Is an intrauterine device (IUD) contraindicated for a patient with menorrhagia and anemia?

IUD Use in Menorrhagia with Anemia: Not Contraindicated and Often Therapeutic

An IUD is not contraindicated for a patient with menorrhagia and anemia—in fact, the levonorgestrel-releasing IUD (LNG-IUD) is specifically recommended as a therapeutic option for treating heavy menstrual bleeding and can improve anemia markers. 1, 2

Why IUDs Are Safe and Beneficial in This Context

Levonorgestrel IUD as Treatment for Menorrhagia

The LNG-IUD directly addresses the underlying problem rather than being contraindicated:

• The LNG-IUD significantly reduces menstrual blood loss in women with menorrhagia, with studies showing mean bleeding scores dropping from 338-368 to 52-70 after treatment (p < 0.001). 3

• Laboratory markers of anemia improve significantly within one year of LNG-IUD placement, including hemoglobin (p = 0.014), hematocrit (p < 0.001), serum iron (p = 0.003), and ferritin levels (p < 0.001). 4

• The LNG-IUD is effective for leiomyoma-dependent menorrhagia, showing significant reduction in bleeding scores with increased amenorrhea rates, making it a simple alternative to surgical treatment. 5

Actual Contraindications to IUD Use

The true contraindications to IUD placement are limited and do not include menorrhagia or anemia 1, 6:

Category 4 contraindications (unacceptable risk):

• Current pregnancy 1, 6
• Distorted uterine cavity incompatible with IUD insertion 1
• Current or recent (past 3 months) pelvic inflammatory disease 1
• Current gonorrhea, chlamydia, or purulent cervicitis 1
• Current breast cancer (for LNG-IUD only; copper IUD remains category 1) 1
• Cervical, endometrial, or gestational trophoblastic malignancy 1
• Post-septic abortion or puerperal sepsis 1
• Unexplained vaginal bleeding (until evaluated) 1, 6
• Wilson disease (for copper IUD only) 1

Clinical Decision Algorithm

Step 1: Rule Out Contraindications

• Perform pregnancy test 7
• Screen for active pelvic infection (gonorrhea/chlamydia can be done at insertion) 1
• Evaluate for structural uterine abnormalities that would prevent placement 1
• Ensure bleeding pattern has been adequately evaluated to exclude malignancy 6

Step 2: Choose IUD Type Based on Patient Goals

For menorrhagia with anemia:

• First choice: LNG-IUD (Mirena, 52mg or newer 19.5mg formulations) provides both contraception and therapeutic reduction in menstrual blood loss 1, 2, 4
• The LNG-IUD reduces menstrual blood loss by 40-50% and induces amenorrhea in a significant proportion of users 1
• Improvement in dysmenorrhea is an additional benefit 1, 2

For patients who prefer non-hormonal contraception:

• Copper IUD is acceptable but will not treat the menorrhagia and may worsen bleeding 1
• In this clinical scenario with existing menorrhagia and anemia, copper IUD would be contraindicated from a practical standpoint, though not from a safety perspective 1

Step 3: Counsel on Expected Bleeding Pattern Changes

• Initial irregular bleeding/spotting is common in the first 1-3 months after LNG-IUD insertion 1, 3
• Significant reduction in bleeding typically occurs after 1 month and continues to improve over subsequent months 3
• NSAIDs for 5-7 days can manage breakthrough bleeding if needed 1
• Amenorrhea rates increase over time and represent a therapeutic benefit, not a complication 3, 5

Common Pitfalls to Avoid

Do not withhold IUD placement due to:

• Anemia itself—this is an indication for LNG-IUD, not a contraindication 2, 4
• Nulliparity (though expulsion rates may be slightly higher, continuation rates remain ≥75% at 1 year) 1, 7
• HIV/AIDS or immunosuppression 1, 8
• History of ectopic pregnancy 9
• Presence of uterine fibroids (unless they distort the cavity) 2, 5

Do not use copper IUD in this patient:

• While not contraindicated from a safety perspective, copper IUDs can increase menstrual blood loss and would worsen the patient's anemia 1

Monitoring After Placement

• No routine follow-up visit is required for IUD users 1
• Advise patient to return if she has concerns, wants to check IUD strings, or experiences persistent problematic bleeding 1
• Consider checking anemia markers at 6-12 months to document improvement 4
• If bleeding persists despite LNG-IUD, evaluate for underlying pathology 1