Contraception for Menorrhagia and Dysmenorrhea

Primary Recommendation: Levonorgestrel IUD (LNG-IUD)

The American College of Obstetricians and Gynecologists recommends the levonorgestrel-releasing IUD as a highly effective contraceptive method that also treats menorrhagia and dysmenorrhea, with a reduction in menstrual blood loss of 71-95% 1, 2, 3
The Centers for Disease Control and Prevention (CDC) classifies the LNG-IUD as Category 1 for women with heavy or prolonged bleeding, noting its potential as a useful treatment for menorrhagia, with evidence demonstrating its benefits and no increase in adverse effects 1
The LNG-IUD decreases dysmenorrhea significantly, with evidence showing reduction in menstrual pain comparable or superior to oral contraceptives, providing highly effective long-term contraception for up to 5 years 1, 2

Combined Oral Contraceptives (COCs) reduce menstrual blood loss and dysmenorrhea, but have important limitations, including daily adherence requirements, increased risk of venous thromboembolism (VTE), and less effective reduction in menstrual blood loss compared to the LNG-IUD 3, 4, 5, 6
Depo-Provera/DMPA is less appropriate as a first-line option due to initial irregular bleeding patterns, significant weight gain, and bone mineral density loss 5
NSAIDs alone are not a contraceptive method and do not address the patient's primary request for contraception, although they can reduce menstrual blood loss and dysmenorrhea when used during menses 2

The LNG-IUD can be inserted at any time if reasonably certain the patient is not pregnant, with backup contraception recommended if inserted more than 7 days after menstrual bleeding started 7, 3
Counseling points include expected unscheduled spotting or light bleeding during the first 3-6 months, decreased bleeding over time, and the reassurance that amenorrhea with LNG-IUD is not harmful and does not require treatment 8, 2