What are the treatment options for a female patient of reproductive age with a Mirena (levonorgestrel-releasing intrauterine device) IUD experiencing pelvic pain and bleeding?

Treatment Options for Pelvic Pain and Bleeding with Mirena IUD

The first priority is to rule out serious underlying conditions through systematic evaluation: verify IUD position by checking for visible strings, obtain a pregnancy test to exclude ectopic pregnancy, screen for sexually transmitted infections, and evaluate for new uterine pathology—only after excluding these conditions should symptomatic treatment or expectant management be considered. 1, 2

Immediate Diagnostic Evaluation Required

Critical Exclusions (Must Be Done First)

• Pregnancy testing is mandatory as the first step, since ectopic pregnancy carries significant morbidity and mortality risk 2, 3
• Perform speculum examination to verify IUD strings are visible and the device is properly positioned, as displacement is a common cause of abnormal bleeding and pain 2, 4
• Screen for sexually transmitted infections (gonorrhea and chlamydia), particularly if risk factors are present, as STDs can manifest as abnormal bleeding and pelvic pain 1, 2
• Evaluate for new uterine pathology including polyps, fibroids, or endometrial abnormalities through pelvic ultrasound if clinically indicated 1, 2

Special Consideration for IUD Malposition

• Three-dimensional ultrasound may be superior to standard 2D imaging for detecting IUD malposition, as abnormally embedded devices (arms extending into myometrium) cause significantly higher rates of pain (39.3%) and bleeding (35.7%) compared to normally positioned IUDs 4
• Position-dependent symptoms (such as pain or bleeding with certain movements) strongly suggest partial expulsion or malposition 3

Management Based on Findings

If Pregnancy is Confirmed

• Evaluate immediately for ectopic pregnancy, which is life-threatening 5
• Remove the IUD as soon as possible if strings are visible or can be retrieved safely from the cervical canal, as this improves pregnancy outcomes 5
• Advise the patient that leaving the IUD in place increases risk for spontaneous abortion (including septic abortion), preterm delivery, and infection 5

If IUD Displacement/Malposition is Confirmed

• Remove the displaced IUD immediately and offer alternative contraception 2, 3
• Studies show that 95% (20 of 21) of patients with abnormally located IUDs experienced symptom improvement after removal 4

If Infection is Present

• Treat according to CDC STD treatment guidelines for pelvic inflammatory disease 5, 3
• The IUD does not need to be removed before completing evaluation, but treatment should be initiated promptly 2

If No Pathology is Found (Most Common Scenario)

Reassurance and Expectant Management

• Unscheduled spotting or light bleeding is expected during the first 3-6 months of Mirena use and is generally not harmful 5, 1
• Approximately 50% of users experience amenorrhea or oligomenorrhea by 2 years, with bleeding typically decreasing over time 5, 1
• Provide reassurance and education about expected bleeding patterns, which has been shown to improve method continuation 1

Medical Treatment Options

• NSAIDs (mefenamic acid, naproxen, or ibuprofen) for 5-7 days during bleeding episodes are first-line therapy and can reduce menstrual blood loss by 20-60% 2, 6
• Avoid aspirin, as it may paradoxically increase bleeding in some women 2
• NSAIDs may also help with pelvic pain related to prostaglandin release from the endometrium 7

When to Remove the Mirena IUD

Remove the IUD if:

• Medical management fails and the patient finds symptoms unacceptable 1, 2
• Underlying pathology is identified that cannot be adequately treated with the IUD in place 2
• IUD malposition or partial expulsion is confirmed 2, 3, 4
• Patient preference after counseling on alternatives 5, 1

After Removal

• Counsel on alternative contraceptive methods and offer another method if desired 5, 1
• Consider that the Mirena IUD itself is actually beneficial for treating menorrhagia in properly positioned devices, so switching to copper IUD would likely worsen bleeding 5, 2

Critical Pitfalls to Avoid

• Do not attribute persistent bleeding solely to "normal Mirena side effects" without proper evaluation—this can mask serious pathology including cervical cancer 8
• Do not assume bacterial infection is absent based on symptoms alone; asymptomatic endometritis can cause pain and bleeding, and treatment may alleviate symptoms without requiring IUD removal 9
• Do not rely solely on 2D ultrasound if malposition is suspected—3D coronal views detect abnormal IUD positioning that 2D imaging misses 4
• The IUD does not need to be removed before completing diagnostic evaluation for unexplained bleeding 2