Managing the risks of mood symptoms with LNG-IUS: a clinical perspective

Figures & data

Table 1. Counselling women about the risk of mood symptoms with LNG-IUS to facilitate informed choice.

1. Clarify general risk of potential mood symptoms	It is uncommon to see mood changes with use of the LNG-IUS; however, some women have an increased sensitivity to certain hormones
2. Use the medical history to identify individual risk Using questions that identify elements of history that may put a woman at risk, in addition to a general, neutral question about medication use	Idiopathic sensitivity to hormones	History of psychological symptoms
	Increased risk due to established hormone sensitivity: • For example, have you had any notable reactions to hormonal fluctuations within the menstrual cycle or notable reaction to use of an oral contraceptive pill in the past? Then if needed: • Did you notice a change in mood, irritability, anxiety, sleep pattern? • Was the reaction severe? How long did it last? How was it resolved?	Increased risk due to previous episode of mood disorder or depressive symptoms, for example, • Have you ever experienced any previous depressive episodes or anxiety disorders? • Have you ever taken any medication for depression? • Have you ever been hospitalised with depression? • Have you ever seen a psychiatrist for depression?
3. Counsel according to either general or individual risk	No evidence of risk	Suggested wording for simple counselling of risks • For all women, there is a possibility of a change in mood with hormonal contraception; for some, it is positive, for others, it can be negative • If it does occur, it is most likely in the first few weeks of use but it is reversible • The change can be due to fluctuating levels of hormone but if it does not resolve after 6–12 weeks OR is bothersome and causing concern, please return
	Evidence of risk	Suggested additional wording where there is evidence of risk • Your history suggests that you may be more sensitive to hormone changes or prone to changes to in mood and may be more likely to experience such a change

Table 2. Counselling LNG-IUS users presenting with mood symptoms or concerns about developing mood symptoms.

Counsel a returning patient according to timing of symptom onset
Symptoms ≤6 weeks post-insertion	• Assess severity and impact on daily living   ^ If mild to moderate, explain that plasma hormone levels reach their peak at 6 weeks and suggest waiting a little longer (agree suitable time to return) to see if the symptoms resolve on their own ^ If severe, refer for psychiatric evaluation and discuss removal of LNG-IUS • If previous history – ask if symptoms are similar to what they’ve experienced before or different • Ask about any changes/life events that could be causing the symptoms • If patient requests removal: • Counsel on implications of removal, for example, contraceptive efficacy or changes in bleeding if used for heavy menstrual bleeding (discuss other treatment options) • Counsel on possibility of similar effect with other hormonal preparations • If patient still requests removal, counsel around contraceptive options accordingly
Symptoms within 6–12 weeks of insertion	• Assess severity and impact on daily living • If mild to moderate discuss strategies to manage symptoms (including removal of LNG-IUS) • If severe, refer for psychiatric evaluation and discuss removal of LNG-IUS • If previous history – ask if symptoms are similar to what they’ve experienced before or different • Ask about any changes/life events that could be causing the symptoms • If patient requests removal: • Counsel on implications of removal, for example, contraceptive efficacy or changes in bleeding if used for heavy menstrual bleeding (discuss other treatment options) • Counsel on possibility of similar effect with other hormonal preparations • If patient still requests removal, counsel around contraceptive options accordingly
Symptoms 12 months after insertion	• Counsel that reactions to the hormone in the LNG-IUS usually occur within the first three months [42,43] therefore her symptoms are unlikely to be related • Counsel as above if patient expresses continued concern or requests removal
Patient returns (at any time point) expressing concern about the likelihood of developing symptoms prompted by media stories	• Counsel that reactions to the hormone in the LNG-IUS usually occur within the first three months [42,43] and ask about timing of onset • If insertion <3 months, refer to patient history screening questions • If insertion >3 months ago, counsel that reactions to the hormone in the LNG-IUS usually occur within the first three months therefore if she has not developed any symptoms by now, she is unlikely to do so in the future • If patient requests removal: • Counsel on implications of removal, for example, contraceptive efficacy or changes in bleeding if used for heavy menstrual bleeding (discuss other treatment options) • Counsel on possibility of similar effect with other hormonal preparations • If patient still requests removal, counsel around contraceptive options accordingly

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