Malposition and expulsion of the levonorgestrel intrauterine system among women with inherited bleeding disorders

Abstract

The levonorgestrel-releasing intrauterine system (LNG-IUS) is indicated for the management of menorrhagia and for contraception. The LNG-IUS is effective at reducing menstrual bleeding and improving haemoglobin among women with bleeding disorders. Expulsion rates for the LNG-IUS among normal women are reported to be approximately 5-10%. The aim of this study was to examine the malposition and expulsion rates of the LNG-IUS among women with inherited bleeding disorders. We conducted a retrospective study of women with an inherited bleeding disorder in Kingston, Canada treated with an LNG-IUS between May 2005 and June 2012. The primary outcome was a combined endpoint of expulsion and/or malposition. Predetermined secondary outcomes were patient satisfaction and changes in haemoglobin and ferritin levels. The median age of the women at the time of LNG-IUS insertion was 31 years (range 18-43, mean 32.1 years). The most common diagnosis was type 1 VWD (12/20, 60%). There were three LNG-IUS expulsions and two episodes of device malposition resulting in removal [5/20 (25.0%), 95% CI 11.2-46.9%]. An additional five women had their device removed prematurely. The overall proportion of devices resulting in discontinuation in this population was 10/20 (50.0%, 95% CI 29.9-70.1%). In this retrospective study, a significant proportion of women with an inherited bleeding disorder had an LGN-IUS removed due to poor patient satisfaction, malposition, or expulsion. Further studies into the causes of higher complication rates and interventions such as premedication or prolonged treatment with antifibrinolytic agents targeted at improving outcomes in this population are required.

Disorders of Menstruation in Adolescent Girls

“…If an LIUS is inserted, the expulsion rate may be higher than usual. 57 If NSAIDs are to be used for dysmenorrhea, the hematologist should know and they should be used for only a couple of days each month to avoid aggravating hemostasis with platelet dysfunction. Sometimes hematologists prescribe desmopressin acetate (DDAVP) if the teen is a DDAVP responder.…”

Heavy menstrual bleeding in women with inherited bleeding disorders

“…Expulsion rates among women without an inherited bleeding disorder have been reported to be approximately 5%‐10% and 8% in women with IBD . In a small retrospective study, three expulsions and two device malpositions were reported among 20 women with inherited bleeding disorders . Prolonged therapy with tranexamic acid may be beneficial in preventing expulsion among these women as is the use of specific haemostatic therapies directed at controlling bleeding around the time of LNG‐IUS insertion …”

A 24-year-old woman with heavy menstrual bleeding

“…The patient was also referred to a gynecologist affiliated with the hemophilia treatment centre, who inserted a progesterone-eluting intrauterine device under hemostatic coverage with desmopressin, to decrease the risk of its expulsion. 14 The patient received resources containing additional information about her illness and emergency medical treatment and was connected to the Canadian Hemophilia Society for additional support and registered for continued follow-up.…”