Levonorgestrel IUD is the Optimal Choice for This Patient
For a 19-year-old with increased menstrual clotting and heavy flow on combined oral contraceptives, switch to a levonorgestrel-releasing intrauterine device (LNG-IUD), which reduces menstrual blood loss by 71-95% and provides highly effective contraception without increasing thrombotic risk. 1
Primary Recommendation: Levonorgestrel IUD
The LNG-IUD is the most effective long-term management for heavy menstrual bleeding, resulting in dramatic reductions in menstrual blood loss (71-95% reduction), with many women eventually experiencing only light bleeding or amenorrhea over time 1
The LNG-IUD carries no increased risk of venous thromboembolism (RR 0.61,95% CI 0.24-1.53), making it safer than combined hormonal contraceptives for patients with any concern about clotting 2
This method provides highly effective contraception while simultaneously addressing her heavy flow and clotting concerns 2
The patient's anxiety history is not a contraindication to LNG-IUD placement 2
Why Not Continue Combined Oral Contraceptives
Quarter-sized clots and intermittent heavy flow after 2 months suggest the current combined hormonal contraceptive is inadequate for controlling her menstrual symptoms 3
While combined oral contraceptives can reduce menstrual blood loss compared to placebo (OR 5.15,95% CI 3.16 to 8.40), they are significantly less effective than the LNG-IUD (OR 0.21,95% CI 0.09 to 0.48 favoring LNG-IUD) 4
Combined estrogen-progestin contraceptives carry a 36 times higher risk of venous thromboembolism compared to baseline, with odds ratios ranging from 2.2 to 6.6 depending on progestin type 2
Alternative Options If LNG-IUD Is Declined
Second-Line: Progestin-Only Pill
Progestin-only pills carry no increased VTE risk (RR 0.90,95% CI 0.57-1.45) and are safer than combined contraceptives for patients with bleeding concerns 2
However, progestin-only pills are less effective as contraceptives than IUDs and may not adequately reduce menstrual flow 2
Third-Line: NSAIDs as Adjunctive Therapy
NSAIDs (mefenamic acid 500mg three times daily for 5-7 days during bleeding) are first-line treatment for heavy menstrual bleeding and can be used as adjunctive therapy with any contraceptive method 1, 5
Multiple NSAIDs have demonstrated significant reductions in menstrual blood loss, including mefenamic acid, indomethacin, flufenamic acid, and diclofenac 1
NSAIDs are particularly effective for IUD-associated heavy bleeding 1
Methods to Avoid
Do NOT use depot medroxyprogesterone acetate (DMPA) - it carries increased VTE risk (RR 2.67,95% CI 1.29-5.53), similar to combined oral contraceptives, and may worsen bone density in young women 2
Avoid copper IUD - while highly effective for contraception, it may increase menstrual bleeding and cramping for several months, worsening her current symptoms 2
Do NOT use aspirin - it has not shown effectiveness and may actually increase blood loss 1, 6
Critical Evaluation Steps Before Switching
Rule out pregnancy, sexually transmitted infections, and pathologic uterine conditions (polyps, fibroids, endometrial abnormalities) before attributing bleeding to contraceptive method alone 5, 6, 3
Assess whether the patient has been taking pills consistently, as missed pills commonly cause breakthrough bleeding and spotting 3, 7
Screen for medication interactions (antibiotics, anticonvulsants, St. John's Wort) that may reduce contraceptive efficacy and cause irregular bleeding 7
Counseling Points
Enhanced counseling about expected bleeding patterns improves continuation rates - inform her that with LNG-IUD, bleeding typically decreases over 3-6 months, with eventual light bleeding or amenorrhea 5, 6
Quarter-sized clots during menses, while concerning to patients, are generally not harmful unless accompanied by symptoms of anemia (fatigue, weakness, shortness of breath - which she denies) 5
The LNG-IUD addresses both her contraceptive needs and menstrual symptoms simultaneously, eliminating the need for daily pill-taking 1