrhea was more common with combined treatment (59% versus 46%). Over two years, fewer women needed additional medication for bleeding (6% versus 16%), and fewer reported cyclical pain at two years (17% versus 25%).

Serious adverse events occurred in approximately 8% of both groups, with no treatment-related deaths. However, IUD side effects were commonly reported and could lead to discontinuation. Counseling should distinguish these tolerability concerns from serious complications when helping patients weigh the additional treatment.

“The combined treatment appears to be a safe adjunctive strategy for heavy menstrual bleeding that does not increase the risk of complications,” the authors concluded.

Source: Oderkerk TJ, et al. (2026 Oct 21) Lancet. Endometrial ablation plus levonorgestrel-releasing intrauterine system versus endometrial ablation alone in women with heavy menstrual bleeding in The Netherlands (MIRA2): a multicentre, open-label, randomised, controlled, superiority trial