How does an intrauterine device (IUD) affect the diagnosis of menopause?

Diagnosing Menopause with an IUD in Place

In women using a levonorgestrel-releasing IUD (LNG-IUD), hormonal assays and pelvic ultrasound are not recommended for diagnosing menopause; instead, remove the IUD and observe for 12 months of amenorrhea to confirm menopausal status. 1

The Core Problem

The LNG-IUD fundamentally interferes with menopause diagnosis because:

• Amenorrhea is expected with LNG-IUD use: Approximately 50% of LNG-IUD users develop amenorrhea or oligomenorrhea by 2 years of use, making the standard clinical criterion of 12 consecutive months of amenorrhea unreliable 2
• Hormonal testing is unreliable: FSH and estradiol levels vary markedly during the menopausal transition, making single measurements poor indicators of menopausal status even without an IUD 3
• The IUD masks natural bleeding patterns: You cannot distinguish between IUD-induced amenorrhea and menopause-related amenorrhea while the device remains in place 1

Recommended Diagnostic Approach

For LNG-IUD Users

The only reliable strategy is device removal followed by clinical observation:

1. Remove the LNG-IUD when menopause diagnosis becomes clinically relevant (typically after age 45-50) 1
2. Observe for 12 months of consecutive amenorrhea after removal to confirm menopause 1, 4
3. Do not rely on hormonal assays (FSH, estradiol) during this period, as they remain unreliable guides to menopausal status during the transition 3

For Copper IUD Users

• Copper IUDs do not interfere with menstrual patterns or hormonal function 2
• Standard diagnostic criteria apply: 12 months of amenorrhea in a woman over age 45 confirms menopause 4
• No need for IUD removal for diagnostic purposes alone

When to Consider IUD Removal

The CDC recommends the Mirena can remain in place until menopause is confirmed, without removal based solely on age 5. However, removal becomes necessary when:

• Menopausal status must be determined for clinical decision-making (e.g., discontinuing contraception, initiating hormone therapy) 1
• The woman is over age 50-55 and wishes to discontinue contraception 5
• Cancer treatment planning requires accurate hormonal status (particularly for breast cancer, where premenopausal vs. postmenopausal status determines treatment selection) 1

Critical Pitfalls to Avoid

Do Not Order Hormonal Testing While IUD is In Place

• FSH and estradiol measurements are not recommended for diagnosing menopause in LNG-IUD users 1
• These tests will not reliably guide the decision to stop contraception 1
• Hormone levels fluctuate widely during the menopausal transition regardless of IUD presence 3

Do Not Assume Amenorrhea Equals Menopause

• Amenorrhea with an LNG-IUD is a drug effect, not necessarily menopause 2
• Ovarian function may still be active despite absent bleeding 1
• Contraceptive protection is still needed until menopause is confirmed after IUD removal 1

Special Clinical Scenarios

After Hysterectomy with IUD Previously in Place

• Clinical amenorrhea cannot be assessed as a diagnostic criterion 1
• Consider repeat FSH ≥40 IU/L combined with estradiol <20 pg/mL at least 3 months apart as diagnostic orientation toward menopause 1
• This remains imperfect and should be interpreted cautiously 1

After Gonadotoxic Cancer Treatment

• The standard 12-month amenorrhea criterion cannot reliably diagnose menopause in women who received chemotherapy 2, 1
• No examination can definitively diagnose menopause in this population 1
• For breast cancer patients: If menopausal status was unknown at diagnosis due to hormonal contraception (including LNG-IUD), default to considering the patient as premenopausal for treatment selection 1
• Empirical diagnosis may require: Amenorrhea for at least 2 years, persistent postmenopausal hormonal profile, and vaginal ultrasound showing non-functioning ovaries 2

Practical Timeline

For a typical perimenopausal woman with LNG-IUD:

• Age 50-52: Consider discussing IUD removal if menopause diagnosis is desired 5
• After removal: Wait 12 months of amenorrhea to confirm menopause 1, 4
• Total timeline: Expect 1+ years from removal to confirmed diagnosis
• During observation: Use barrier contraception if pregnancy prevention remains necessary 2