What birth control options are recommended for a 16-year-old patient with menorrhagia (heavy periods) and iron deficiency anemia?

Birth Control Options for 16-Year-Old with Heavy Periods and Iron Deficiency

The levonorgestrel IUD is the most effective birth control option for a 16-year-old with heavy menstrual bleeding and iron deficiency, providing excellent menstrual suppression while offering long-term contraception. 1

First-Line Options

Levonorgestrel IUD

• Recommended by the American Academy of Pediatrics as the most effective option for teens with heavy menstrual bleeding 1
• Provides significant improvement in heavy menstrual bleeding with high satisfaction rates (≥75% at 1 year) 1
• Does not contain estrogen, making it suitable for teens with contraindications to estrogen 1
• Effectively reduces menstrual blood loss, which directly addresses the underlying cause of iron deficiency 1

Combined Oral Contraceptives (COCs)

• Provide decreased menstrual cramping and blood loss, making them effective for treating heavy periods 1
• Low-dose pills containing 30-35 μg ethinyl estradiol with levonorgestrel or norgestimate are commonly recommended for adolescents 1, 2
• Use of oral contraceptives is associated with decreased risk for iron deficiency 3
• Extended or continuous cycle regimens are particularly appropriate for teens with heavy bleeding or anemia 1
• COCs act by suppressing gonadotropins, inhibiting ovulation, and thinning the endometrium, which reduces menstrual blood loss 4, 5

Alternative Options

Depot Medroxyprogesterone Acetate (DMPA)

• Provides improvement in dysmenorrhea and protection against iron-deficiency anemia 1
• Convenient injection every 13 weeks, which may improve compliance 1, 3
• May cause menstrual irregularities, which requires counseling to improve continuation rates 1, 3
• May cause reductions in bone mineral density, though substantial recovery occurs after discontinuation 1

Efficacy for Heavy Menstrual Bleeding

Levonorgestrel IUD

• Most effective option for reducing menstrual blood loss 1, 5
• The LNG IUS was more effective than COCPs in reducing menstrual blood loss in clinical trials 5

Combined Oral Contraceptives

• Moderate-quality evidence suggests that COCs over six months reduces heavy menstrual bleeding from 12% to 77% (compared to 3% in women taking placebo) 5
• Monophasic COCs containing 30-35 μg of ethinyl estradiol are particularly effective for teens with heavy bleeding 1

Addressing Iron Deficiency

• Heavy menstrual blood loss (≥80 mL/month) is an important risk factor for iron-deficiency anemia, affecting approximately 10% of women in the United States 3
• Only one-fourth of adolescent girls meet the recommended dietary allowance for iron through diet 3
• Hormonal contraception that reduces menstrual blood loss directly addresses the cause of iron deficiency 6
• For immediate management of iron deficiency, iron supplementation may be required alongside hormonal contraception 7, 8

Management Algorithm

1. First choice: Levonorgestrel IUD

   • Most effective for reducing heavy menstrual bleeding 1, 5
   • Long-acting, reversible, with high satisfaction rates 1
   • No negative effect on long-term fertility 1

2. Second choice: Combined Oral Contraceptives

   • Start with a monophasic pill containing 30-35 μg ethinyl estradiol with levonorgestrel or norethisterone 1, 2
   • Consider extended or continuous regimen to further reduce menstrual blood loss 1
   • Effective if taken correctly, with relatively low risk of venous thromboembolism 2

3. Third choice: Depot Medroxyprogesterone Acetate

   • Consider if other options are contraindicated or not preferred 1
   • Recommend calcium (1300 mg) and vitamin D (600 IU) daily 1
   • Counsel about potential menstrual irregularities to improve continuation rates 3, 1

Important Considerations

• Discuss the need for consistent condom use for STI protection regardless of contraceptive method chosen 1
• For all methods, provide counseling about expected bleeding patterns to improve continuation rates 3
• Consider iron supplementation until menstrual blood loss is controlled and iron stores are replenished 7, 8
• Schedule follow-up to assess improvement in menstrual bleeding and iron status 3