Contraception for adolescents and young adults (AYA) helps prevent unintended pregnancies and treats other adolescent gynecologic concerns such as heavy menstrual bleeding and irregular menstrual cycles. The levonorgestrel intrauterine device (LNG-IUD) is a long-acting reversible contraceptive (LARC) method that has high efficacy and is safe for adolescents, and can be used for treatment of heavy menstrual bleeding, dysmenorrhea, and abnormal uterine bleeding.1, 2, 3, 4, 5

Expulsion is a known risk of LNG-IUD placement.5 Published IUD expulsion rates for AYA are between 3-18.8%,6, 7, 8, 9, 10, 11, 12 although the best pooled estimate from a recent systematic review is 8.0%.13 Risk factors for expulsion among AYA include abnormal uterine bleeding (AUB), and elevated body mass or obesity.9

Recent data indicate that 19.9% of girls ages 12-19 in the United States experience obesity and that obesity prevalence has risen in the last several years.14 Metabolic and bariatric surgery (MBS) is the most effective and durable treatment for severe complicated obesity in AYA, and rates of these procedures are increasing in this population.14, 15, 16, 17, 18 The 2023 American Academy of Pediatrics clinical practice guideline on obesity recommends that pediatric health care providers discuss referral for a MBS evaluation to adolescents 13 years and older with severe obesity (BMIP ≥120% of 95th percentile for age and sex or BMI ≥35kg/m2, whichever is lower).19 Current guidelines recommend that all MBS patients avoid pregnancy for 12 to 18 months postoperatively.20 Contraception is routinely recommended to AYA undergoing MBS, and the LNG-IUD is an option for those who desire heavy menstrual bleeding control, dysmenorrhea treatment, or lighter menses/amenorrhea, with relatively lower systemic hormonal exposure as compared to other hormonal methods.21 LNG-IUD does not cause weight gain and remains effective in patients with elevated body mass.22 While there is emerging evidence suggesting an association between higher body mass and expulsion,9,12 there are currently no published studies assessing the one-year rate of LNG-IUD expulsion among AYA with severe obesity who undergo MBS. One study noted minimal expulsion over a 6-month period and that the LNG-IUD was widely accepted among patients undergoing MBS.21 As MBS among AYA has increased in the last several years with patients continuing to elect for LNG-IUD placement, it is important to understand the relationship between MBS and the risk of expulsion to improve patient care. In this study, we hypothesized that participants with higher BMIP or BMI and participants who underwent MBS would have higher rates of LNG-IUD expulsion.