A 28-year-old nulliparous woman attends the family planning clinic seeking long-acting reversible contraception. She has a regular 28-day menstrual cycle with moderate menorrhagia (using 8–10 pads per day). She has no history of pelvic inflammatory disease, ectopic pregnancy, or sexually transmitted infections. On examination, her uterus is normal in size and shape. She asks about both copper and hormonal IUCDs. Which IUCD would be most appropriate for this patient, and why?

Explanation

## Clinical Context This patient has moderate menorrhagia with a regular cycle and no contraindications to IUCD insertion. The choice between copper and hormonal IUCD hinges on her menstrual pattern and side-effect profile. ## Why Levonorgestrel-Releasing IUCD (LNG-IUS) is Correct **Key Point:** The LNG-IUS is the ideal choice for women with menorrhagia because it reduces menstrual blood loss by 40–50% through endometrial suppression, while simultaneously providing excellent contraceptive efficacy (0.2 pregnancies per 100 woman-years) [cite:Park 26e Ch 34]. **Clinical Pearl:** In this patient, the LNG-IUS addresses two problems simultaneously: contraception AND management of excessive menstrual bleeding. This is a therapeutic advantage over the copper IUCD. **High-Yield:** The LNG-IUS is NOT contraindicated in nulliparous women — this is a common misconception. Modern evidence supports IUCD use in nulliparous women, including those with no prior vaginal delivery [cite:WHO Medical Eligibility Criteria 5e]. ## Comparison of Copper vs. Hormonal IUCD in This Case | Feature | Copper IUCD (Cu T 380A) | LNG-IUS | | --- | --- | --- | | **Efficacy** | 0.8 per 100 woman-years | 0.2 per 100 woman-years | | **Effect on menstruation** | Increases blood loss (10–15% heavier) | Decreases blood loss (40–50% reduction) | | **Systemic hormonal effects** | None | Minimal (mostly local) | | **Duration** | 10 years | 5–7 years | | **Cost** | Cheaper | More expensive | | **Nulliparity** | Acceptable | Acceptable | **Tip:** When a woman has BOTH contraceptive needs AND menorrhagia, always consider LNG-IUS first — it is therapeutic, not just contraceptive. ## Why Copper IUCD Would Worsen Her Condition Copper IUCDs increase menstrual blood loss in 10–15% of users, which would exacerbate her existing menorrhagia. This is a relative contraindication in her case.