What is the best contraceptive option for a woman with menorrhagia, a heterozygous factor V Leiden carrier, and mild anemia, who desires a more reliable method?

From the Guidelines

The patient should consider a levonorgestrel intrauterine device (IUD) as the most appropriate contraceptive option. This would provide reliable contraception while also potentially reducing her heavy menstrual bleeding. Given her heterozygous Factor V Leiden mutation and family history of pulmonary embolism, estrogen-containing contraceptives would be contraindicated due to the increased risk of thromboembolism, as noted in the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 1. The levonorgestrel IUD (such as Mirena, Liletta, or Kyleena) would be effective for 3-7 years depending on the specific device chosen. Progestin-only methods like the IUD work primarily by thickening cervical mucus and thinning the endometrial lining, which not only prevents pregnancy but often significantly reduces menstrual flow. This would address her heavy menstruation (menorrhagia) which is likely contributing to her mild anemia (hemoglobin 10 g/dL, hematocrit 30%).

Some key points to consider:

• The patient's Factor V Leiden mutation increases her risk for venous thromboembolism, particularly with estrogen-containing contraceptives 1.
• The levonorgestrel IUD is a progestin-only method that does not increase the risk of thromboembolism and can reduce menstrual flow.
• Other acceptable options could include the progestin-only pill, progestin implant, or depot medroxyprogesterone acetate injections, but the IUD would offer the dual benefit of reliable contraception and menstrual flow reduction.
• The patient should also be counseled about iron supplementation to address her anemia while the hormonal method takes effect.

It's also important to note that the American College of Medical Genetics consensus statement on factor V Leiden mutation testing suggests that testing can be useful in identifying individuals with increased recurrence risk who could then be considered for long-term antithrombotic therapy 1. However, in this case, the patient's primary concern is finding a reliable contraceptive method that does not increase her risk of thromboembolism, making the levonorgestrel IUD a suitable option.

From the FDA Drug Label

INDICATIONS AND USAGE 1. Indications. Progestin-only oral contraceptives are indicated for the prevention of pregnancy. The patient is seeking a reliable form of contraception, and progestin-only oral contraceptives, such as norethindrone, are indicated for the prevention of pregnancy.

• Key Considerations:
  • The patient has a history of heavy menstrual bleeding, which may be managed with hormonal contraceptives.
  • The patient is a heterozygous factor V Leiden carrier, which increases her risk of venous thromboembolism.
  • The patient has no personal history of venous thromboembolism and no other medical conditions. Given the patient's medical history and risk factors, the use of progestin-only oral contraceptives, such as norethindrone, may be considered, but it is essential to weigh the benefits and risks, particularly regarding her increased risk of venous thromboembolism 2.

From the Research

Patient's Condition

The patient is experiencing heavy menstrual bleeding, defined as excessive menstrual blood loss >80 mL per cycle, which interferes with her physical, emotional, social wellbeing, and quality of life 3. She has a history of regular monthly menses with 6 days of bleeding, requiring both a pad and a tampon to prevent blood from getting on her clothing.

Diagnosis and Treatment

The patient's condition can be diagnosed through a menstrual and gynaecological history, a bleeding score, and additional haematological investigations if necessary 3. A pelvic examination and ultrasound scan can help rule out underlying pathology 4. Treatment options for heavy menstrual bleeding include hormonal therapies, such as levonorgestrel-releasing intrauterine system (LNG-IUS) and combined hormonal contraceptives, as well as haemostatic therapies like tranexamic acid and DDAVP (1-deamino-8-D-arginine) 3, 4.

Considerations for Patients with Thrombosis Risk

The patient is a heterozygous factor V Leiden carrier, which increases her risk of thrombosis. Management of heavy menstrual bleeding in patients with a history of thrombosis or at high risk of thrombosis can be challenging 5. Hormonal therapy may be contraindicated in these patients unless they are on anticoagulation. Tranexamic acid, an antifibrinolytic agent, has been shown to be effective in reducing menstrual blood loss in women with heavy menstrual bleeding, including those with intrauterine contraceptive device-associated menorrhagia 6, 7.

Treatment Options for the Patient

Given the patient's condition and risk factors, treatment options may include:

• Tranexamic acid to reduce menstrual blood loss 6, 7
• Hormonal therapies, such as LNG-IUS or combined hormonal contraceptives, if deemed safe and suitable for the patient 3, 4
• Haemostatic therapies, such as DDAVP, if necessary 3
• Surgical options, such as endometrial ablation or hysterectomy, if medical therapies are ineffective or not suitable for the patient 3, 4

Laboratory Results

The patient's laboratory results show a hemoglobin level of 10 g/dL, hematocrit of 30%, and ferritin levels are not provided. These results indicate that the patient may be experiencing iron deficiency anemia due to heavy menstrual bleeding. Tranexamic acid has been shown to increase hemoglobin and ferritin levels in women with heavy menstrual bleeding 6.