What is the treatment for heavy menstrual bleeding (HMB) in patients with an intrauterine device (IUD)?

Treatment for Heavy Menstrual Bleeding with an IUD

For heavy menstrual bleeding (HMB) in patients with an intrauterine device (IUD), nonsteroidal anti-inflammatory drugs (NSAIDs) for 5-7 days during bleeding days are the first-line treatment option. 1, 2

Initial Assessment

Before initiating treatment, it's essential to:

1. Rule out underlying gynecological problems:

   • IUD displacement (most common cause of abnormal bleeding)
   • Sexually transmitted infections
   • Pregnancy
   • New pathologic uterine conditions (polyps, fibroids)

2. Differentiate between copper IUD and hormonal IUD:

   • Copper IUD users commonly experience increased menstrual bleeding
   • LNG-IUD (levonorgestrel) users typically have irregular bleeding but heavy bleeding is uncommon and warrants evaluation

Treatment Algorithm

First-Line Treatment:

• NSAIDs for 5-7 days during bleeding days 1, 2
  • Options include:
    • Mefenamic acid
    • Naproxen
    • Ibuprofen
    • Flufenamic acid
    • Diclofenac sodium
  • NSAIDs have been shown to reduce menstrual blood loss by 26-60% 3
  • Mechanism: Inhibit prostaglandin synthesis which contributes to heavy bleeding

Second-Line Treatment:

• Tranexamic acid (if NSAIDs are ineffective) 2, 4
  • Dosage: 3.9-4 g/day for 4-5 days starting from the first day of the menstrual cycle
  • Reduces menstrual blood loss by 26-60%
  • Important contraindications:
    • Active thromboembolic disease
    • History or intrinsic risk for thrombosis or thromboembolism

Third-Line Option:

• Consider alternative contraceptive methods if bleeding persists and is unacceptable to the patient 1
  • For copper IUD users with persistent HMB, switching to LNG-IUD may be beneficial as it reduces menstrual blood loss more effectively than other treatments 5

Comparative Effectiveness

• LNG-IUD is more effective than tranexamic acid in reducing HMB 4, 5
• Tranexamic acid is more effective than NSAIDs for HMB 6
• Mefenamic acid appears to be more effective than tranexamic acid in some studies (MD -64.26,95% CI -105.65 to -22.87) 3
• No significant differences have been found between different types of NSAIDs (naproxen vs. mefenamic acid) 7

Common Pitfalls to Avoid

1. Don't use aspirin for HMB treatment - it has not shown benefit and may actually increase blood loss 2

2. Don't ignore persistent bleeding - if heavy bleeding persists despite treatment, further evaluation and consideration of alternative methods is necessary 1, 2

3. Don't assume bleeding is normal with LNG-IUD - heavy bleeding with LNG-IUD is uncommon and warrants evaluation 2

4. Don't overlook IUD displacement - this is a common cause of abnormal bleeding and should be ruled out first 2

5. Don't continue ineffective treatments - if NSAIDs don't provide adequate relief after a full treatment course, move to second-line therapy or consider alternative contraceptive methods

By following this structured approach, heavy menstrual bleeding associated with IUD use can be effectively managed in most patients, improving their quality of life while maintaining their chosen contraceptive method.