Decline in Danish use of oral tranexamic acid with increasing use of the levonorgestrel-releasing intrauterine system, A nationwide drug utilization study

OBJECTIVE: To study patterns of oral tranexamic acid use among pre- and perimenopausal Danish women following the introduction of the levonorgestrel-releasing intrauterine system.

STUDY DESIGN: We conducted a nationwide descriptive drug utilization study including all 15-54-year-old Danish women during the period 1996-2017. National health registers provided information on use of oral tranexamic acid, the levonorgestrel-releasing intrauterine system, other hormonal contraceptives, and cyclical oral progestogens as well as incidence rates of endometrial ablations and hysterectomies. Linear calendar time trends in usage of these treatments were tested using Poisson and logistic regression models, which adjusted for user age and provided p-values for significance.

RESULTS: During the study period, use of the levonorgestrel-releasing intrauterine system increased 14-fold among women aged 15-54 years, from 2.3 in 1996 to 32 users per 1,000 person-years in 2017 (p<0.001). The increase happened consistently throughout the study period for women aged 20-54 years, but not for the youngest age group, 15-19 years, among whom the increase only happened in the end of study period following the introduction of a levonorgestrel-releasing intrauterine system with a smaller frame. Use of oral tranexamic acid declined from 11.3 in 1996 to 6.3 per 1,000 person-years in 2017 among women aged 20-54 years (p<0.001) but increased from 1.4 to 1.9 users per 1,000 person-years among those aged 15-19 years (p<0.001). Use of other hormonal contraceptives remained stable over time at around 300 users per 1,000 person-years, while the use of cyclical oral progestogens decreased from 4 to 0.1 users per 1,000 person-years (p<0.001). The incidence of hysterectomies decreased from 3.1 to 2.1 per 1,000 person-years (p<0.001), while the incidence rate of endometrial ablations increased from 0.7 to 1.3 per 1,000 person-years (p<0.001).

CONCLUSIONS: In Denmark, increasing use of the levonorgestrel-releasing intrauterine system has been accompanied by a decrease in use of oral tranexamic acid, cyclical oral progestogens, and hysterectomy.

IMPLICATION: Increasing use of the levonorgestrel-releasing intrauterine system was accompanied by declining use of other therapies used to decrease menstrual bleeding. The non-contraceptive benefits of hormonal contraception should be considered in cost-effectiveness analyses.