Should the Mirena intrauterine system be offered (unless contraindicated) to women presenting with postmenopausal bleeding at the time of endometrial sampling?

Postmenopausal bleeding (PMB) is a common but potentially serious clinical presentation, with 5–10% of women ultimately diagnosed with endometrial carcinoma. Although most causes are benign, histological assessment remains essential, as imaging alone cannot reliably exclude premalignant or malignant pathology. Increasing evidence demonstrates that proliferative endometrium and endometrial hyperplasia carry measurable risks of progression to carcinoma, and that the levonorgestrel-releasing intrauterine system (LNG-IUS; Mirena) achieves high rates of histological regression while providing durable endometrial suppression. This review examines whether Mirena should be routinely offered, unless contraindicated, at the time of endometrial sampling in women presenting with PMB. The uterine causes of PMB, including atrophic endometrium, endometrial polyps, proliferative endometrium, endometrial hyperplasia with or without atypia, and endometrial carcinoma, are reviewed with particular emphasis on the effects of levonorgestrel released by LNG-IUS on endometrial proliferation and hyperplasia. Evidence demonstrates suppression of proliferative activity in most treated women and regression rates exceeding 90% in non-atypical hyperplasia and approximately 70–90% in atypical hyperplasia, with additional roles in temporizing management of selected early-stage carcinoma. Cervical stenosis is a common finding in postmenopausal women. To obtain an endometrial biopsy, these women may require general anesthesia, cervical dilatation, and hysteroscopy. Under these circumstances, LNG-IUS insertion during the initial hysteroscopy would avoid women undergoing repeat procedures should progesterone treatment be required. Current evidence supports consideration of offering LNG-IUS insertion, unless contraindicated, at the time of endometrial biopsy in appropriately selected patients. This approach would combine diagnosis and treatment in women with proliferative endometrium and endometrial hyperplasia.