What is a good birth control option for a 28-year-old female with menorrhagia (heavy menstrual bleeding)?

Best Birth Control Options for Heavy Menstrual Bleeding

For a 28-year-old female with heavy menstrual bleeding (menorrhagia), a hormonal IUD is the most effective birth control option as it significantly reduces menstrual blood loss while providing excellent contraception.

First-Line Options for Heavy Menstrual Bleeding

Hormonal IUD (Levonorgestrel Intrauterine System)

• Most effective option for managing menorrhagia while providing contraception 1
• Reduces menstrual blood loss by up to 90% within 3-6 months
• More effective than combined oral contraceptives for reducing menstrual blood loss 2
• Typical failure rate of 0.1-0.2% as contraceptive 1
• Long-acting (3-7 years depending on type)
• No daily compliance required

Combined Hormonal Contraceptives

• Effective for both contraception and reducing menstrual blood loss 1, 2
• Available options:
  • Combined oral contraceptives (COCs) - particularly those containing drospirenone
  • Contraceptive vaginal ring
  • Contraceptive patch
• Typical failure rate: 5-9% 1
• Benefits:
  • Decreased menstrual cramping
  • Reduced blood loss
  • Improvement in acne 1
  • Can be used in extended or continuous cycles for women with severe menorrhagia 1

Specific Recommendations for COCs

If choosing a COC, consider one containing drospirenone:

• Drospirenone has antimineralcorticoid activity that helps prevent water retention and weight gain 3
• Available in formulations with 20μg or 30μg ethinyl estradiol 4
• For heavy bleeding, the 30μg formulation may provide better cycle control 3
• Can be started on Day 1 of menstrual cycle or on the first Sunday after onset of menstruation 4

Alternative Options

Progestin-Only Methods

• Progestin-only contraceptives can be effective for women with menorrhagia 1
• Options include:
  • Progestin-only pills (typical failure rate: 5-9%)
  • Injectable contraception (DMPA) (typical failure rate: 0.3-6%)
  • Contraceptive implant (typical failure rate: 0.05%)

Non-Hormonal Options

• Copper IUD: Effective contraception (0.8% failure rate) but may increase menstrual bleeding 1
• Tranexamic acid: Can be used during menstruation to reduce bleeding by 20-60% 5
• NSAIDs (mefenamic acid, naproxen): Can reduce bleeding by 20-40% when taken during menstruation 5

Important Considerations

Contraindications to Combined Hormonal Methods

Avoid combined hormonal contraceptives if the patient has:

• History of deep vein thrombosis or pulmonary embolism
• Migraines with aura
• Uncontrolled hypertension
• Liver disease or tumors
• Undiagnosed uterine bleeding 1

Follow-up and Monitoring

• For hormonal IUD users: Check for proper placement after insertion
• For COC users: Monitor for side effects and adherence
• All patients should be assessed for improvement in menstrual bleeding 1

Algorithm for Decision-Making

1. Rule out pathology: Ensure heavy bleeding isn't caused by fibroids, polyps, or other conditions
2. Assess contraindications: Check for conditions that would preclude certain methods
3. Consider effectiveness needs: If high effectiveness is priority, choose LARCs
4. Consider bleeding pattern preferences:
   • Maximum reduction in bleeding → Hormonal IUD
   • Regular, lighter periods → COCs
5. Consider administration preferences:
   • No daily action required → IUD or implant
   • Daily/weekly/monthly action acceptable → COCs, patch, or ring

The hormonal IUD remains the gold standard for treating heavy menstrual bleeding while providing contraception, but COCs are a good alternative if the patient prefers a non-invasive method or has contraindications to IUD use.