What are the next steps for managing spotting 10 months after Intrauterine Device (IUD) placement?

Management of Persistent Spotting 10 Months After IUD Placement

Evaluate for underlying gynecological problems including IUD displacement, sexually transmitted infections, pregnancy, and new pathologic uterine conditions (polyps or fibroids), as spotting beyond 3-6 months after insertion suggests pathology rather than normal adjustment bleeding. 1

Critical Evaluation Steps

At 10 months post-insertion, persistent spotting is abnormal and requires investigation rather than reassurance:

Rule Out Structural and Infectious Causes

• Perform a speculum examination to check for IUD string presence to exclude displacement or partial expulsion, which commonly causes abnormal bleeding 1
• Obtain pregnancy testing (urine or serum) to exclude intrauterine or ectopic pregnancy, as IUD failure can occur 2
• Screen for sexually transmitted infections (gonorrhea and chlamydia), particularly if risk factors exist, as STDs frequently present with abnormal bleeding in IUD users 1, 2
• Evaluate for new pathologic uterine conditions including endometrial polyps, fibroids, or endometrial pathology through pelvic ultrasound or hysteroscopy if clinically indicated 1, 2

Type-Specific Considerations

For Copper IUD (Cu-IUD):

• Unscheduled spotting or heavy bleeding is common only during the first 3-6 months and should decrease with continued use 1
• Persistent bleeding at 10 months indicates an underlying problem requiring investigation 1

For Levonorgestrel IUD (LNG-IUD):

• Most users achieve amenorrhea or oligomenorrhea by 10 months, making new or persistent bleeding particularly concerning 2
• New-onset bleeding after stable use represents a significant change from baseline requiring evaluation 2

Medical Management After Excluding Pathology

If no underlying condition is identified:

First-Line Treatment

• Prescribe NSAIDs for 5-7 days during bleeding episodes as first-line symptomatic treatment 1, 3
• NSAIDs reduce menstrual blood flow acutely and are effective for both Cu-IUD and LNG-IUD users 1

Additional Options for LNG-IUD Users

• Consider hormonal treatment with combined oral contraceptives or estrogen for 10-20 days if medically eligible and NSAIDs are ineffective 1, 3
• This approach is specifically recommended for LNG-IUD users with persistent bleeding 1

When Conservative Management Fails

If bleeding persists despite treatment or the woman finds it unacceptable, counsel on alternative contraceptive methods and offer device removal with replacement or alternative method. 1, 3

Critical Pitfalls to Avoid

• Do not assume spotting at 10 months is "normal adjustment bleeding" - the initial adjustment period is 3-6 months, and bleeding beyond this timeframe requires investigation 1, 2
• Do not delay evaluation - the combination of prolonged IUD use and persistent bleeding necessitates prompt assessment 2
• Do not treat empirically without excluding infection - bacterial endometritis can cause persistent bleeding and pain in IUD users and requires specific treatment 4
• Consider hysteroscopy if malposition is suspected - this allows direct visualization and potential repositioning of a displaced IUD during the same procedure, potentially avoiding unnecessary removal 5

Follow-Up Approach

• No routine follow-up visits are required for asymptomatic IUD users 1
• Advise the patient to return for any persistent symptoms, side effects, or concerns 1
• Assess satisfaction with the method and any health status changes that would affect continued safe use 1