LNG-IUD safe and effective for managing heavy menstrual bleeding in adolescents with inherited bleeding disorders: Study
One in four adolescents with heavy menstrual bleeding (HMB)
since menarche may have an inherited bleeding disorder (IBD).
Levonorgestrel-containing intrauterine devices (LNG-IUDs) are the preferred
treatment for HMB in adolescents owing to the substantial and extended
reduction in bleeding and favorable side effect profile. Medical management
alone is frequently insufficient in persons with IBDs, yet several barriers
impact the use of LNG-IUDs in those with IBDs, including a lack of standardized
periprocedural guidelines, perceived higher bleeding risk associated with IUD
insertion complications, and placement-related pain. In addition, a recent
history of HMB increases the risk of IUD expulsion threefold. Moreover, first
spontaneous IUD expulsion is more frequent among adolescents, potentially because
of small uterine size. Expulsion risk factors include young age, history of
anemia, concurrent bleeding disorder diagnosis, and abnormal uterine bleeding.
While the LNG-IUD is as effective for HMB treatment in adolescents with IBDs as
those without IBDs, a key barrier to securing this extended efficacy is a more
frequent IUD expulsion rate within 30 days of insertion. Importantly,
expulsions after 30 days are not more frequent than in adolescents without
IBDs.
Cygan et al hypothesize dthat prophylactic menstrual
suppression after IUD insertion may reduce early (≤30 days) device expulsion.
The primary objective was to examine the rates of early IUD expulsion in
adolescents with IBDs with concurrent menstrual suppression.
The Penn State Health Women and Girls Bleeding Disorder
Clinic provides women’s health services for patients with suspected or
confirmed IBDs, including Ehlers-Danlos syndrome. This retrospective study included
adolescent girls (aged 10–21 years) with known or suspected IBDs undergoing IUD
insertion between November 1st, 2019 and September 7th, 2022. According to the
clinic practice pattern, participants continued their prior hormonal therapy
for at least 30 days after insertion. IUD insertion was within 60 days of the
last depot medroxyprogesterone acetate injection to ensure adequate coverage
for 30 days. Assessed data included the incidence of IUD expulsion, bleeding
disorder diagnosis, mode of menstrual suppression in the first 30 days after
insertion, subjective reported bleeding profiles at follow-up, and any observed
complications. Bleeding patterns were categorized as amenorrheic, light,
normal, or heavy.
Chart review identified 24 IUD insertions in 22 adolescents.
First follow-up for all 24 insertions occurred approximately 30 days after
insertion (mean 30 days).
For patients initially seen at 30 days, a second follow-up
visit was reviewed to confirm at least 30-day compliance with menstrual
suppression, evaluate bleeding pattern, and assess IUD status.
Hormonal menstrual suppression was utilized for 22 of 24
(92%) insertions.
Menstrual suppression was shown to be effective, with 14 of
24 patients (58%) reporting light bleeding and seven of 24 patients (29%)
reporting amenorrhea.
Altogether, no early expulsions because of excess bleeding
were noted after any of the 24 IUD insertions. There were no expulsions because
of heavy bleeding before 30 days for 21 of 22 individuals. One individual with
type IIA von Willebrand disease had two expulsions (the first within 30 days of
insertion and the second within 4 months [137 days]), neither associated with
excessive bleeding.
Given the absence of HMB, expulsions in this youngest
individual in the cohort were likely attributable to uterine size. A subsequent
19.5-mg LNGIUD inserted 1 year later remained in place for >12 months. One
individual experienced partial expulsion in the setting of excess bleeding more
than 6 months after placement, supporting the relationship between heavy blood
flow and displacement of the IUD from the endometrial cavity. One IUD was
electively removed within 4 months because of cramping without excessive
bleeding. No other expulsions were observed at the final follow-up. This
includes five individuals evaluated through 6 months and 11 individuals
followed through 12 months.
At final follow-up, for those whose IUDs remained in place,
bleeding was well controlled; 11 of 19 (58%) had amenorrhea and seven of 19
(36%) had light bleeding. In addition, there was no uterine perforation,
hemorrhage, or bleeding that required further hemostatic interventions.
No early (≤30 days after insertion) IUD expulsions because
of heavy bleeding were observed. If the risk for IUD expulsion in IBDs is
decreased during the first menses following insertion, the LNG-IUD’s favorable
bleeding profile may contribute to lower rates of late expulsion once patients
experience a reduction in monthly blood loss. While acknowledging that this
study is limited by loss of follow-up and subjective assessment of bleeding
profile improvement, the absence of early expulsion observed here in the
context of menstrual suppression is a promising improvement over similarly
sized studies that have reported higher rates of IUD expulsion in adolescents
with IBDs. The LNG-IUD is a safe and effective method of managing HMB in
adolescents with IBDs. Concurrent menstrual suppression for at least 30 days
after insertion, to prevent bleeding-related early expulsion in this
population, may maximize safety and minimize complications for this at-risk
group.
Source: CYGAN et al.; Int J Gynecol Obstet. 2024;00:1–4.
DOI: 10.1002/ijgo.16063
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