What is the best birth control option for a 17-year-old with menorrhagia (heavy menstrual bleeding)?

Best Birth Control for a 17-Year-Old with Heavy Periods

For a 17-year-old with heavy menstrual bleeding, start with combined oral contraceptives (COCs) containing 30-35 μg of ethinyl estradiol as first-line therapy, or consider the levonorgestrel IUD as the most effective option if she is willing to use an intrauterine device. 1, 2

First-Line Hormonal Options

Combined Oral Contraceptives (Preferred Initial Choice)

• Prescribe a monophasic COC containing 30-35 μg of ethinyl estradiol with levonorgestrel or norgestimate. 1, 2 These formulations decrease menstrual blood loss and cramping by inducing regular shedding of a thinner endometrium. 1

• COCs provide additional benefits beyond bleeding control: improvement in acne, reduced risk of endometrial and ovarian cancers, and protection against iron-deficiency anemia. 1, 2

• For adolescents with heavy bleeding or anemia, use extended or continuous cycle regimens where she takes active pills continuously for 3-4 months, followed by a 4-7 day hormone-free interval. 1, 2 This approach maximizes menstrual suppression.

• If breakthrough bleeding occurs with extended regimens, she can take a 3-4 day hormone-free interval to temporarily induce bleeding, but not during the first 21 days of use and not more than once per month. 3, 1

Levonorgestrel IUD (Most Effective Option)

• The levonorgestrel IUD is the most effective birth control for heavy menstrual bleeding in adolescents, providing excellent menstrual suppression with high satisfaction and continuation rates (≥75% at 1 year). 2

• This option allows effective menstrual suppression without exogenous estrogen exposure, making it ideal for teens with contraindications to estrogen. 2

• The levonorgestrel IUD is particularly useful for adolescents requiring long-term menstrual suppression and has no negative effect on long-term fertility. 2

• Backup contraception is needed for 7 days only if inserted more than 7 days after menses starts. 3

Alternative Options

Depot Medroxyprogesterone Acetate (DMPA)

• DMPA can be considered as second-line treatment, providing improvement in dysmenorrhea and protection against iron-deficiency anemia with convenient injection every 13 weeks. 1, 2

• Important counseling point: DMPA may cause reductions in bone mineral density (BMD), though substantial recovery occurs after discontinuation. 2 Recommend calcium (1300 mg) and vitamin D (600 IU) daily for teens using DMPA. 2

• Amenorrhea is common after ≥1 year of continuous use. 3 Enhanced counseling about expected bleeding patterns (amenorrhea and unscheduled spotting) improves continuation rates. 3, 2

• For heavy or prolonged bleeding with DMPA, NSAIDs for 5-7 days may be effective. 1

Contraceptive Vaginal Ring

• The contraceptive vaginal ring releases 15 μg ethinyl estradiol and 120 μg etonogestrel daily, providing comparable effectiveness to COCs with a simpler once-monthly insertion regimen. 1

Management of Breakthrough Bleeding

• For heavy or prolonged bleeding with COCs, consider NSAIDs for 5-7 days during days of bleeding. 3, 1

• If using extended regimen COCs, a hormone-free interval of 3-4 days may help (but not during first 21 days of use). 1

• If clinically indicated, rule out underlying gynecological problems such as STDs, pregnancy, or new pathologic uterine conditions (polyps or fibroids). 3

Monitoring and Follow-Up

• No routine follow-up visit is required, but the patient should return if she experiences side effects or concerns. 1

• Monitor blood pressure at follow-up visits for patients on COCs. 1

• Schedule follow-up to assess improvement in menstrual bleeding and iron status. 2

Critical Safety Considerations

• COCs increase the risk of venous thromboembolism (VTE) three to fourfold (up to 4 per 10,000 woman-years). 1 Screen for VTE risk factors before prescribing.

• Emphasize consistent condom use for STI protection regardless of contraceptive method chosen. 2 All sexually active adolescents should be encouraged to use condoms. 3

Adolescent-Specific Counseling

• Ensure confidential discussion of family planning needs, as adolescents are significantly less likely to use family planning services without assurances of confidentiality. 3

• Provide counseling about potential changes in bleeding patterns before initiating any hormonal method. 3, 1

• Reassure that amenorrhea with hormonal contraceptives does not require medical treatment and is generally not harmful. 3