How to manage bleeding associated with a hormonal Intrauterine Device (IUD)?

Managing Bleeding with Hormonal IUDs

For patients experiencing bleeding with hormonal IUDs, NSAIDs such as mefenamic acid are recommended as first-line treatment, taken for 5-7 days during bleeding episodes to reduce menstrual blood loss by approximately 20%. 1

Treatment Options for Hormonal IUD-Associated Bleeding

First-Line Treatments:

• NSAIDs during days of bleeding (5-7 days)
  • Mefenamic acid has shown effectiveness in reducing menstrual blood loss compared to tranexamic acid 1, 2
  • Naproxen may help reduce pain associated with bleeding 2
  • Ibuprofen is another option, though evidence shows mixed results for prevention of heavy bleeding 2

Second-Line Treatments:

• Tranexamic acid
  • Can be considered as a non-hormonal option for managing abnormal bleeding 1
  • May be less effective than mefenamic acid for reducing blood volume but can still help 2

Third-Line Treatments:

• Low-dose combined oral contraceptives (COCs)
  • Can be used for short-term treatment (10-20 days) to manage irregular bleeding 1
  • May reduce menstrual blood loss by up to 50% in some women 1

Time Course of Bleeding with Hormonal IUDs

• Irregular bleeding and spotting are common during the first 3-6 months of hormonal IUD use 1, 3
• Most bleeding patterns stabilize after this initial adjustment period
• Counseling and reassurance are appropriate during this initial period, but medical intervention should be considered if bleeding is heavy or prolonged 4

Important Considerations

When to Investigate Further

• Rule out other causes of abnormal bleeding if:
  • Bleeding persists beyond 6 months
  • Bleeding pattern suddenly changes after a period of stability
  • Bleeding is accompanied by severe pain or other concerning symptoms

Contraindications to Treatment Options

• COCs should not be used in women with:
  • History of arterial thromboembolic disease
  • Breast cancer or other estrogen/progestin-sensitive cancers
  • Uncontrolled hypertension or liver disease
  • History of deep vein thrombosis or pulmonary embolism
  • Migraine with aura if >35 years of age
  • Smoking if >35 years of age 1

Common Pitfalls and Caveats

• Avoid high-dose aspirin in women with menorrhagia as it may increase blood loss 5
• Bleeding irregularities are a leading reason for IUD discontinuation, but proper management can improve continuation rates 5
• Vitamin B1 has shown some promise in reducing bleeding days and pad usage in copper IUD users, but evidence for hormonal IUDs is limited 2
• Prophylactic use of NSAIDs at the time of IUD insertion may not significantly impact long-term continuation rates 5

Treatment Algorithm

1. First 3-6 months after insertion: Provide counseling and reassurance about the expected adjustment period
2. For persistent or heavy bleeding:
   • Start with NSAIDs (mefenamic acid, naproxen, or ibuprofen) for 5-7 days during bleeding episodes
   • If ineffective, consider tranexamic acid
   • For persistent issues, short-term COCs may be considered if not contraindicated
3. Reassess after 3 months of therapy to evaluate response and consider alternative approaches if bleeding persists 1

Remember that while bleeding is common with hormonal IUDs, it typically decreases over time, and the high contraceptive efficacy (0.1-0.2% failure rate) makes it worth managing these side effects for many patients 1.