Menorrhagia, Bleeding Disorders, and the Levonorgestrel IUD

Abstract & Commentary

By Frank W. Ling, MD, Clinical Professor, Dept. of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, TN, is Associate Editor for OB/GYN Clinical Alert

Dr. Ling reports no financial relationship to this field of study.

Synopsis: In a group of women with inherited bleeding disorders, improvement of menorrhagia and amenorrhea was seen in more than half of the group along with an increase in hemoglobin concentration.

Source: Kingman CE, et al. The use of levonorgestrel-releasing intrauterine system for treatment of menorrhagia in women with inherited bleeding disorders. BJOG. 2004;111:1425-1428.

This is a prospective trial in which the levonorgestrel-releasing IUD was used in 16 patients who had an inherited bleeding disorder including 13 with von Willebrand’s disease and 2 with factor XI deficiency. No pelvic pathology was identified in any patient. All previous therapies had been unsuccessful. The follow-up for patients was for 9 months, with all patients having an improvement in menorrhagia with 56% becoming amenorrheic.

Commentary

I call your attention to a related article that looked at 115 women with menorrhagia, of whom 25 were adolescents, 25 were perimenopausal women, and 65 were reproductive-aged. Hemostatic abnormalities were identified in 47%. Of note, adolescents and perimenopausal patients were as likely to have a clotting abnormality as a reproductive-aged patient.1

These 2 articles are an important reminder to a precept that we all learned in medical school. In particular in adolescents first starting their periods, menorrhagia should be a potential symptom of an underlying bleeding disorder. In this age patient, it certainly makes sense since the periods are heavy from the onset of periods, reflecting a heretofore unknown problem. We should not be lulled into a false sense of security, however, just because the woman is at reproductive age or even perimenopausal. Bleeding abnormalities appear to be just as likely later on in life when a thorough investigation is initiated.

So let’s work our way back to the topic of levonorgestrel-releasing IUD’s. With another apparently effective treatment modality for menorrhagia, (in addition to the likes of oral contraceptives, the contraceptive patch, depot-medroxyprogesterone acetate, endometrial ablation and hysterectomy) we shouldn’t forget that the underlying work-up to look for the etiology is still of primary importance. Before treatment is initiated, I want to re-emphasize the 4 traditional elements of diagnosis:

  1. History—make sure that the patient truly has menorrhagia, ie, are the periods predictable and heavy, otherwise it may well be dysfunctional anovulatory bleeding;
  2. Physical—determine if there is any palpable etiology of the heavy bleeding, eg, fibroids;
  3. Imaging—utilize cost-effective imaging including transvaginal ultrasound and possibly saline hysterosonography to identify fibroids and/or endometrial polyps, and;
  4. Laboratory—obtain baseline blood count as well as clotting studies to rule out a bleeding disorder.

It is with this return to basics of menorrhagia diagnosis, that the most logical treatment options can be offered patients of any age. Certainly it appears that the levonorgestrel-releasing IUD will become one of the options we need to offer our patients.

Reference

  1. Philipp CS, et al. Age and prevalence of bleeding disorders in women with menorrhagia. Obstet Gynecol. 2005;105:61-66.