A 28-year-old woman with a history of heavy menstrual bleeding (HMB) and dysmenorrhoea presents to the contraception clinic. She has completed her family and seeks long-acting reversible contraception. Pelvic examination and transvaginal ultrasound are normal. She is counselled about both copper IUCD and levonorgestrel-releasing IUCD (LNG-IUS). What is the most appropriate next step in management?

Explanation

## Choosing the Optimal IUCD for Heavy Menstrual Bleeding **Key Point:** In a woman with HMB and dysmenorrhoea seeking long-acting contraception, the levonorgestrel-releasing IUCD (LNG-IUS) is the device of choice because it addresses both contraceptive and therapeutic needs. ### Comparison: Copper IUCD vs. LNG-IUS in HMB | Feature | Copper IUCD | LNG-IUS | |---------|-------------|----------| | **Effect on menstrual blood loss** | Increases by 20–30% | Reduces by 40–60% | | **Effect on dysmenorrhoea** | May worsen | Improves significantly | | **Contraceptive efficacy** | 99.2% (0.8 failures/100 woman-years) | 99.8% (0.2 failures/100 woman-years) | | **Suitable for HMB?** | **Contraindicated** | **First-line** | | **Suitable for dysmenorrhoea?** | Worsens symptoms | Alleviates symptoms | | **Cost** | Lower | Higher | **High-Yield:** LNG-IUS is listed as a **first-line treatment for HMB** in international guidelines (NICE, ACOG, FIGO) and provides dual benefit: contraception + therapeutic effect. ### Why LNG-IUS Is Optimal Here 1. **Therapeutic benefit:** Reduces menstrual blood loss by 40–60% within 3–6 months 2. **Symptom relief:** Improves dysmenorrhoea in >80% of users 3. **Contraceptive efficacy:** Highest among reversible methods (99.8%) 4. **Convenience:** Single insertion; effective for 5–7 years (depending on product) 5. **Addresses the patient's chief complaint:** HMB and dysmenorrhoea, not just contraception **Clinical Pearl:** The LNG-IUS is so effective for HMB that it is often used as a **first-line medical treatment** even in women not seeking contraception, as an alternative to hysterectomy or other surgical interventions. ### Why Copper IUCD Is Inappropriate **Warning:** Inserting a copper IUCD in a woman with HMB will **worsen menstrual bleeding** and dysmenorrhoea, making her symptoms intolerable and likely leading to early removal. This violates the principle of "first, do no harm." ```mermaid flowchart TD A["Woman with HMB + dysmenorrhoea seeking LARC"]:::outcome --> B{"Uterus normal?"}:::decision B -->|"Yes"| C{"Which IUCD?"}:::decision B -->|"No (fibroid, adenomyosis)"| D["Manage underlying pathology first"]:::action C -->|"Copper IUCD"| E["Worsens HMB + dysmenorrhoea"]:::urgent C -->|"LNG-IUS"| F["Reduces HMB, improves dysmenorrhoea"]:::action E --> G["Early removal; patient dissatisfaction"]:::urgent F --> H["Improved quality of life + contraception"]:::outcome ``` **Mnemonic:** **HMB + IUD = LNG-IUS** (not copper). Copper worsens bleeding; LNG-IUS heals it. [cite:NICE NG30 Contraception; Park 26e Ch 10]