Treatment of Abnormal Bleeding with IUD
For abnormal bleeding associated with IUDs, NSAIDs are recommended as the first-line treatment for 5-7 days during bleeding episodes, while ensuring iron supplementation with ferrous sulfate 200mg three times daily to correct anemia. 1
First-Line Management Approach
For Copper IUD-Related Bleeding:
- NSAIDs (5-7 days during bleeding episodes) 1, 2
- Reduce menstrual blood loss and bleeding duration
- Options include ibuprofen, naproxen, or mefenamic acid
- Start at the onset of bleeding for maximum effectiveness
For Hormonal IUD-Related Bleeding:
- Counseling and reassurance as initial approach 1
- Irregular bleeding is common during first 3-6 months and typically improves with time
- NSAIDs for persistent or heavy bleeding 1, 2
Iron Supplementation
- Ferrous sulfate 200mg three times daily for all patients with iron deficiency 1
- Continue for three months after correction of anemia
- Monitor hemoglobin concentration:
- After initial treatment
- Every three months for one year once normal
- Then after another year
Second-Line Treatment Options
For Persistent Bleeding with Copper IUD:
- Antifibrinolytic agents (tranexamic acid) 2, 3
- May significantly reduce blood loss
- Use during heavy bleeding episodes
For Persistent Bleeding with Hormonal IUD:
- Short-term hormonal treatment 1
- Low-dose combined oral contraceptives for 10-20 days
- Short course of estrogen supplementation
Monitoring and Follow-Up
- Assess hemoglobin levels to monitor for anemia
- Evaluate effectiveness of treatment after 1-3 cycles
- Consider IUD removal if bleeding remains problematic despite treatment
Special Considerations
When to Consider IUD Removal:
- Severe, persistent bleeding despite treatment
- Significant anemia not responding to iron supplementation
- Intolerable symptoms affecting quality of life
When to Seek Immediate Medical Attention:
- Severe abdominal pain
- Signs of infection
- Very heavy bleeding with clots or soaking through protection hourly
Evidence Quality Assessment
The evidence supporting NSAIDs for IUD-related bleeding is of fair to poor quality but consistent across multiple studies 2. The systematic review by 2 found that NSAIDs may significantly reduce menstrual blood loss among copper IUD users with heavy bleeding. Limited evidence also suggests antifibrinolytic agents may be helpful, though their safety profile is less well documented 2, 3.
Older research from 1982 demonstrated that various NSAIDs (indomethacin, alclofenac, and flufenamic acid) all reduced IUD-induced bleeding, with flufenamic acid showing the greatest reduction 4, though these findings should be interpreted cautiously given the study's age and small sample size.
The American Gastroenterological Association and CDC recommendations for iron supplementation and NSAID use represent the most authoritative guidance available 1.