Case 1: A 26-Year-Old Woman With Heavy Periods

History and Presentation

Megan, a married 26-year-old executive assistant, leads an active life, including
caring for her 2 children under the age of 6. She was recently diagnosed with
ulcerative colitis, but has had no surgery and controls the condition with topical
mesalamine. Megan has no other chronic or significant illnesses and is a nonsmoker.
Recently, her periods have become heavier, causing her concern, and she asks to
switch from a copper IUD to another contraceptive method.

Vital signs

Blood pressure (BP): 122/70 mm Hg

Body mass index (BMI): 24 kg/m2

Current medications

Topical mesalamine: 4 g daily for ulcerative colitis

Prednisone: 30 mg, as needed, to treat flare-ups

Selection Rationale
A. VIABLE OPTION. Previously, providers had no guidance for managing women
with inflammatory bowel disease (IBD) who require contraception. The US MEC
includes IBD (ulcerative colitis, Crohns disease) as a medical condition associated
with increased risk in some circumstances [SLIDE 8].5 The use of COCs/patch/ring is
assigned a category of 2 for mild IBD and 3 for IBD with venous thromboembolism
risk (ie, active or extensive disease, surgery, immobilization, corticosteroid use,
vitamin deficiencies, fluid depletion). Megans disease is mild and her condition is,
therefore, a category 2 risk. If she had more severe disease, this option would not be
appropriate.

B. VIABLE OPTION. The presence of mild IBD gives POPs and DMPA injection a
US MEC category of 2 for Megan; therefore, the advantages of these methods
generally outweigh the theoretical or proven risks.

C. NO RESTRICTION. The US MEC category for the use of an implant in women

with IBD is 1, meaning that it is safe and may be used without restriction.

D. NO RESTRICTION. The US MEC category for the use of an LNG-IUD in women

with IBD is 1 and is therefore safe and used without restriction, as is the copper IUD,
the contraceptive method Megan is currently using.

Case (contd)
Megan is presented with all of the above contraceptive options. After risks and
benefits of each option are considered, Megan selects the LNG-IUD because she is
comfortable using the copper IUD but would like a method that lightens her bleeding
and a method that is more forgettable. She is prescribed a LNG-IUD. At her 1-year
follow-up visit, she reports that her periods have become much lighter and she has no
discernable side effects from using this method. Megans last ulcerative colitis flareup was approximately 6 months ago
Selection Rationale
A. CORRECT. Use of the LNG-IUD may be considered to reduce heavy menstrual
bleeding11 and therefore should help to lighten Megans heavier periods.

B. INCORRECT. There is no evidence that the use of an LNG-IUD has an effect on

PMDD [SLIDE 9].

C. CORRECT. The incidence of endometrial cancer is reduced with use of an LNGIUD [SLIDE 9].

D. INCORRECT. There is no evidence that the use of an LNG-IUD improves

headache [SLIDE 9].

Case Summary
Because Megan has only mild IBD, there are no restrictions regarding contraceptive
choice. Most contraceptive methods offer noncontraceptive benefits; Megans use of
the LNG-IUD will help provide lighter periods. The LNG-IUD has also been shown
to reduce risk of endometrial cancer and pelvic inflammatory disease (PID).11-13