The 41-year-old housewife was married for 20 years. After the birth of her youngest child 8 years ago, an LNG-IUS (Mirena ) was chosen as a long-term contraception owing to the patients` preference. Of note, there was no other gynecological indication (e.g. menorrhagia) for the insertion of the device. Except for daily tasks involving her household and taking care of her four children, no psychosocial stress factors were reported. There was no history of psychiatric disorders or general medical condition, neither in the past nor within her family. The patient reported from a regular menstrual cycle and denied current or previous pre- or perimenstrual syndromes. Moreover, there was no other medication than the LNG-IUS within the last few years. After 5 years of implantation of the first LNG-IUS and approximately 2.5 years from present, a second LNG-IUS was inserted. 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. Repeated medical examinations by the family doctor, including ECG, blood tests (thyroid hormones, glucose, infection parameters, liver and kidney values, electrolytes, differential blood count) were without any significant findings. A cardiologic examination including a long-term ECG, exercise ECG and cardiac ultrasound revealed supraventricular extrasystoles without any other pathological findings. These internal and cardiological non-findings could however, not calm the patients  worries down and had no impact on her well-being. Her anxieties still worsened with an increased frequency of panic attacks including the fear to faint or even to die and led to an emergency call. Due to the pelvic pain, a rheumatological examination including the determination of autoantibodies (antinuclear antibodies, ANA; anti-neutrophil cytoplasmic antibodies, ANCA) was conducted but also without any pathological findings. Several gynecological examinations led to the presumptive diagnosis of a premenopausal syndrome in the context of an early menopause. However, since the previous somatic examinations revealed no pathological findings, a mental origin was assumed and a psychiatric treatment was recommended. At this time the duration of the symptomatic has worsened over the course of 3 years. Figure 1 shows a timeline with information about the course of symptoms, the performed examinations and the treatment.
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.