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"5 IUD myths dispelled.".

ANNE A, MOORE, DNP, APN (SEPTEMBER 2013)

For an anovulatory patient with PCOS, Mirena may confer several benefits

Having read with interest the article by Dr. Anne Moore on IUD myths, I would like to communicate several concerns that I have about the proposed assessment of the patient described in Case 3, who is anovulatory with heavy menstrual periods. ]he case is indeed suggestive of a diagnosis of polycystic ovary syndrome (PCOS). However, the many follicles evident in the ovaries of women with PCOS are not "growing" Nor is the aim of therapy to "suppress follicular activity" as Dr. Moore stated. Given the patient's obesity (and likely concomitant dyslipidemia, which is commonly encountered in this population) and anovulatory cycles, she is at risk for endometrial pathology because of her chronic exposure to unopposed estrogen, hyperinsulinemia, insulin resistance, and even dysglycemia (commonly encountered in women with pcos).

Contrary to Dr. Moore's conclusion, the levonorgestrel-releasing intrauterine system (Mirena) would be an optimal agent for this patient. Besides offering contraceptive efficacy, it would confer endometrial protection without worsening her triglyceride or glycemic profile. It also would allow flexibility in the use of anti-androgen therapy to specifically target the patient's hyperandrogenism.

Lubna Pal, MBBS

New Haven, Connecticut

>> Dr. Moore responds

Granted, Mirena has superior endometrial suppression in that it provides a progestin at the endometrium. It is not efficient, however, in promoting ovarian quiescence. As the package insert states, "Sometimes atresia of the follicle is delayed and the follicle may continue to grow. Enlarged follicles have been diagnosed in about 12% of the subjects using Mirena." (1) I have a number of patients with PCOS who experience discomfort and dyspareunia and who have an elevated risk of ovarian torsion.

Because oral estrogens increase sex hormone binding globulin, oral contraceptives could help ameliorate symptoms commonly associated with the diagnosis of PCOS--specifically, androgenic presentations.

Let me be clear, I am wholeheartedly a supporter of long-acting reversible contraception for all eligible women.

Reference

(1.) Mirena [package insert]. Wayne, New Jersey: Bayer HealthCare Pharmaceuticals; 2013.

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Title Annotation:Comment & Controversy
Author:Pal, Lubna
Publication:OBG Management
Date:Dec 1, 2013
Words:337
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