A 28-year-old nulliparous woman from Delhi presents to the family planning clinic requesting long-acting reversible contraception. She has a regular menstrual cycle (28 days, 4-day duration) and no history of pelvic inflammatory disease or sexually transmitted infections. On examination, her uterus is normal size and anteverted. She is concerned about heavy menstrual bleeding as her sister experienced after copper IUCD insertion. Which IUCD would be most appropriate for this patient?

Explanation

## Clinical Rationale **Key Point:** The levonorgestrel-releasing IUCD (LNG-IUS) is the ideal choice for this patient because it reduces menstrual blood loss, whereas copper IUCDs increase it—a critical consideration given her family history of heavy menstrual bleeding. ## Comparison of IUCD Types | Feature | Copper IUCD (TCu 380A) | LNG-IUS | Progesterone IUCD | |---------|----------------------|---------|-------------------| | **Mechanism** | Foreign body + copper ions | Hormonal (progestin) | Hormonal (progesterone) | | **Menstrual bleeding** | Increases 20–30% | Decreases 50–90% | Decreases moderately | | **Duration** | 10–12 years | 5–7 years (Mirena) | 1–2 years | | **Systemic absorption** | Minimal | Low (mostly local) | Minimal | | **Cost** | Low | High | Moderate | | **Nulliparity** | Safe | Safe | Safe | ## Why LNG-IUS for This Patient 1. **Menorrhagia prevention:** The patient has a family history of heavy bleeding post-copper IUCD. LNG-IUS actually reduces menstrual blood loss by 50–90% through endometrial suppression. 2. **Long-acting reversibility:** Provides 5–7 years of contraception (Mirena) with rapid return to fertility. 3. **No contraindications:** Nulliparity is not a contraindication; the uterus is normal size. 4. **Additional benefits:** May improve dysmenorrhea and reduce ovarian cyst formation. **High-Yield:** LNG-IUS is contraindicated in current or recent breast cancer (within 5 years) and undiagnosed abnormal uterine bleeding, but neither applies here. **Clinical Pearl:** Copper IUCDs increase menstrual flow by 20–30% on average; this is a known side effect and a reason for discontinuation in 5–10% of users. The LNG-IUS is the antidote to this problem.