A 32-year-old multiparous woman requests long-acting reversible contraception. She has a history of dysmenorrhoea and menorrhagia. Regarding the choice between Cu-IUCD and levonorgestrel-releasing intrauterine system (LNG-IUS), all of the following statements are correct EXCEPT:

Explanation

## Cu-IUCD vs LNG-IUS: Clinical Differentiation ### Correct Statements (Options 0, 1, 3) **Option 0 — LNG-IUS and menorrhagia:** **High-Yield:** The LNG-IUS (Mirena) is the gold standard for women with menorrhagia and dysmenorrhoea. It reduces menstrual blood loss by 50–90% over 3–6 months through endometrial atrophy and suppression of prostaglandin synthesis. This is a major advantage over Cu-IUCD in this clinical scenario. **Option 1 — Cu-IUCD and menstrual changes:** **Key Point:** Cu-IUCDs typically increase menstrual blood loss by 20–30% in the first 3–6 months due to increased endometrial prostaglandin production and local inflammatory response. This is a well-documented side effect and a major disadvantage in women with baseline menorrhagia. **Option 3 — LNG-IUS and breast cancer:** **Clinical Pearl:** The LNG-IUS releases levonorgestrel systemically (unlike Cu-IUCD, which is purely local). WHO classifies LNG-IUS as **Category 4** (contraindicated) in women with current or recent (within 5 years) breast cancer due to the systemic progestin effect and potential to stimulate estrogen-dependent breast tissue. This is an important absolute contraindication. ### Incorrect Statement (Option 2 — The Answer) **Warning:** This statement contains a critical error regarding ectopic pregnancy risk. **Ectopic pregnancy rates with IUCDs:** 1. **Cu-IUCD:** Ectopic pregnancy rate ≈ 0.3–0.4 per 100 woman-years (very low absolute risk, but accounts for ~5–10% of all pregnancies that occur). 2. **LNG-IUS:** Ectopic pregnancy rate ≈ 0.02–0.05 per 100 woman-years (significantly LOWER than Cu-IUCD). **Why the difference?** - **Cu-IUCD:** Primarily prevents intrauterine pregnancy through sperm immobilization; tubal pregnancy prevention is less effective. - **LNG-IUS:** Systemic and local progestin effects thicken cervical mucus, suppress ovulation (in some cycles), and alter tubal motility — providing dual protection against both intrauterine and ectopic pregnancy. **Mnemonic:** **LNG > Cu for ectopic protection** = Levonorgestrel's systemic effect provides Greater protection against both intrauterine AND tubal pregnancy, whereas Copper is primarily local and less effective at preventing ectopic pregnancy. ## Comparative Table: Cu-IUCD vs LNG-IUS in Menorrhagia | Feature | Cu-IUCD | LNG-IUS | | --- | --- | --- | | **Effect on menstrual bleeding** | Increases 20–30% | Decreases 50–90% | | **Effect on dysmenorrhoea** | May worsen | Improves significantly | | **Ectopic pregnancy rate (per 100 WY)** | 0.3–0.4 | 0.02–0.05 | | **Systemic progestin effect** | None (local only) | Yes (significant) | | **Contraindication: Breast cancer** | No | Yes (Category 4) | | **Best choice for menorrhagia** | No | Yes | **Clinical Decision:** In this patient with menorrhagia and dysmenorrhoea, **LNG-IUS is clearly superior** to Cu-IUCD because it reduces bleeding and pain while providing excellent contraception. However, breast cancer history would be an absolute contraindication to LNG-IUS. [cite:WHO Medical Eligibility Criteria 5e; NFOG Contraception Guidelines 2022; Harrison 21e Ch 297]