EXECUTIVE SUMMARY
Adolescents and adults with endometriosis or menstrual cramping can alleviate their symptoms by using a hormonal intrauterine device (IUD) or another type of hormonal contraceptive.
- The levonorgestrel IUD and the contraceptive patch can improve dysmenorrhea.
- Hormonal implants also can reduce cramping and cyclical menstrual pain and discomfort.
- Providers should discuss with adolescent patients and their guardians how some contraceptives can alleviate menstrual pain.
Research suggests hormonal intrauterine devices (IUDs) can relieve pelvic pain and endometriosis.1-4
One recent study revealed that levonorgestrel IUDs (LNG-IUDs) can improve endometriosis and ovarian function when combined with gonadotropin-releasing hormone agonists. They also can alleviate the symptoms of sexual intercourse pain and dysmenorrhea and control the risk of postoperative recurrence.3
The authors of a different study found benefits of LNG-IUDs for adolescents, including the noncontraceptive benefits of treating heavy menstrual bleeding, dysmenorrhea, pelvic pain, and endometriosis.4
Endometriosis can cause severe pain, and clinicians should be sensitive to helping patients find solutions, says Robert A. Hatcher, MD, chairman of the Contraceptive Technology Update editorial board and professor emeritus in gynecology and obstetrics at Emory University.
IUDs, implants, birth control pills, and Depo-Provera can all decrease symptoms related to endometriosis, Hatcher adds. Pain related to endometriosis can be incapacitating. “In fact, in some women, the pain from endometriosis was as bad as pain they had experienced from delivering a baby.”
“I’ve talked to large groups of women in courses we do for contraception. When we’re talking about menstrual cycle contraception, I asked all the people in the room how many had endometriosis,” Hatcher recalls. “At each conference, several people who previously delivered one child and who also experienced pain from endometriosis said pain from endometriosis was worse than pain from labor and delivery. When people talk about Depo-Provera [injections], levonorgestrel IUD, combined birth control pills, and implants, they tend not to stress the effects of those contraceptives that are not contraceptive benefits.”
Reproductive health providers need to let patients know that suffering from endometriosis could be alleviated with several hormonal contraceptives. The contraceptive implant can help patients with endometriosis and the pain it causes, says Sarah Pitts, MD, co-director of the adolescent/young adult LARC program in the division of adolescent/young adult medicine at Boston Children’s Hospital. Pitts also is a professor of pediatrics at Harvard Medical School.
“Some people who have endometriosis are treated successfully, even with a typical birth control pill, and some will go on a progestin-only agent,” Pitts says. “The Depo shot suppresses women’s own estrogen production the most. With IUDs and implants, they’re still making some estrogen. That’s not a bad thing from a bone health standpoint.”
LNG-IUDs and hormonal implants also can relieve cramping and cyclical menstrual pain and discomfort. “If you’re having less bleeding and not ovulating [with an implant], you’re also having less cramping, and you’re having less pain,” Pitts adds.
Menstrual Management for Teens
Some adolescents who are not sexually active use hormonal contraception to help them manage irregular and painful periods. “Continuation rates for both the IUD and implant are excellent,” Pitts says.
The 52 mg LNG-IUD can alleviate this pain, says Mitchell Creinin, MD, a professor and director of the Complex Family Planning Fellowship at University of California, Davis Health.
“For people with known endometriosis, it really is a great benefit,” Creinin. “In a study of prolonged use over five years for people who have dysmenorrhea, it was a known benefit — reducing pain, flow, and everything associated with menstruation.”
Adolescents often welcome hormonal IUDs to curb menstrual pain, even if they are not sexually active, says Monica Woll Rosen, MD, an assistant professor in the department of obstetrics and gynecology at the University of Michigan.
“We put in IUDs all the time, especially in adolescents who are not sexually active, for heavy menstrual bleeding and menorrhea,” Rosen says. “There is significantly less bleeding and pain associated with it.”
The American Academy of Pediatrics recommends LARC for adolescents to prevent pregnancy and to reduce menstrual blood flow and dysmenorrhea.5 “Doctors should know that nobody should suffer from having painful periods,” Rosen says. “It is something very easily treatable, with many different options for treatment. If pediatricians don’t feel comfortable treating it, they should refer patients to a gynecologist for further management.”
When clinicians work with youth younger than age 18 years, they should talk with parents about contraceptives and the difference between treating someone with contraception vs. treating them for heavy or painful periods.
“There is not a contradiction in any state for treating patients for painful periods, so we emphasize we don’t use [LARC] only for birth control, and they can be used for many other indications, as well,” Rosen explains.
The LNG-IUD also is a good option for pain prevention among patients in their 20s. “Not uncommonly, I see a lot of early-20s women or women in their middle 20s who have pretty severe, chronic pelvic pain, especially with their periods,” says Stephanie Delkoski, DNP, APRN, WHNP-BC, a clinical assistant professor at the University of Minnesota School of Nursing. “A lot of their pain lingers, including pain with intercourse and periods, but some received really good relief with contraceptive methods. The LNG-IUD worked best for them.”
Discuss Expectations Around Pain
Clinicians should be aware of the short-term pain some patients experience with IUD insertion and help prepare patients for that. “Most women report there is mild to moderate discomfort with placement, but it’s short in duration,” says Jeffrey T. Jensen, MD, MPH, a professor and vice chair of research in the department of obstetrics and gynecology at Oregon Health & Science University. “We’re honest about that. I had a patient yesterday, and I told her what to expect. At the end of the procedure, it was more painful than she expected.”
One problem is how IUD insertion pain is discussed on social media. “Someone will go on and describe their whole experience in great detail, and you see that with childbirth, as well,” Jensen explains. “There’s an absence of good strategies to completely manage that.”
Providers need experience to place these devices with minimal discomfort to patients. They should take time to discuss patients’ expectations about the pain. “We’re doing a procedure with long-lasting benefit, and it will reduce menstrual pain,” Jensen says. “If we can get through that, this two-minute procedure will have long-lasting benefit.”
REFERENCES
- Zieman M, Hatcher RA, Allen AZ, Haddad L. Managing Contraception 2021-2022. 16th Edition. Bridging the Gap Foundation.
- Hatcher RA, Nelson AL, Trussell J, et al. Contraceptive Technology. 21st Edition. Ayer Company Publishers, Inc. 2018.
- Fenghua Y, Rong S, Juan S, Guan L. Effect of Mirena intrauterine device combined with GNRH-A on endometriosis, sex hormone level and carbohydrate antigen 125. Cell Mol Biol (Noisy-le-grand) 2022;68: 22-26.
- Adeyemi-Fowode OA, Bercaw-Pratt JL. Intrauterine devices: Effective contraception with noncontraceptive benefits for adolescents. J Pediatr Adolesc Gynecol 2019;32:S2-S6.
- HealthyChildren.org. American Academy of Pediatrics updated recommendations on contraception and adolescents. July 20, 2020.
Research suggests hormonal intrauterine devices (IUDs) can relieve pelvic pain and endometriosis. One recent study revealed that levonorgestrel IUDs can improve endometriosis and ovarian function when combined with gonadotropin-releasing hormone agonists. They also can alleviate the symptoms of sexual intercourse pain and dysmenorrhea and control the risk of postoperative recurrence.
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