How should I evaluate and manage heavy or prolonged bleeding after removal of a Mirena (levonorgestrel‑releasing intrauterine device)?

Heavy Bleeding After Mirena IUD Removal

After Mirena (levonorgestrel-releasing IUD) removal, heavy bleeding represents the return of your patient's baseline menstrual pattern that was previously suppressed by the device, and management should focus on ruling out pregnancy and structural pathology, then treating the underlying menorrhagia with first-line NSAIDs or considering Mirena reinsertion if contraception is still desired.

Initial Diagnostic Evaluation

Your first priority is excluding life-threatening conditions:

• Obtain a pregnancy test immediately (urine or serum) to rule out pregnancy, including ectopic pregnancy, which carries significant morbidity and mortality risk 1, 2
• Perform a speculum examination to assess for cervical pathology, retained IUD fragments, or other sources of bleeding 1, 2
• Screen for sexually transmitted infections (gonorrhea and chlamydia), particularly if risk factors are present, as STIs can manifest as abnormal bleeding 1, 2
• Evaluate for structural uterine pathology through pelvic ultrasound if clinically indicated, looking for polyps, fibroids, or endometrial abnormalities that may have developed during IUD use 1, 2

Understanding the Mechanism

The heavy bleeding after Mirena removal is typically not a complication but rather the unmasking of the patient's baseline menstrual pattern:

• The levonorgestrel-releasing IUD causes profound endometrial suppression during use, reducing menstrual blood loss by 71-95% 3
• Menstrual patterns return to baseline within 1-2 cycles after removal, and fertility returns quickly 4, 5, 6
• Women who had menorrhagia before insertion will likely experience heavy bleeding again after removal 4, 5

First-Line Medical Management

If no pathology is identified and the patient requires treatment for heavy bleeding:

• Initiate NSAIDs for 5-7 days during menstruation as first-line therapy, which reduces menstrual blood loss by 20-60% 3, 1, 2
• Specific NSAIDs include mefenamic acid, naproxen, or ibuprofen, but avoid aspirin as it may paradoxically increase bleeding 1, 2

Second-Line Treatment Options

If NSAIDs are insufficient:

• Add tranexamic acid for 5 days during menstruation, which reduces blood loss by 40-60%, but is contraindicated in women with active thromboembolic disease or history of thrombosis 1, 2
• Consider hormonal treatment with combined oral contraceptives or estrogen for 10-20 days if medically eligible 3, 1

Definitive Management: Mirena Reinsertion

If the patient still requires contraception and finds the bleeding unacceptable, reinsertion of a levonorgestrel-releasing IUD is the most effective reversible treatment for menorrhagia:

• The levonorgestrel-releasing IUD is comparable in efficacy to endometrial ablation for treating heavy menstrual bleeding, with 71-95% reduction in menstrual blood loss 3
• Reinsertion provides both contraception and treatment of the underlying menorrhagia 4, 5, 6
• Most women experience amenorrhea or minimal bleeding after 3-6 months of use, though initial irregular spotting is common 4, 5, 6

Alternative Contraceptive Options

If the patient does not want Mirena reinsertion:

• Counsel on alternative contraceptive methods that may also reduce bleeding, such as other hormonal contraceptives 3, 1
• Consider endometrial ablation if contraception is not needed and medical management fails, though this has higher reintervention rates compared to starting with the levonorgestrel-releasing IUD 7

Common Pitfalls to Avoid

• Do not dismiss heavy bleeding without ruling out pregnancy, infection, or structural pathology, as these require specific interventions 1, 2
• Do not delay evaluation beyond 3-6 months if bleeding persists or worsens, as this warrants reassessment for new pathologic conditions 1, 2
• Do not assume the bleeding is abnormal without understanding the patient's pre-IUD menstrual pattern, as return to baseline heavy bleeding is expected in women who had menorrhagia before insertion 4, 5

When to Consider Surgical Intervention

If medical management fails and the patient finds bleeding unacceptable:

• Endometrial ablation techniques (thermal balloon, microwave, radiofrequency) may be considered for definitive management, particularly if the patient does not desire future fertility 3
• Surgical intervention has greater long-term efficacy than oral medical treatment for heavy menstrual bleeding 3