A 35-year-old multiparous woman with a history of dysmenorrhoea and menorrhagia (soaking 6–8 pads per day for 6 days) requests long-acting contraception. She has no contraindications to hormonal methods and wishes to avoid surgical intervention. On examination, she has a normal uterine size and no adnexal masses. Pelvic ultrasound shows no fibroids or adenomyosis. She is counselled about both copper T380A and LNG-IUS. Which device is most appropriate for this patient, and why?

Explanation

## Clinical Appropriateness: IUCD Selection in Menorrhagia and Dysmenorrhoea ### Patient's Clinical Problem **Key Point:** This patient has two key issues: 1. **Menorrhagia** — heavy menstrual bleeding (>80 mL/cycle or soaking 6–8 pads/day) 2. **Dysmenorrhoea** — painful menses Both conditions are significantly worsened by copper T380A and improved by LNG-IUS. ### Comparison of IUCDs in Menorrhagia | Feature | Copper T380A | LNG-IUS | | --- | --- | --- | | **Effect on menstrual bleeding** | Increases by 20–30% (contraindicated in HMB) | Decreases by 60–70% (first-line for HMB) | | **Effect on dysmenorrhoea** | May worsen pain | Reduces pain by 50–70% | | **Mechanism of benefit** | N/A (harmful in HMB) | Endometrial atrophy + reduced prostaglandin synthesis | | **Efficacy in HMB** | Poor choice | Excellent (comparable to hysterectomy) | | **Return to fertility** | Immediate | Immediate (within 1–3 cycles) | | **Systemic hormone exposure** | None | Minimal (mostly local) | ### Why LNG-IUS is Superior in This Case **High-Yield:** LNG-IUS is the **first-line medical management** for heavy menstrual bleeding and dysmenorrhoea. It: 1. **Reduces menstrual blood loss** by 60–70% (often to <20 mL/cycle) 2. **Relieves dysmenorrhoea** through: - Endometrial atrophy (reduced prostaglandin production) - Decreased uterine contractility - Local anti-inflammatory effect 3. **Provides contraception** with efficacy >99% 4. **Avoids surgery** (hysterectomy, myomectomy) **Clinical Pearl:** In women with HMB and dysmenorrhoea, LNG-IUS is as effective as hysterectomy but preserves fertility and is reversible. It is the preferred first-line intervention before considering surgical options. ### Why Copper T380A is Inappropriate Here **Warning:** Copper T380A is **contraindicated in women with menorrhagia or dysmenorrhoea** because: - Increases menstrual blood loss by 20–30% (worsens her bleeding) - May increase dysmenorrhoea severity - Copper-induced endometrial inflammation increases prostaglandin synthesis - Would likely worsen her presenting complaint ### Mechanism of LNG-IUS Benefit in Dysmenorrhoea ```mermaid flowchart TD A[LNG-IUS inserted]:::action --> B[High local progestin concentration]:::outcome B --> C[Endometrial atrophy]:::outcome B --> D[Reduced prostaglandin synthesis]:::outcome C --> E[Decreased uterine contractility]:::outcome D --> F[Reduced myometrial sensitivity to prostaglandins]:::outcome E --> G[Pain relief]:::outcome F --> G C --> H[Reduced menstrual flow]:::outcome ``` **Key Point:** The local progestin effect suppresses endometrial prostaglandin production, which is the primary driver of dysmenorrhoea pain. ### Suitability in Multiparous Women **High-Yield:** Both copper T380A and LNG-IUS are suitable for multiparous women. Multiparity is *not* a contraindication to either device. In fact, multiparous women have higher continuation rates with IUCDs due to easier insertion and lower expulsion rates. [cite:Park 26e Ch 8; WHO Guideline on Menorrhagia Management (2019)]