What are the treatment options for breakthrough bleeding with an Intrauterine Device (IUD)?

Management of Breakthrough Bleeding with IUD

For breakthrough bleeding with an IUD, first rule out pregnancy, infection, and IUD displacement, then treat with NSAIDs for 5-7 days during bleeding episodes as first-line therapy. 1, 2

Initial Assessment

Before initiating any treatment, evaluate for underlying pathology that could explain the bleeding:

• Check for IUD displacement by verifying string presence on pelvic examination 1, 2
• Rule out pregnancy with urine or serum hCG testing 3
• Screen for sexually transmitted infections (STDs), particularly if the patient has been using the IUD for several months and develops new-onset bleeding 1
• Consider new pathologic uterine conditions such as polyps or fibroids, especially in established IUD users with new bleeding patterns 1

If any underlying gynecological problem is identified, treat the condition or refer for specialized care rather than treating the bleeding symptomatically. 1

Counseling and Expectant Management

Reassure patients that breakthrough bleeding is common and generally not harmful, particularly during the first 3-6 months of IUD use. 1, 2

Copper IUD (Cu-IUD):

• Unscheduled spotting, light bleeding, heavy bleeding, or prolonged bleeding is expected during the first 3-6 months 1
• Bleeding typically decreases with continued use 1

Levonorgestrel IUD (LNG-IUD):

• Irregular bleeding is common in the first 3-6 months 2
• Approximately 50% of users experience amenorrhea or oligomenorrhea by 2 years of use 2

Medical Treatment Algorithm

First-Line Treatment: NSAIDs

If bleeding persists beyond the initial adjustment period and the patient requests treatment, prescribe NSAIDs for 5-7 days during bleeding episodes. 1, 2, 4

• NSAIDs reduce menstrual blood loss by 20-60% in Cu-IUD users 5, 4
• Multiple NSAIDs have demonstrated efficacy including mefenamic acid, indomethacin, flufenamic acid, and diclofenac 1, 4
• Avoid aspirin, as it may increase bleeding in some patients 1

Second-Line Treatment for LNG-IUD Users

If NSAIDs are ineffective in LNG-IUD users, add hormonal treatment with combined oral contraceptives (COCs) or estrogen for 10-20 days. 2, 3

This approach is specific to LNG-IUD users and provides additional hormonal support during the adjustment period. 2, 3

Alternative Agents (Limited Evidence)

Tranexamic acid can be considered for Cu-IUD users with heavy bleeding, though safety data are limited. 1, 5, 4

• One study showed significant reduction in menstrual blood loss with tranexamic acid 1
• Critical caveat: Tranexamic acid is contraindicated in women with active thromboembolic disease or history of thrombosis 1
• Use for 5 days during menstruation if prescribed 5

When to Consider IUD Removal

If bleeding persists despite treatment and the patient finds it unacceptable, counsel about alternative contraceptive methods and offer method change. 1, 2

The decision to remove the IUD should be made when:

• Medical treatment fails to adequately control bleeding 1, 2
• The patient's quality of life is significantly impacted 1
• Underlying pathology is identified that warrants removal 2

Common Pitfalls to Avoid

• Do not dismiss bleeding without ruling out pregnancy, infection, or structural pathology 3
• Do not routinely schedule follow-up visits—instead, advise patients to return if they have concerns or if bleeding becomes unacceptable 1
• Do not assume all bleeding is benign—new-onset heavy bleeding in established IUD users warrants investigation for pathology 1