Original StudiesIntrauterine Device Outcomes in Young Women with Heavy Menstrual Bleeding: Comparing Patients with and without Inherited Bleeding Disorders
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
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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.
References (19)
- et al.
Heavy menstrual bleeding in adolescents
J Pediatr Adolesc Gynecol
(2017) - et al.
Intrauterine devices: effective contraception with noncontraceptive benefits for adolescents
J Pediatr Adolesc Gynecol
(2019) - et al.
Standardizing care to manage bleeding disorders in adolescents with heavy menses—A joint project from the ISTH pediatric/neonatal and women's health SSCs
J Thromb Haemost
(2020) - et al.
Levonorgestrel-releasing intrauterine system for the management of heavy menstrual bleeding in women with inherited bleeding disorders: long-term follow-up
Contraception
(2011) - et al.
Retrospective review of intrauterine device in adolescent and young women
J Pediatr Adolesc Gynecol
(2012) - et al.
Efficacy, acceptability and side effects of the levonorgestrel intrauterine system for menorrhagia
Int J Gynaecol Obstet
(2007) - et al.
The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review
BJOG
(2001) - et al.
Levonorgestrel-releasing intrauterine device use in female adolescents with heavy menstrual bleeding and bleeding disorders: single institution review
J Pediatr Adolesc Gynecol
(2017) - et al.
Rates of intrauterine device expulsion among adolescents and young women
J Pediatr Adolesc Gynecol
(2021)
Cited by (0)
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.