74. Use of the Levonorgestrel Intrauterine System in Adolescents and Young Adults with Heavy Menstrual Bleeding Due to a Bleeding Diathesis

Abstract

Background Heavy menstrual bleeding (HMB) is a common problem among adolescent girls, exacerbated by Inherited Bleeding Disorders (IBD) and Joint Hypermobility (JH), including Ehlers-Danlos Syndrome (EDS). Studies have examined use of the levonorgestrel intrauterine system (LNG-IUS) in adult women with IBDs, showing reduction in menstrual blood loss and high continuation rates, but questions remain regarding rates of IUS expulsion and need for hemostatic agents with insertion. A few studies have addressed teens with IBDs or JH and LNG-IUS, reinforcing positive outcomes. However, study sizes were small, limiting conclusions regarding bleeding profiles, IUS expulsion, and long-term continuation. The objective of this study was to report on our patients with HMB and a bleeding diathesis using the LNG-IUS, including post-IUS bleeding profiles, rates of IUS expulsion and long-term continuation. Methods After IRB approval, we conducted a retrospective review of females, ages 12-25, who presented to our multidisciplinary bleeding clinic with HMB. Charts were selected using ICD-10 codes for HMB and diagnosis of an IBD or JH Disorder, treated with the LNG-IUS. Data was extracted from the chart by a single provider, including demographics, bleeding diagnosis, bleeding profiles before and after insertion, medications prescribed, continuation rate, and complications. Primary outcome was bleeding pattern after insertion. Secondary outcomes included rates of IUD expulsion and continuation. Descriptive statistics were reported as means, ranges and frequencies. LNG-IUS continuation rates were recorded and used to construct a survival graph. Results 35 patients met inclusion criteria. Mean age at menarche was 11.6. Mean age at insertion was 16.9 (range 11-23); majority were Caucasian (73.3%). Von Willebrand Disease was present in 16 patients (45.7%) and JH Disorders in 12 (34.3%, Table 1). Majority (91.4%) had tried at least one hormonal regimen prior to LNG-IUS. Follow up bleeding data was available on 33 patients (Table 1); one patient was excluded for same-day removal and one for removal at 2 weeks for cramping. Majority (81.8%) reported improvement in bleeding, with 60.6% reporting spotting or amenorrhea. IUS expulsion occurred in 3 patients (9.1%) despite hemostatic agents administered at insertion. Mean continuation was 5.08 years (95% CI 4.24-5.92), with 79% likelihood that patients kept their IUD in place for at least 2.5 years, and some up to 6 years (Figure 1). Conclusions The LNG-IUS is an effective treatment for adolescents and young adults with HMB and a bleeding diathesis, with high rates of amenorrhea. Rates of IUD expulsion appear higher than the general population during first 30 days, but long-term continuation rates remain high.