PCOS & Heavy Flow - Cyclic Medroxyprogesterone or the Mirena® IUD?

Question

I am a health care provider wishing to treat PCOS and menorrhagia in my patient. Current clinical practice where I am is to offer the Mirena® IUD (long term levonorgestrel). What are the pros and cons of using cyclic medroxyprogestrone versus the "Mirena® IUD" in treating these conditions?

Answer

Thanks for your good question. 
For heavy flow (menorrhagia) in premenopausal women ibuprofen 200 mg with breakfast, lunch and dinner on every heavy flow day may be enough - See Resouces: Heavy Flow
In premenopause if ibuprofen is not sufficient, add cyclic medroxyprogesterone (10 mg/d) or progesterone (300 mg at bedtime/d) - See Resouces: Cyclic Prgesterone Therapy. If the Mirena IUD is your choice for contraception, that will also help heavy flow if ibuprofen doesn’t improve it enough.

Always combine ibuprofen with any heavy flow therapy.

However, if possible for premenopausal women, it is better to use something (like cyclic medroxyprogesterone or progesterone) that will make cycles more normal, not something (like Mirena®) that will make them become light or go away—having our periods connects us with our bodies and helps us understand and “own” our experiences.

For heavy flow in perimenopause, progesterone or medroxyprogesterone (10 mg a day) needs to be given daily for three months before going to cyclic progesterone or medroxyprogesterone. My preference is daily progesterone/progestin with ibuprofen at breakfast, lunch and dinner. However, my concerns about taking away flow with the Mirena® IUD are less in perimenopause. However, it is still important to know when your last flow occurs since you are officially menopausal 12 months later. I’ve seen women at 52 or 54 who got a nasty surprise when they took out their Mirena believing they were menopausal and didn’t need it any more and started having cycles again!

Mirena® has the advantage that it is delivering the progestin to the lining of the uterus so the levonorgestrel does not have major whole-body effects.

For PCOS and heavy flow—again I would start with ibuprofen. For the PCOS itself however, (not just the heavy flow) I think women really need cyclic progesterone (or perhaps medroxyprogesterone). I usually recommend spironolactone (a direct androgen-receptor blocker) along with cyclic progesterone once the heavy flow is under control. That usually allows women to start ovulating on their own http://www.cemcor.ca/resources/topics/anovulatory-androgen-excess-aae.