Risk-Adapted Approach to Levonorgestrel-Containing Intrauterine Devices Placement for Heavy Menstrual Bleeding in Adolescents with Bleeding Disorders [A92

Abstract

INTRODUCTION: Females with inherited bleeding disorders (IBD) are disproportionately affected by reproductive tract bleeding, and can suffer adverse physical, social, and emotional outcomes. Recent guidelines advise development of perioperative management protocols for women undergoing invasive procedures, but do not provide specific guidance and rely on provider-level expertise. Optimizing the care of these patients requires a multidisciplinary approach. METHODS: Patients with known/suspected bleeding disorders present to the women and girls’ bleeding disorder clinic for evaluation and counseling. A collaborative protocol is generated by hematologists and gynecologists for the patients who desire levonorgestrel-containing intrauterine devices (LNG-IUD). A periprocedural hemostatic treatment protocol is tailored to the patient’s bleeding disorder. Ultrasound is performed in advance for uterine size and device selection. Placement is performed under ultrasound guidance in an operative setting without the use of a tenaculum. In instances where patients have severe bleeding histories or ongoing vaginal bleeding at the time of LNG-IUD placement, they may elect to use anti-fibrinolytics or continue an additional form of menstrual management such as combined oral contraceptive pills (OCPs) for one to three menstrual cycles to decrease the risk of heavy bleeding and expulsion. Patients then have a short-interval follow-up for monitoring. RESULTS: Eighteen patients, ages 10-19 years, underwent LNG-IUD placement in the operating room without complications such as hemorrhage or uterine perforation. None of the patients required any further hematologic interventions that were outside the protocols as outlined preoperatively. CONCLUSION: Highly efficacious heavy menstrual bleeding (HMB) treatment can be offered to persons with IBD via a multidisciplinary approach to assure patient safety and satisfaction.