What is the treatment for heavy menstrual bleeding in a patient with a Mirena (levonorgestrel-releasing intrauterine device) IUD?

Management of Heavy Menstrual Bleeding in a Patient with Mirena IUD

For a patient experiencing heavy menstrual bleeding despite having a Mirena (levonorgestrel-releasing intrauterine device), first rule out underlying gynecological problems before considering short-term NSAID treatment or alternative contraceptive methods. 1, 2

Initial Assessment

When a patient with a Mirena IUD presents with heavy menstrual bleeding, consider:

1. Rule out underlying conditions:

   • LNG-IUD displacement or malposition
   • Sexually transmitted infections
   • Pregnancy (including ectopic)
   • Pathologic uterine conditions (polyps, fibroids)
   • Endometrial pathology (especially important if patient is perimenopausal) 1, 2

2. Timing considerations:

   • Heavy bleeding is uncommon with LNG-IUD use, especially after the first 3-6 months
   • By 2 years of use, approximately 50% of LNG-IUD users experience amenorrhea or oligomenorrhea 1

Treatment Algorithm

First-line approach:

• Confirm proper IUD placement via ultrasound or pelvic examination
• If IUD is properly positioned and no underlying pathology is found:
  • NSAIDs for short-term treatment (5-7 days during bleeding episodes)
    • Ibuprofen 400-800 mg every 4-6 hours
    • Mefenamic acid (has shown significant reductions in menstrual blood loss) 1, 3
    • Naproxen or other NSAIDs are also effective options 3

Second-line options (if NSAIDs ineffective):

• Tranexamic acid during days of bleeding
  • Typically 3.9-4 g/day for 4-5 days starting from first day of menstrual cycle
  • Contraindicated in women with active thromboembolic disease or history/risk of thrombosis 1, 4
  • More effective than NSAIDs for reducing blood loss 4

If bleeding persists and remains unacceptable:

1. Counsel on alternative contraceptive methods 1
2. Consider removal of the LNG-IUD and switch to:
   • Another contraceptive method, or
   • A new LNG-IUD (if displacement was the issue)

Important Considerations

• LNG-IUD mechanism: The Mirena IUD works by releasing levonorgestrel locally within the uterine cavity, causing suppression of endometrial growth and reducing menstrual blood loss 2

• Expected bleeding patterns: Unscheduled spotting or light bleeding is common in the first 3-6 months of LNG-IUD use, but heavy or prolonged bleeding is uncommon 1, 2

• Comparative effectiveness: LNG-IUD is more effective at reducing menstrual blood loss than tranexamic acid, which is more effective than NSAIDs 5

  • LNG-IUD can reduce menstrual blood loss by 88-95% after 6-12 months
  • Tranexamic acid reduces blood loss by approximately 44%
  • NSAIDs reduce blood loss by approximately 20% 5

• Vascular effects: LNG-IUD increases resistance indices of intra-myometrial arteries, which may be one mechanism by which it reduces menstrual blood flow 6

Pitfalls to Avoid

• Don't assume bleeding is normal with LNG-IUD: Heavy bleeding is uncommon with Mirena and warrants evaluation 1, 2

• Don't overlook displacement: IUD displacement is a common cause of abnormal bleeding and should be ruled out first 1

• Don't use aspirin: Unlike other NSAIDs, aspirin has not shown benefit for heavy menstrual bleeding and may actually increase blood loss 1

• Don't ignore persistent bleeding: If heavy bleeding persists despite treatment, further evaluation and consideration of alternative methods is necessary 1, 2