Dual Progestin System (DPS) via levonorgestrel-releasing intrauterine system (LNG-IUS) and etonogestrel subdermal implant (ESI) for severe, refractory endometriosis-associated pain: A retrospective case series report

• Dual Progestin System (DPS) using LNG-IUS + ESI provides strong pain relief in severe, refractory endometriosis. • Significant reduction in VAS pain scores observed within 3–6 months, sustained long-term. • DPS offers combined local and systemic progestin exposure to overcome partial progesterone resistance. • High continuation rates and only mild, well-tolerated side effects reported. • Represents a promising alternative to repeated surgery and hypoestrogenic GnRH therapies. To evaluate the clinical effectiveness of a dual progestogen-delivery system (DPS) using a levonorgestrel-releasing intrauterine system (LNG-IUS) combined with an etonogestrel subdermal implant (ESI) in women with severe, refractory endometriosis-associated pelvic pain. A retrospective analysis of 105 patients treated with simultaneous LNG-IUS and ESI for durations ranging from 24 to 102 months. Tertiary referral centers and university-affiliated hospitals. Women with surgically confirmed endometriosis and persistent pelvic pain unresponsive to standard care (medical and/or surgical management). Pain relief (measured by VAS), continuation rates, treatment duration, and reported adverse events. The mean treatment duration was 28.1 months. Significant pain reduction was reported in 85% of patients, with VAS scores decreasing from a baseline mean of 9/10 to 3/10 (SD ± 1.04) by 3 months, and to minimal or no pain by 6 months. Most patients (n = 90/105, 85%) sustained symptom relief throughout therapy. Mild adverse effects were reported in 50% of patients, though primarily mild and non-disruptive. The DPS represents a promising, alternative, long-term therapeutic option for managing severe, refractory endometriosis-related pain, offering both uterine and systemic suppression of endometriotic activity.