Depressive Disorder With Panic Attacks After Replacement of an Intrauterine Device Containing Levonorgestrel: A Case Report

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René Zeiss, Carlos Schönfeldt-Lecuona, Maximilian Gahr, Heiko Graf

Frontiers in Psychiatry

August 28, 2020

With this case, we strengthen previous observations regarding mood changes under LNG-IUS. Moreover, we illustrate that psychiatric symptoms may also occur as ADRs during the subsequent insertion. Thus, we emphasize that psychiatric symptoms have to be clearly communicated as ADRs to patients with LNG-IUS within a written informed consent and should be routinely examined by gynecologists.

Excerpts from Abstract

……Whereas most of these studies report psychiatric ADRs after the first implantation of the LNG-IUS, it has to be considered that these may also occur after replacement, even when psychiatric symptoms were not evident at the time of the initial insertion. A potential explanation for the development of psychiatric ADRs in subsequent LNG-IUS may rely on fluctuations of sex hormones throughout the female life cycle with changing windows of vulnerabilities for developing mood disorders. Thus, the reliable contraception for women remains a continual challenge. We present the case of a 41-year-old woman that used the LNG-IUS (Mirena®) for contraception over 5 years without any complaints. Within the first weeks after insertion of the second LNG-IUS, she developed a depressive syndrome and anxieties. An extensive somatic, including gynecological examination revealed no pathological findings and a mental disorder was suggested. Due to the patient´s request and the recommendation of her psychiatrist, the device was removed and led to a remission of her mental complaints up to a 6- and 12-months follow-up. Beyond the mood changes considerably affecting her quality of life, the patient raised the concerns that she has never been informed about potential ADRs on mental health and her remarks regarding the potential association between psychiatric symptoms and the LNG-IUS were considered as groundless.

…. The removal of the first and the insertion of the new LNG-IUS occurred on the same day. Within the first weeks after the insertion of the second device, she experienced an increasing psychomotor restlessness that was pronounced in the evening and during the night. She also reported from episodes of tachycardia and experienced an irregular heartbeat. Within the next 6 months, symptoms worsened and she developed sleep disturbances, anxiety in the night, emotional lability and suicidal ideations. She also reported of somatic complaints such as shivering, hot flashes, and pelvic pain with variable intensity….

…Due the suspected diagnosis of a depressive and anxiety disorder, the family doctor initiated an antidepressive medication with sertraline (100 mg OPD) and mirtazapine (7.5 mg OPD). This medication was taken daily for 6 months. In addition, lorazepam (0.5–1 mg) was prescribed as medication on demand. With medication, she reported from a minor improvement of sleep disturbances and from a remission of panic attacks, but still, higher levels of anxiety, depressed mood, inner restlessness, rumination and emotional lability persisted. Thus, the patient consulted a psychiatrist and underwent a supportive psychotherapy for five sessions in total. At this time, psychometric subjective measures of depressive mood conducted with the Beck depression inventory1 (BDI), revealed a sum-score of 42, indicating a severe depressive syndrome. After psychoeducation regarding depressive symptoms, the psychiatrist informed the patient about the potential association between changes in mood and the use of hormonal contraceptives. The psychiatrist also recommended the removal of the LNG-IUS. The gynecologist initially denied the potential association between the psychiatric symptoms and the LNG-IUS since changes in mood or anxiety were not evident during the first period of the LNG-IUS contraception. Nevertheless, the LNG-IUS was removed due to patient’s request…..

….Two weeks after removal of the LNG-IUS, psychiatric and in particular depressive symptoms improved markedly up to a BDI sum-score of 18, indicating a mild depressive syndrome, despite reduction of antidepressants. After two further weeks, the antidepressive medication was stopped. Four weeks after removal of the LNG-IUS, the patient reported that depressive symptoms and anxiety remitted completely (BDI sum-score: 6). In a 6- and 12-months follow-up, there were no clinically relevant symptoms of depression or anxiety (BDI: 2 respectively 2) observed….

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