From the Guidelines
Treatment for intrauterine device (IUD) expulsion with severe bleeding in a hemodynamically stable patient should focus on managing the bleeding and considering alternative contraceptive methods.
Treatment Options
- For patients with an expelled IUD and severe bleeding, nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or mefenamic acid, can be used for 5-7 days to help reduce bleeding 1.
- Tranexamic acid, an antifibrinolytic agent, can also be considered for 5 days to help manage heavy menstrual bleeding 1.
- Hormonal treatment, such as low-dose combined oral contraceptives (COCs) or estrogen, may be used for 10-20 days to help control bleeding 1.
- If the patient desires to continue using an IUD, a new IUD can be inserted, and the patient can be advised on how to manage bleeding irregularities 1.
Considerations
- It is essential to explore patient goals, including continued method use or method discontinuation, and provide reassurance and advice on managing bleeding irregularities 1.
- If an underlying health condition is suspected, such as interactions with other medications, sexually transmitted infections, pregnancy, thyroid disorders, or new pathologic uterine conditions, it should be investigated and treated 1.
- The patient should be counseled on alternative contraceptive methods and initiated on a new method if desired 1.
Important Notes
- Ultrasonography can be used to determine the location of the IUD if it is not visible or cannot be retrieved safely 2.
- Patients with heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever should be advised to seek care promptly 2.
From the Research
Treatment Options for Intrauterine Device (IUD) Expulsion with Severe Bleeding
- For patients who are hemodynamically stable, treatment options for IUD expulsion with severe bleeding include: + Suture fixation of the levonorgestrel-releasing intrauterine device (LNG-IUD) under hysteroscopic guidance, which has been shown to be a minimally invasive and effective option for patients with a history of expulsion 3, 4 + Re-insertion of the LNG-IUD, which can be effective in reducing menstrual bleeding in patients with abnormal uterine bleeding (AUB) stratified by underlying pathology, with an overall effectiveness of 82% 5
- The effectiveness of the LNG-IUD in reducing menstrual bleeding varies depending on the underlying pathology, with higher effectiveness in patients with adenomyosis, endometrial hyperplasia, and not otherwise classified causes, and lower effectiveness in patients with leiomyoma 5
- In patients with adenomyosis, suture fixation of the LNG-IUD using the hysteroscopic cold-knife surgery system can be a minimally invasive and effective alternative for treating adenomyosis, especially in patients who have previously expelled an LNG-IUD 4
- It is essential to note that IUD expulsion can be associated with other complications, such as migration of the IUD, which can occur in approximately 1-2 per 1000 insertions, and may require laparoscopic removal 6
- The use of the levonorgestrel intrauterine system has also been reported to be effective in treating heavy menstrual bleeding in adolescents and young adults with inherited bleeding disorders and Ehlers-Danlos syndrome, with high rates of amenorrhea and low rates of expulsion 7