Original Studies
Intrauterine Device Outcomes in Young Women with Heavy Menstrual Bleeding: Comparing Patients with and without Inherited Bleeding Disorders

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ABSTRACT

Study Objective

To evaluate the use of intrauterine devices (IUDs) in two young women's hematology clinics and compare adverse events in adolescents with and without inherited bleeding disorders (BDs)

Design

Retrospective multicenter cohort study from February 2014 through February 2020

Setting

Young women's hematology clinics at Nationwide Children's Hospital in Columbus, Ohio, and Children's Medical Center in Dallas, Texas

Participants

Female patients evaluated for heavy menstrual bleeding (HMB) who underwent IUD placement

Interventions and Main Outcome Measures

Rates of IUD expulsion, malposition, and ongoing HMB requiring additional medical treatment

Results

We identified 43 patients with BDs and 35 patients without BDs who underwent placement of an IUD for HMB. The mean age was 14.9 years (range 11.0-21.4 years) at the time of presentation and 15.8 years (range 11.0-21.4 years) at IUD placement. Those with BDs were younger at the time of IUD insertion. Most patients (90%) had previously failed other methods to control HMB. The annual rate of IUD adverse events was 0.25 per year of use, and all adverse events occurred in the first 20 months after placement. There were no significant differences in adverse IUD events in patients with and without BDs, although those without BDs requested IUD removal more frequently.

Conclusions

In this cohort of adolescent females, the presence of a BD was not associated with a higher IUD expulsion rate. IUD placement should be considered a first-line option for adolescents with BDs who experience HMB.

Introduction

Heavy menstrual bleeding (HMB) is a common reason adolescent females seek medical care, with an estimated prevalence as high as 37%.1 Although an immature hypothalamic-pituitary-ovarian axis is the most common etiology of HMB, inherited bleeding disorders (BDs) are diagnosed in an estimated 20-30% of adolescents presenting for evaluation of HMB.2,3 Given the high rate of BDs within this population, management of HMB can be challenging.

Numerous options are available for medical management of HMB in adolescent females, ranging from combination oral contraceptive pills to levonorgestrel-releasing intrauterine devices (LNG-IUDs).2 Current guidelines recommend administering estrogen-containing or progesterone-only hormones to manage short-term bleeding episodes. Once bleeding is controlled, patients can be transitioned to maintenance therapy, typically following a taper from the initial hormonal regimen. Long-acting reversible contraceptives, including LNG-IUDs, are particularly attractive for adolescent patients given their high efficacy and minimal user responsibility.4

LNG-IUDs were deemed an appropriate first-line treatment of HMB in BDs by an international panel of experts in hematology, adolescent medicine, and obstetrics-gynecology, endorsed by the International Society of Thrombosis and Haemostasis; however, this is based on expert opinion.5 The current literature in adult women with BDs is conflicting, with some studies showing higher rates of IUD expulsion and others with rates comparable to that of the general public, between 3 and 10%.6., 7., 8., 9., 10. Even less is known about the use of LNG-IUDs for treating HMB in adolescents with BDs. Prior data suggested that expulsion rates are higher in the general adolescent population compared with their adult counterparts, regardless of parity.11 This study, however, did not evaluate for differences in those with and without BDs. Additional studies regarding the use of LNG-IUDs in adolescent females with BDs are limited by small sample sizes.12,13

We sought to evaluate the use of LNG-IUDs in two young women's hematology clinics and to compare adverse events in adolescents with and without inherited BDs. We specifically examined rates of IUD expulsion, malposition, and ongoing heavy bleeding requiring additional medical treatment. Prior data have shown an increased risk of IUD expulsion with both adolescent patients and history of HMB; therefore, we hypothesized that rates of IUD expulsion would be higher in adolescents diagnosed with BDs than those without BDs.11

Section snippets

Materials and Methods

We performed a multicenter retrospective cohort study of adolescents presenting to young women's hematology clinics at Nationwide Children's Hospital in Columbus, Ohio, and Children's Medical Center in Dallas, Texas. These interdisciplinary clinics combine the expertise of hematology and reproductive health providers to care for patients with abnormal uterine bleeding concerning for a BD. All new patients presenting with HMB at both clinics are offered enrollment in an HMB research registry or

Results

We identified 78 adolescent females with HMB who underwent IUD placement at a mean age of 15.8 years (range 11.0 to 21.4 years) (Table 1). Patient-reported races were 74% White, 15% African American, and 6% multiracial. Nine percent of patients reported Hispanic ethnicity. Approximately half of the participants were diagnosed with a BD (n = 43), with the most common diagnoses being bleeding tendency due to joint hypermobility/Ehlers-Danlos syndrome (35%), von Willebrand disease/low von

Discussion

In this population of young women presenting to multidisciplinary clinics for evaluation and management of HMB, 10% of women experienced IUD expulsion, with an additional 10% requesting device removal due to pain, bleeding, or patient preference. Adolescents with BDs were younger at the time of IUD insertion compared with those without BDs. Although there was no significant difference in rates of adverse IUD events, those with BDs were less likely to request removal than those without BDs.

Conclusion

In this pediatric cohort, the presence of a BD was not associated with higher IUD expulsion rates than healthy peers with HMB. Our findings should help guide IUD counseling and informed decision-making in this unique patient population. Long-acting reversible contraceptives should be discussed as first-line options in adolescents with HMB and BD as part of the decision-making process. However, young women should be counseled that breakthrough bleeding is common and may require intervention in

Conflicts of Interest Statement

The authors have no conflicts of interest to declare.

Funding

No specific funding was received for this work.

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This work was presented virtually as a poster at the 62nd American Society of Hematology Annual Meeting and Exposition on December 5-8, 2020, due to the COVID-19 pandemic.

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