Special Report: Contraception As Medicine
Contraception provides benefits beyond just preventing pregnancy. In this edition of Contraceptive Technology Update, we will focus on the medical benefits of contraception. This includes benefits from various contraceptive methods, including the three most effective reversible contraceptives: the contraceptive implant, the hormonal intrauterine device (IUD), and the copper IUD.
Modern contraception offers a variety of benefits to users, in addition to effective pregnancy prevention. Perhaps the most common noncontraceptive reasons people may select some of these hormonal methods is to reduce or stop menstrual bleeding, cramping, and pain.
The levonorgestrel intrauterine device (LNG-IUD) is among the more popular contraceptives for the goal of reducing or ending monthly periods. The LNG-IUD also provides a host of additional benefits to users, including reducing pain and cramping, preventing some cancers, and treating endometriosis.1,2
While the device is not a perfect fit for every woman, it offers the benefit of effective pregnancy prevention for up to eight years. The non-contraceptive benefits may last as long for some people.
“I love IUDs. They’re the single most impactful intervention that has occurred in my medical career, stretching back to 1985,” 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 in Portland. “The availability of the hormonal IUD and how many problems it has solved is extraordinary. It’s a fantastic system, but it’s not for everyone.”
Menstrual Management
For women with few complaints about menstrual discomfort other than bleeding, the contraceptive is useful for that purpose alone. Most people using a hormonal IUD, such as Mirena and Liletta, report lighter periods or no periods at all after an initial phase of irregular periods.1,2
“The [hormonal] IUD has a better benefit for bleeding than implants,” Jensen says. “It’s a very satisfactory choice for many women who say, ‘I don’t have a problem with my period, but having less of it is something I would like.’”
Decreasing menstrual flow is especially important for women with a significant or bothersome heavy flow, says Mitchell Creinin, MD, a professor and director of the Complex Family Planning Fellowship at the University of California, Davis Health. “Everyone judges their own flow,” he says.
Even when a patient’s menstrual bleeding does not affect blood count, it still could be bothersome. Clinicians should take note and help patients find a potential solution, such as a hormonal IUD. The copper IUD does not improve bleeding patterns.
“The levonorgestrel IUD is commonly used for management of menstrual cycles, particularly heavy bleeding,” says Stephanie Delkoski, DNP, APRN, WHNP-BC, a clinical assistant professor at the University of Minnesota School of Nursing. “But even with frequent menstrual bleeding or polymenorrhea, it can significantly reduce the amount of bleeding they’re having.” This is a nice option for patients who are experiencing anemia because of their bleeding, she notes.
The Mirena IUD is approved to treat heavy menstrual bleeding, and the Liletta IUD is expected to receive approval for this sometime in 2023. Creinin and co-investigators submitted a paper on a study of Liletta for heavy menstrual bleeding among Liletta users. The Mirena IUD study on menstrual bleeding took place about a decade ago.
“In our study, we had many obese users and nulliparous users who were not in the Mirena study,” Creinin explains. “These are people that have to lay a towel on their bed. They’re really heavy bleeders.”
Among this cohort, there was a 90% decrease in blood flow within three months, he adds.
In addition to decreasing blood flow, the LNG-IUD also decreased cramping and menstrual pain, Creinin says. For people with menstrual bleeding that is so severe it can affect their blood count, IUDs can help improve their anemia.
Contraceptive implants are an alternative long-acting reversible contraceptive (LARC) that can improve menstrual bleeding. “There is less overall bleeding with Nexplanon and more amenorrhea, which can be good,” says Robert A. Hatcher, MD, chairman of the Contraceptive Technology Update editorial board and professor emeritus in gynecology and obstetrics at Emory University. “People need to know that in the long haul, they are more likely to stop having any bleeding at all.” Most people can live with irregular periods once they know what to expect, he adds.
“For some people, it can be very effective in reducing overall bleeding,” 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 professor of pediatrics at Harvard Medical School. “It doesn’t happen for everyone. In the first three to six months, bleeding is more likely to be irregular, but it can get better over time. “
The main thing young patients need to know is how to work with their clinician to address irregular bleeding. If they can tolerate the early discomfort, they may have the experience of less or no bleeding they want, Pitts explains. The contraceptive implant, like other hormonal contraceptives, does not completely suppress bleeding because it is not the same as menopause.
