What is the management for a patient experiencing bleeding with an Intrauterine Device (IUD)?

Management of Bleeding with an Intrauterine Device (IUD)

For patients experiencing bleeding with an IUD, management should include evaluation for potential causes such as IUD displacement, infection, or underlying uterine pathology, followed by appropriate treatment with NSAIDs as first-line therapy for heavy bleeding, or consideration of IUD removal if bleeding persists despite interventions. 1

Initial Assessment

• Determine the bleeding pattern and severity:

  • Normal adjustment bleeding (first 3-6 months of use)
  • Heavy menstrual bleeding
  • Intermenstrual spotting
  • Persistent bleeding after previously stable patterns

• Evaluate for concerning features:

  • IUD displacement or partial expulsion
  • Signs of infection (pelvic pain, fever, discharge)
  • Underlying uterine pathology

Diagnostic Approach

• Perform ultrasound to assess IUD position

  • Three-dimensional ultrasound is particularly useful to visualize the entire device and detect abnormal positioning 2
  • Malpositioned IUDs (extending into myometrium or cervix) are associated with significantly higher rates of bleeding (35.7%) and pain (39.3%) compared to normally positioned IUDs 2

• Consider the PALM-COEIN classification system to evaluate for other causes of abnormal uterine bleeding 1:

  • Structural causes (PALM): Polyps, Adenomyosis, Leiomyoma, Malignancy
  • Non-structural causes (COEIN): Coagulopathy, Ovulatory disorders, Endometrial, Iatrogenic, Not otherwise classified

Treatment Options

For Normal Adjustment Bleeding (First 3-6 Months)

• Patient education and reassurance that bleeding typically improves over time
• NSAIDs during menstruation to reduce bleeding 3
  • Ibuprofen 400-800 mg three times daily
  • Naproxen 500 mg twice daily

For Heavy or Prolonged Menstrual Bleeding

1. First-line: NSAIDs

   • Multiple studies demonstrate NSAIDs can significantly reduce menstrual blood loss and bleeding duration in Cu-IUD users 3
   • Start during menstruation and continue for 5 days or duration of bleeding

2. Second-line: Antifibrinolytic agents

   • Tranexamic acid 1000-1500 mg three to four times daily during menstruation
   • Evidence suggests these may help reduce blood loss 3

3. For persistent bleeding with levonorgestrel IUD:

   • Note that effectiveness varies by underlying pathology:
     • 95.5% effectiveness for endometrial hyperplasia
     • 88.7% effectiveness for adenomyosis
     • Only 55.6% effectiveness for leiomyoma 4

For Malpositioned IUD

• If ultrasound confirms malposition, IUD removal is recommended
• 95% of patients with malpositioned IUDs report improvement in symptoms after removal 2

Special Considerations

• Copper vs. Hormonal IUDs:

  • Copper IUDs are more commonly associated with heavy menstrual bleeding
  • Hormonal IUDs typically reduce bleeding over time but may cause irregular spotting initially 1

• Treatment effectiveness by underlying pathology:

  • LNG-IUD is less effective for bleeding control in patients with leiomyomas (55.6%) compared to other conditions 4
  • Consider alternative contraceptive methods if bleeding persists in patients with fibroids

When to Consider IUD Removal

• Persistent heavy bleeding despite medical management
• Confirmed malposition of the IUD
• Signs of infection or perforation
• Patient preference after counseling about alternatives

Preventive Strategies

• Prophylactic NSAIDs may help prevent bleeding irregularities in new Cu-IUD users, though this doesn't necessarily improve continuation rates 3
• Antifibrinolytic agents might help prevent heavy bleeding in new users, though safety data is limited 3

Common Pitfalls to Avoid

• Failing to evaluate IUD position in patients with persistent bleeding
• Assuming all bleeding with IUDs is normal adjustment bleeding
• Not considering underlying uterine pathology (especially fibroids) that may limit treatment effectiveness
• Using high-dose aspirin, which can increase blood loss in patients with baseline menorrhagia 3