What are the considerations for a progestin-releasing IUD in a woman with oligomenorrhea, menorrhagia, and obesity?

From the Guidelines

The progestin-releasing intrauterine device (IUD) is the most suitable contraceptive option for this patient, and I strongly recommend proceeding with its placement. The patient's heavy and irregular menstrual bleeding can be significantly reduced with the use of a levonorgestrel IUD, such as Mirena, Liletta, or Kyleena, which provide highly effective contraception (>99%) for 5-7 years depending on the specific product 1.

Key Considerations

• The device can be inserted during this office visit since her pregnancy test is negative and she recently had her period, ensuring she is not pregnant, as per the guidelines outlined in the 2024 U.S. Selected Practice Recommendations for Contraceptive Use 1.
• Despite her nulliparity and high BMI (44 kg/m²), neither factor is a contraindication to IUD use, according to the U.S. Medical Eligibility Criteria for Contraceptive Use 1.
• The progestin IUD works primarily by thickening cervical mucus to prevent sperm entry, thinning the endometrial lining, and in some cases suppressing ovulation.
• She should be advised that irregular spotting is common in the first 3-6 months after insertion, but bleeding typically decreases substantially over time, as noted in the 2013 U.S. Selected Practice Recommendations for Contraceptive Use 1.
• Her history of treated Trichomonas infection is not a concern as long as she has no current signs of infection.
• The family history of breast cancer in her elderly grandmother does not contraindicate hormonal contraception, particularly the progestin IUD, which has minimal systemic hormone absorption, as indicated by the U.S. Medical Eligibility Criteria for Contraceptive Use 1.

Additional Guidance

• The patient should be informed about the potential benefits and side effects of the progestin IUD, including the reduction of menstrual bleeding and the possibility of irregular spotting in the first few months after insertion.
• Regular follow-up appointments should be scheduled to monitor the patient's response to the IUD and address any concerns or side effects that may arise.

From the Research

Patient's Condition

The patient is a 34-year-old woman experiencing heavy vaginal bleeding and passage of clots, with intermittent light spotting in between her menses, which occur every 8 to 12 weeks. She has no chronic medical conditions, takes no daily medications, and has a history of Trichomonas vaginitis treated at age 16.

Menstrual Bleeding

• Menorrhagia is defined as menstrual periods lasting more than 7 days and/or involving blood loss greater than 80ml 2.
• The patient's symptoms align with menorrhagia, given the heavy bleeding and passage of clots.
• A blood count for red cells and platelets to test for anemia is recommended on a first-line basis for women consulting for abnormal uterine bleeding (AUB) whose history and/or bleeding score justify it 2.

Contraception Options

• The patient is interested in a more reliable method of contraception, having previously used condoms.
• Intrauterine devices (IUDs) provide highly effective, long-term, safe, reversible contraception, and are the most widely used reversible contraceptive method worldwide 3.
• The levonorgestrel-releasing IUD (LNG-IUD) is recognized to provide non-contraceptive health benefits, including reduction of heavy menstrual bleeding and dysmenorrhea 3.
• Long-acting methods, such as IUDs and subdermal implants, have failure rates of less than 1% per year 4.

Progestin-Releasing Intrauterine Device

• The LNG-IUD is beneficial for reducing menstrual problems, including heavy bleeding and dysmenorrhea 3.
• Placement of a levonorgestrel IUD is recommended for women with idiopathic AUB 2.
• Unscheduled vaginal bleeding is a common side effect of progestin-only contraception, including the LNG-IUD, but overall satisfaction among women using these methods is high 5.

Trichomoniasis History

• The patient has a history of Trichomonas vaginitis, which may be relevant when considering the use of an IUD, as some studies suggest that IUD usage might increase the risk of Trichomonas infection 6.
• However, the patient's Trichomonas vaginitis was treated at age 16, and there is no current evidence of infection.

BMI Consideration

• The patient's BMI is 44 kg/m², which may be relevant when considering the effectiveness and potential side effects of different contraceptive methods.
• Some studies suggest that severely obese women may experience benefits from using the LNG-IUD for menstrual problems 3.