What is the best birth control option for a 16-year-old girl with menorrhagia (heavy menstrual bleeding) who is not sexually active?

Management of Heavy Menstrual Bleeding in a Non-Sexually Active 16-Year-Old

For a 16-year-old with heavy menstrual bleeding lasting 10 days per month who is not sexually active, the levonorgestrel-releasing intrauterine device (LNG-IUD) is the most effective first-line treatment option. 1

Initial Assessment

• Evaluate for underlying gynecological problems:

  • Interactions with medications
  • Sexually transmitted infections
  • Pregnancy (even if reported as not sexually active)
  • Thyroid disorders
  • Pathologic uterine conditions (polyps, fibroids)
  • Bleeding disorders (especially von Willebrand disease, which has high incidence in adolescents with heavy menstrual bleeding) 2

• Check for anemia and assess severity of bleeding

  • Heavy menstrual bleeding is clinically defined as ≥80 mL blood loss per cycle 1
  • Assess impact on quality of life and daily activities

Treatment Options (In Order of Effectiveness)

1. Levonorgestrel-Releasing IUD (First Choice)

• Most effective option for reducing heavy menstrual bleeding (up to 90% reduction) 1
• Superior to oral medications for treating menorrhagia 1
• Safe and effective in adolescents, including those with bleeding disorders 2
• Provides long-term solution with high continuation rates (≥75% at 1 year) 3
• Benefits:
  • Improvement in dysmenorrhea
  • No need for daily compliance
  • Effective for 3-7 years depending on device
  • Can be used in adolescents regardless of sexual activity status

2. Combined Hormonal Contraceptives (Second Choice)

• Effective for reducing menstrual blood loss
• Options include pills, patch, or vaginal ring
• Can be started at any time if reasonably certain patient is not pregnant 3
• Consider extended or continuous regimen to reduce number of periods
• For heavy/prolonged bleeding while using CHCs, consider:
  • NSAIDs for 5-7 days during bleeding episodes 3
  • Not recommended to take hormone-free interval during first 21 days of use 3

3. Depot Medroxyprogesterone Acetate (DMPA) (Third Choice)

• Injectable option every 13 weeks
• Advantages:
  • Improvement in dysmenorrhea
  • Protection against iron-deficiency anemia
  • No daily compliance needed 3
• For breakthrough bleeding on DMPA:
  • NSAIDs for 5-7 days
  • Hormonal treatment (low-dose COCs or estrogen) for 10-20 days 3
• Major disadvantages:
  • Menstrual irregularities (nearly universal initially)
  • Potential weight gain
  • Concerns about bone mineral density with long-term use 3

4. Other Medical Therapies

• Tranexamic acid: Reduces menstrual blood loss by 20-60% 4
• NSAIDs: Effective for short-term treatment (5-7 days) during bleeding episodes 3

Treatment Algorithm

1. Start with LNG-IUD if:

   • Bleeding is severe
   • Anemia is present
   • Patient can tolerate insertion procedure
   • Long-term solution is desired

2. Use Combined Hormonal Contraceptives if:

   • Patient declines IUD
   • IUD insertion needs to be delayed
   • Consider extended cycling (84 active pills/7 placebo) to reduce periods to 4 per year 5

3. Consider DMPA if:

   • Patient declines or has contraindications to above options
   • Compliance with daily medication is a concern
   • Ensure adequate calcium (1300mg) and vitamin D (600 IU) intake 3

Important Considerations

• Bleeding disorders: Screen for bleeding disorders, especially von Willebrand disease, which is common in adolescents with heavy menstrual bleeding 2

• Follow-up: Advise patient to return if bleeding persists or worsens despite treatment

• Common pitfalls to avoid:

  • Assuming heavy bleeding is "normal" in adolescents
  • Delaying effective treatment, which can lead to anemia requiring transfusion
  • Limiting treatment options based on sexual activity status (LNG-IUD can be used regardless of sexual activity)
  • Not screening for underlying bleeding disorders

• If bleeding persists despite initial treatment:

  • Reevaluate for underlying conditions
  • Consider referral to adolescent gynecology or hematology if bleeding disorder is suspected

The LNG-IUD provides the most effective reduction in menstrual blood loss with high satisfaction rates and should be strongly considered as first-line therapy, even in adolescents who are not sexually active 1, 2.