What is the management plan for a female patient of reproductive age with an intrauterine device (IUD) experiencing prolonged menstruation for 2 weeks?

Management of Prolonged Menstruation (2 Weeks) in an IUD User

Start with NSAIDs (ibuprofen, naproxen, or mefenamic acid) for 5-7 days as first-line therapy, which reduces menstrual blood loss by 20-60% in copper IUD users, while simultaneously completing a diagnostic evaluation to rule out pregnancy, infection, IUD displacement, and uterine pathology. 1, 2, 3

Immediate Diagnostic Evaluation

Before initiating treatment, complete the following assessments:

• Pregnancy test (urine or serum) to exclude intrauterine or ectopic pregnancy, which carries significant morbidity and mortality risk 1, 2
• Speculum examination to verify IUD strings are visible and the device is properly positioned, as displacement is a common cause of abnormal bleeding 1, 2
• STI screening (gonorrhea and chlamydia) if risk factors are present, as infections can manifest as abnormal bleeding 1, 2
• Pelvic ultrasound if clinically indicated to evaluate for new uterine pathology including polyps, fibroids, or endometrial abnormalities 1, 2

First-Line Medical Management

Initiate NSAIDs immediately for 5-7 days during the bleeding episode, as this is the CDC-recommended first-line therapy 1, 2, 3:

• Specific NSAIDs studied include mefenamic acid, naproxen, and ibuprofen 1, 3
• These agents reduce menstrual blood loss by 20-60% in copper IUD users 1, 4, 3
• Avoid aspirin, as high-dose aspirin paradoxically increases blood loss in women with baseline menorrhagia 1, 3

Second-Line Treatment Options

If NSAIDs fail after 5-7 days:

• Add tranexamic acid for 5 days during menstruation, which reduces blood loss by 40-60% 1, 4, 3
• Tranexamic acid is contraindicated in women with active thromboembolic disease or history of thrombosis 1
• Consider hormonal treatment with combined oral contraceptives or estrogen for 10-20 days if the patient is using the IUD solely for contraception 1

IUD Type-Specific Considerations

For Copper IUD Users:

• Heavy or prolonged bleeding is common during the first 3-6 months and generally decreases over time 2, 5
• If medical management fails and bleeding remains unacceptable, remove the copper IUD and replace with a levonorgestrel-releasing IUD, which is highly effective for treating menorrhagia 1

For Levonorgestrel IUD Users:

• Heavy or prolonged bleeding is uncommon with LNG-IUDs 2
• If bleeding persists beyond 3-6 months, evaluate for IUD displacement, infection, pregnancy, or new pathologic uterine conditions 1
• Provide reassurance and expectant management if no pathology is found, as bleeding typically decreases over time 1, 2

When to Remove the IUD

Remove the IUD if:

• Medical management fails and the patient finds bleeding unacceptable 1
• Underlying pathology is identified that cannot be adequately treated with the IUD in place 1
• Patient preference after counseling on alternative contraceptive methods 1, 2

The IUD does not need to be removed before completing the diagnostic evaluation 1

Critical Pitfalls to Avoid

• Do not attribute bleeding solely to the IUD without first ruling out pregnancy, infection, displacement, and uterine pathology 1, 2
• Do not use aspirin for bleeding control, as it may worsen menorrhagia 1, 3
• Do not delay pregnancy testing, as ectopic pregnancy carries significant mortality risk 1
• Do not automatically remove the IUD before attempting medical management, unless the patient specifically requests removal or pathology requires it 1

Counseling and Follow-Up

• Counsel the patient that bleeding irregularities with copper IUDs are generally not harmful but can deplete iron stores, particularly in women with baseline low ferritin 2, 5
• If bleeding persists despite medical management, counsel on alternative contraceptive methods including switching to an LNG-IUD, combined hormonal contraceptives, or barrier methods 1, 2
• Continuation rates improve when patients receive proper counseling about expected bleeding patterns before IUD insertion 2