Management of Bleeding After IUD Insertion
For bleeding after IUD insertion, initiate NSAIDs (ibuprofen, naproxen, or mefenamic acid) for 5-7 days during bleeding episodes as first-line therapy, which reduces menstrual blood loss by 20-60%. 1, 2
Initial Diagnostic Evaluation
Before treating bleeding, systematically rule out serious causes:
- Perform a pregnancy test (urine or serum) to exclude pregnancy, including ectopic pregnancy, which carries significant morbidity and mortality risk 2
- Conduct a speculum examination to verify IUD strings are visible and the device is properly positioned, as displacement is a common cause of abnormal bleeding 2
- Screen for sexually transmitted infections (gonorrhea and chlamydia), particularly if risk factors are present, as STDs can manifest as abnormal bleeding 2
- Evaluate for new uterine pathology (polyps, fibroids, endometrial abnormalities) through pelvic ultrasound if clinically indicated, especially in women who have been using the IUD for months and develop new-onset heavy bleeding 1, 2
Counseling and Expectant Management
Provide reassurance that unscheduled spotting, light bleeding, heavy or prolonged bleeding is common during the first 3-6 months of Cu-IUD use, is generally not harmful, and decreases with continued use. 1
- For levonorgestrel-releasing IUDs, bleeding typically decreases over time, and expectant management is appropriate if no pathology is found 2
- Enhanced counseling about expected bleeding patterns reduces method discontinuation 1
Medical Treatment Algorithm
First-Line Treatment
NSAIDs for 5-7 days during bleeding episodes:
- Specific agents include mefenamic acid, naproxen, and ibuprofen 1, 2, 3
- Avoid aspirin as it may paradoxically increase bleeding 2
- NSAIDs are effective in reducing menstrual blood loss in both Cu-IUD and LNG-IUD users 3
Second-Line Treatment (if NSAIDs fail)
For Cu-IUD users with persistent heavy bleeding:
- Add tranexamic acid for 5 days during menstruation, which reduces blood loss by 40-60% 2, 4
- Contraindicated in women with active thromboembolic disease or history of thrombosis 2
- Consider hormonal treatment with combined oral contraceptives or estrogen for 10-20 days 2
Alternative Strategy for Cu-IUD Users
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 2
IUD Removal Criteria
Remove the IUD when:
- Medical management fails and the patient finds bleeding unacceptable 1, 2
- Underlying pathology is identified that cannot be adequately treated with the IUD in place 2
- The patient requests removal after counseling on alternative contraceptive methods 1
The IUD does not need to be removed before completing the diagnostic evaluation for unexplained bleeding. 2
Common Pitfalls to Avoid
- Do not dismiss bleeding without ruling out pregnancy, infection, or structural pathology 5
- Do not recommend prophylactic ibuprofen administration with the first six menses after insertion, as studies show no effect on pain or discontinuation 3
- Do not delay evaluation beyond 3-6 months if bleeding persists, as this warrants reassessment for IUD displacement, infection, pregnancy, or new pathologic conditions 1, 2
Follow-Up Recommendations
No routine follow-up visit is required, but advise women to return at any time to discuss side effects, concerns, or if they want to change methods 1, 5
At other routine visits, assess satisfaction with the method, changes in health status, and consider checking for IUD string presence 1