“There are some women who make estrogen on their own even with the implant in, and that can have an impact on bleeding,” Pitts adds.
From a patient’s perspective, the LNG-IUD results in less menstrual pain and lighter to no periods. “It improves symptoms of heavy menstrual bleeding, and sometimes takes that away completely,” Hatcher says.
The hormonal IUD also improves symptoms of endometriosis, reduces pain, and decreases the risk of endometrial cancer. “It’s also true that, in the beginning, the IUD has more days of bleeding, and that could be considered a disadvantage for the first months,” Hatcher says. “But in the long run, the periods are less painful, and there are lighter or no periods.”
In clinical trials, Mirena and Liletta were shown to be effective as a contraceptive for up to eight years. Mirena also was evaluated for use in controlling heavy menstrual bleeding for eight years, but too few women with heavy bleeding enrolled in the study to evaluate that outcome, Jensen explains.
When patients experience menorrhagia or report uncomfortably heavy bleeding, clinicians may want to inform them that the levonorgestrel-releasing intrauterine system may be less effective at preventing heavy bleeding in later years of use.
“These studies give us the important news that if your reason for use is contraception, you can be extremely comfortable that it will work for eight years of use,” Jensen says. “If you’re uncomfortable with your bleeding problem, then you may need to change it out earlier.”
But for some women, the IUD may continue to provide favorable bleeding patterns in the sixth, seventh, and eighth year of use. “I saw one woman at the clinic yesterday [who is] doing well and will continue with the IUD through eight years of use,” Jensen recalls. “But for those who are not satisfied with bleeding, they shouldn’t say the system failed, but there is a dose-related effect on the endometrium. The relationship to bleeding is related.”
The results of a recent study revealed that levonorgestrel IUDs can work well for adolescent and young adult patients with an inherited bleeding disorder, as well as for those with heavy menstrual bleeding.3
“The anecdotal feedback I get from my patients are terms like ‘game-changer’ and ‘life-changing,’” says Sarah O’Brien, MD, MSc, study co-author and an associate professor of pediatrics on the hematology/oncology team at Nationwide Children’s Hospital in Columbus, OH. “It can have a positive impact on their quality of life.”
There are treatment options for patients with heavy menstrual bleeding and those uncomfortable with the irregular bleeding from the early months after IUD insertion. For example, if the patient was taking a hormonal birth control pill before IUD insertion, the clinician can ask if the patient would like to continue taking the pill for a few months to reduce their breakthrough bleeding.
“For those with bleeding disorders, the breakthrough bleeding can be more frequent and heavier,” O’Brien notes. Keeping those patients on the pill for four to six months can help with breakthrough bleeding, she adds.
Reproductive health providers, including pediatricians, should keep in mind that not all young patients seeking an IUD are sexually active. “Two-thirds of our patients were not sexually active,” O’Brien says.
Providers should open their eyes to the wide range of patients and conditions that contraception can help. For instance, contraceptives to reduce or prevent bleeding could be an appealing option to some patients with physical or mental disabilities and who find monthly bleeding a particular challenge.
“They may have a hard time changing menstrual pads,” Delkoski explains. “It could be bothersome for some people to see blood in that area, so using an IUD to decrease the amount of bleeding is a really nice fit for those patients.”
REFERENCES
- Zieman M, Hatcher RA, Allen AZ, Haddad L. Managing Contraception 2021-2022. 16th Edition. Bridging the Gap Foundation.
- Cwiak C, Edelman A. Cobined oral contraceptives (COCs). Contraceptive Technology. 21st Edition. Ayer Company Publishers, Inc. 2018.
- Kendel NE, Zia A, Rosenbaum LE, et al. Intrauterine device outcomes in young women with heavy menstrual bleeding: Comparing patients with and without inherited bleeding disorders. J Pediatr Adolesc Gynecol 2022;35:653-658.
Modern contraception offers a variety of benefits to users, in addition to effective pregnancy prevention. Perhaps the most common noncontraceptive reasons people may select some of these hormonal methods is to reduce or stop menstrual bleeding, cramping, and pain.
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