From the Guidelines
The progestin-releasing intrauterine device (IUD) is the most appropriate contraceptive choice for this patient, and I strongly recommend proceeding with its placement. The patient's history of heavy, irregular periods, which occur every 8 to 12 weeks, makes the progestin IUD an ideal option, as it typically reduces menstrual bleeding over time 1. Her recent menstrual period ensures she is not pregnant, making the timing appropriate for IUD insertion. The progestin IUD provides highly effective contraception (>99%) for 5-7 years, depending on the specific product, such as Mirena, Liletta, or Kyleena.
The patient's BMI of 44 kg/m² does not contraindicate IUD use, as the IUD is one of the few contraceptive methods whose efficacy is not reduced by higher body weight 1. Her history of treated Trichomonas infection is not a concern, as it was remote and successfully treated, and according to the U.S. Medical Eligibility Criteria for Contraceptive Use, a history of vaginitis, including Trichomonas vaginalis, is classified as a Category 2 condition for IUD use, indicating that the benefits of using the method generally outweigh the risks 1. The family history of breast cancer in an elderly relative is also not a contraindication for hormonal IUD use, as the U.S. Medical Eligibility Criteria for Contraceptive Use classify a family history of cancer as a Category 1 condition for IUD use, indicating that there are no restrictions for the use of the method 1.
The patient should be advised that irregular spotting is common in the first 3-6 months after insertion but typically improves over time. She should also be informed that the IUD insertion may cause cramping, which can be mitigated by taking ibuprofen before the procedure. The progestin IUD works primarily by thickening cervical mucus, thinning the endometrial lining, and creating a hostile environment for sperm, while still allowing for ovulation in most cases.
Key points to consider when providing the IUD include:
- Ensuring the patient understands the potential side effects and benefits of the IUD
- Discussing ways to manage potential side effects, such as irregular vaginal bleeding
- Developing a plan for follow-up to address any concerns or issues that may arise after insertion
- Providing information on the importance of using a backup method of contraception, such as condoms, to protect against sexually transmitted infections (STIs) 1.
From the Research
Patient's Condition and Interest in Progestin-Releasing Intrauterine Device
- The patient is a 34-year-old woman interested in a more reliable contraceptive method than condoms, experiencing heavy vaginal bleeding and passage of clots every 8 to 12 weeks, with intermittent light spotting in between.
- She has no chronic medical conditions, takes no daily medications, and has a history of Trichomonas vaginitis treatment at age 16.
- Her maternal grandmother had metastatic breast cancer in her 70s, but this is not directly relevant to her current contraceptive options.
Progestin-Releasing Intrauterine Device (IUD) as a Contraceptive Method
- The levonorgestrel-releasing intrauterine system (LNG IUS) is an effective method for contraception, with a strong antiproliferative action on the endometrium 2.
- It transforms the endometrium, making it unresponsive to ovarian estrogens, leading to a progressive reduction of menstrual blood loss and menstrual duration.
- Scanty and irregular bleeding and/or spotting are common during the first 3 to 4 months, with many women experiencing no bleeding at all after the first 9 months 2.
Benefits and Side Effects of Progestin-Only Contraceptives
- Progestin-only contraceptives, including the LNG IUS, provide long-acting, highly effective reversible contraception, with benefits including reduced risk of pelvic inflammatory disease and endometrial suppression 2, 3.
- However, they can cause steroidal side effects such as mood changes, oily skin, and acne, as well as weight increase similar to that associated with copper intrauterine devices 2.
- Unscheduled vaginal bleeding is a common issue with progestin-only contraceptives, which can lead to dissatisfaction and discontinuation 4, 5.
Considerations for the Patient's Specific Situation
- The patient's heavy menstrual bleeding and passage of clots may be alleviated by the use of the LNG IUS, which has been shown to reduce menstrual blood loss and improve dysmenorrhea 2, 6.
- However, she should be informed about the potential for scanty and irregular bleeding and/or spotting during the first few months of use, as well as the possibility of weight increase and other side effects 2, 3.