Management of Bleeding in IUD Users Desiring Amenorrhea
For a patient with an IUD experiencing persistent monthly bleeding who desires to stop menstruation, norethisterone is NOT the appropriate first-line treatment—instead, NSAIDs (mefenamic acid 500 mg three times daily for 5 days) should be tried first, followed by tranexamic acid if NSAIDs fail, with norethisterone reserved only as an off-label option after ruling out underlying pathology. 1, 2, 3
Initial Evaluation Required
Before initiating any treatment, the following must be excluded: 1, 4
- IUD displacement (check for presence of strings and proper positioning) 4
- Pregnancy (especially if bleeding pattern changed abruptly) 1, 4
- Sexually transmitted infections or pelvic inflammatory disease 1, 4
- New pathologic uterine conditions (polyps, fibroids) 1, 4
- Thyroid disorders 3
Treatment Algorithm for IUD-Associated Bleeding
First-Line: NSAIDs
- Mefenamic acid 500 mg three times daily for 5 days during bleeding episodes 2, 3
- Alternative: Ibuprofen for 5-7 days 3
- NSAIDs have demonstrated statistically significant reductions in mean menstrual blood loss in copper IUD users 1
- Can be repeated as needed during subsequent cycles 2
Second-Line: Tranexamic Acid
- Tranexamic acid 3.9 grams daily (1.3 grams three times daily) for 5 days starting from first day of bleeding 3
- Use only if NSAIDs fail or are contraindicated 3
- Absolute contraindications: active thromboembolic disease, history of thrombosis, intrinsic thrombosis risk factors, cardiovascular disease 3
- One study showed significant reduction in mean blood loss among copper IUD users with heavy bleeding 1
Third-Line: Combined Oral Contraceptives (if medically eligible)
- Low-dose combined oral contraceptives for 10-20 days 2, 3
- Only for patients without contraindications to estrogen 2
Why Norethisterone Is NOT Standard for IUD Bleeding
Critical limitations of norethisterone in this context:
- Not FDA-approved for contraception and requires alternative barrier contraception if used 5
- Thromboembolism risk: Norethisterone has documented association with increased thrombosis risk, particularly in patients with underlying risk factors 1, 6
- No guideline support: CDC guidelines for IUD-associated bleeding do not recommend progestin therapy for levonorgestrel IUD users 1, 4
- Contraindicated in: history of thromboembolic disorders, severe arterial/cardiovascular disease, undiagnosed vaginal bleeding, liver tumors [@drug label provided@]
If Norethisterone Is Considered (Off-Label)
Should only be attempted after failure of standard therapies and thorough risk assessment: 7
- Dose: 5 mg norethisterone acetate daily (based on research showing efficacy when added to progesterone-only pills) 7
- Duration: Limited to short courses; avoid use >6 months due to meningioma risk 1
- Monitoring: Close surveillance for thrombotic complications 6
- One study showed significant decrease in bleeding frequency at 2,4, and 6 weeks when norethisterone was added to progesterone-only contraception 7
When to Consider IUD Removal
Counsel on alternative contraceptive methods and consider IUD removal if: 1, 2
- Bleeding persists despite medical management 1
- Bleeding severely impacts quality of life 2, 3
- Patient finds bleeding unacceptable after appropriate treatment trials 1, 4
Important Clinical Considerations
Type of IUD Matters
- Copper IUD: Heavy/prolonged bleeding more common; NSAIDs and tranexamic acid have evidence 1, 4
- Levonorgestrel IUD: Spotting common in first 3-6 months, then typically decreases; approximately 50% achieve amenorrhea by 2 years 1, 4
Counseling Points
- Unscheduled spotting/light bleeding during first 3-6 months of LNG-IUD use is expected and generally not harmful 1, 4
- Enhanced counseling about expected bleeding patterns improves continuation rates 4
- Amenorrhea with LNG-IUD does not require treatment—provide reassurance 1
Common Pitfall
Do not automatically attribute new bleeding to concurrent medications without first investigating underlying gynecological causes 4