What is the most appropriate contraceptive method to regulate heavy dysfunctional uterine bleeding in a 41‑year‑old woman with polycystic ovary syndrome, type 2 diabetes, and hypertension, who is not currently using birth control and has no migraine with aura?

Levonorgestrel-Releasing Intrauterine System (LNG-IUD) for Heavy Menstrual Bleeding in PCOS with Diabetes and Hypertension

The levonorgestrel-releasing intrauterine system (LNG-IUD) is the optimal contraceptive choice for this patient, providing superior menstrual blood loss reduction (71-95%) while avoiding estrogen-related thrombotic risks in a woman with multiple cardiovascular risk factors. 1

Why LNG-IUD is Preferred Over Combined Oral Contraceptives

Your patient's clinical profile—type 2 diabetes, hypertension, age 41, and PCOS—creates a constellation of cardiovascular risk factors that makes estrogen-containing contraceptives less ideal, even though combined oral contraceptives (COCs) are typically first-line for heavy menstrual bleeding. 1, 2

Cardiovascular Risk Considerations

• COCs increase venous thromboembolism risk 3-4 fold (up to 4 per 10,000 woman-years), and this baseline risk is already elevated 1.5-fold in women with PCOS before any hormonal therapy. 1, 3

• The combination of diabetes, hypertension, and PCOS substantially amplifies thrombotic risk, making progestin-only methods safer than estrogen-containing options in this 41-year-old patient. 3

• Women with PCOS have increased coronary calcification and more severe arterial stenosis compared to controls, further supporting avoidance of estrogen when effective alternatives exist. 3

Superior Efficacy of LNG-IUD for Heavy Bleeding

• The LNG-IUD reduces menstrual blood loss by 71-95%, which is superior to combined oral contraceptives, oral progestogens, tranexamic acid, and mefenamic acid. 1, 4

• By 2 years of use, approximately 50% of LNG-IUD users experience amenorrhea or oligomenorrhea, effectively eliminating the heavy bleeding problem. 5

• The LNG-IUD provides comparable bleeding reduction to endometrial ablation without requiring surgery, making it an excellent first-line option before considering invasive procedures. 1, 6, 7

Practical Implementation Strategy

Insertion Timing and Contraceptive Coverage

• Insert the LNG-IUD within the first 7 days of her menstrual cycle to avoid the need for backup contraception. 1

• If insertion occurs more than 7 days after menses starts, she must use backup contraception (condoms) for 7 days. 1

• The device can be inserted at any point in the cycle provided pregnancy is reasonably excluded through clinical criteria and negative pregnancy testing when indicated. 1

Managing Expected Bleeding Patterns

• Counsel her before insertion that irregular spotting or light bleeding is common and expected during the first 3-6 months, occurs in most users, is not harmful, and decreases with continued use. 5, 1

• If heavy or prolonged bleeding persists beyond 3-6 months, first-line treatment is NSAIDs (ibuprofen 400-600 mg three times daily) for 5-7 days during bleeding episodes. 1, 2, 8

• If NSAIDs are ineffective, consider a short 10-20 day course of combined oral contraceptives or estrogen as second-line therapy, provided she has no acute contraindications. 1

Follow-Up Requirements

• No routine follow-up visit is required after LNG-IUD insertion; she should return only for concerning symptoms, side effects, or if she desires method change. 1

• Routine IUD string checks at every visit are unnecessary; follow-up should be limited to specific patient concerns. 1

• The LNG-IUD remains effective for 5-8 years depending on the specific device model (Mirena 7-8 years, Kyleena 5 years, Skyla 3 years). 1

Why Not Combined Oral Contraceptives?

While COCs containing 30-35 μg ethinyl estradiol are guideline-recommended first-line therapy for heavy menstrual bleeding in most women, this patient's specific risk profile shifts the balance. 1, 2

• COCs would require daily adherence, whereas the LNG-IUD provides "set and forget" efficacy for years. 6

• The estrogen component in COCs poses unnecessary thrombotic risk when a highly effective progestin-only alternative exists. 1, 3

• Blood pressure monitoring is required at follow-up visits for patients on COCs, adding complexity to management. 1

Common Pitfalls to Avoid

• Do not insert a copper IUD—copper devices exacerbate menstrual bleeding and are contraindicated for heavy bleeding management. 1, 8

• Do not delay LNG-IUD insertion waiting for "perfect timing"—the device can be placed at any cycle point with appropriate pregnancy exclusion and backup contraception if needed. 1

• Do not remove the LNG-IUD prematurely for irregular bleeding in the first 3-6 months—this is expected and resolves with time in most users. 5, 1

• Before treating persistent bleeding, always rule out pregnancy, sexually transmitted infections, IUD displacement, or new uterine pathology (polyps, fibroids). 5, 1

Alternative if LNG-IUD Fails or is Declined

If she declines the LNG-IUD or experiences unacceptable persistent bleeding despite NSAIDs:

• Cyclic oral medroxyprogesterone acetate reduces menstrual blood loss by approximately 87% and avoids estrogen exposure. 1

• Depot medroxyprogesterone acetate (DMPA) 150 mg intramuscularly every 12 weeks is an option, though it causes fluid retention and should be used cautiously given her hypertension. 1

• If all medical therapies fail and bleeding remains unacceptable, discuss definitive surgical options such as endometrial ablation or hysterectomy. 1, 8

The LNG-IUD addresses all her needs simultaneously: highly effective contraception, superior menstrual blood loss reduction, avoidance of estrogen-related risks, and minimal maintenance requirements over 5-8 years of use. 1, 6, 4