What is the initial management for a patient with an Intrauterine Device (IUD) and heavy Dysfunctional Uterine Bleeding (DUB)?

Initial Management of Heavy Dysfunctional Uterine Bleeding in a Patient with an IUD

The first step is to rule out underlying gynecological problems including IUD displacement, pregnancy (including ectopic), sexually transmitted infections, and new pathologic uterine conditions such as polyps or fibroids, followed by initiation of NSAIDs for 5-7 days as first-line symptomatic treatment. 1, 2

Immediate Diagnostic Evaluation

Before initiating treatment, you must systematically exclude specific conditions that present as heavy bleeding in IUD users:

• Perform a speculum examination to verify IUD strings are visible and the device is properly positioned, as displacement is a common cause of abnormal bleeding 1, 3

• Obtain a pregnancy test (urine or serum) to rule out pregnancy, including ectopic pregnancy, which carries significant morbidity and mortality risk 1, 3

• Screen for sexually transmitted infections (gonorrhea and chlamydia), particularly if the patient has risk factors, as STDs can manifest as abnormal bleeding 1, 3

• Evaluate for new uterine pathology including polyps, fibroids, or endometrial abnormalities through pelvic ultrasound or other imaging if clinically indicated 1, 3

Type of IUD Matters for Context

The bleeding pattern differs significantly based on IUD type:

• Copper IUD (Cu-IUD): Heavy or prolonged bleeding is more common and expected, particularly in the first 3-6 months after insertion 1, 4

• Levonorgestrel IUD (LNG-IUD): Heavy or prolonged bleeding is uncommon; when it occurs, it warrants more aggressive investigation for underlying pathology since most LNG-IUD users experience decreased bleeding or amenorrhea over time 1

First-Line Medical Treatment

Once underlying pathology is excluded, initiate NSAIDs for 5-7 days during the bleeding episode as first-line therapy. 1, 2, 5

• NSAIDs reduce menstrual blood loss by 20-60% and are effective regardless of whether bleeding is anovulatory or ovulatory 1, 2, 5

• Specific NSAIDs studied include mefenamic acid, naproxen, and ibuprofen 1, 4

• Do not use aspirin, as it may paradoxically increase bleeding in some women 1, 2

Second-Line Treatment Options

If NSAIDs alone are insufficient and the patient wishes to retain the IUD:

For Cu-IUD users with persistent heavy bleeding:

• Add tranexamic acid for 5 days during menstruation, which reduces blood loss by 40-60% 1, 2, 5

• Important caveat: Tranexamic acid is contraindicated in women with active thromboembolic disease or history of thrombosis 1, 2, 5

• Consider hormonal treatment with combined oral contraceptives or estrogen for 10-20 days if the patient is using the IUD for contraception and bleeding persists 2

For LNG-IUD users with persistent heavy bleeding:

• Initiate NSAIDs for 5-7 days or add hormonal treatment with combined oral contraceptives or estrogen for 10-20 days 2

• The persistence of heavy bleeding with an LNG-IUD is unusual and should prompt more thorough investigation for structural pathology 1

When to Consider IUD Removal

If bleeding persists despite medical management and the woman finds it unacceptable, counsel her on alternative contraceptive methods and offer IUD removal with replacement of another method if desired. 1

The decision to remove the IUD should be based on:

• Failure of medical management with NSAIDs and/or tranexamic acid 1
• Patient preference and tolerance of bleeding 1
• Presence of underlying pathology that cannot be adequately treated with the IUD in place 1

Critical Pitfalls to Avoid

• Do not assume bleeding in the first 3-6 months of IUD use is pathologic—this is common and generally not harmful, particularly with Cu-IUD 1, 3

• Do not delay evaluation of new-onset heavy bleeding in a patient with an established IUD (especially LNG-IUD), as this suggests either device displacement or new pathology 1, 3

• Do not prescribe tranexamic acid without screening for thrombotic risk factors, as it is contraindicated in women with active or history of thromboembolism 1, 2, 5

• Do not remove the IUD immediately without first attempting medical management, unless there is evidence of infection, pregnancy, or the patient desires discontinuation 1

Special Consideration for IUD at End of Lifespan

If the patient has had the IUD for 5 years (particularly LNG-IUD), new-onset bleeding warrants prompt evaluation as the device is at its replacement endpoint and bleeding at this timepoint suggests either device expiration or new pathology 3