How should acute bleeding occurring within 72 hours of levonorgestrel‑releasing intrauterine device (Mirena) removal be evaluated and managed?

Acute Bleeding Within 72 Hours of Mirena Removal: Evaluation and Management

Acute bleeding occurring within 72 hours of Mirena removal requires immediate clinical evaluation to exclude retained products, uterine injury, or underlying pathology, followed by symptomatic management with NSAIDs if no structural cause is identified. 1

Immediate Evaluation Steps

The evaluation must systematically exclude serious complications:

• Rule out incomplete removal or retained fragments by verifying complete device extraction and checking for any remaining IUD components, as displacement or fragmentation can cause acute bleeding 2
• Exclude pregnancy complications, including ectopic pregnancy, which remains a critical differential diagnosis even after recent IUD removal 2, 3
• Assess for uterine perforation or cervical trauma from the removal procedure itself, particularly if bleeding is severe with large clots 1
• Screen for sexually transmitted infections that may have been present during IUD use and are now manifesting as abnormal bleeding 2, 3
• Evaluate for new or previously masked uterine pathology such as polyps, fibroids, or endometrial abnormalities that were suppressed by the levonorgestrel effect 2, 3

Understanding Post-Removal Bleeding Patterns

Context is essential when evaluating post-removal bleeding:

• The levonorgestrel IUD causes profound endometrial suppression during use, with approximately 50% of users experiencing amenorrhea or oligomenorrhea by 2 years 2, 4
• Menstrual patterns and fertility return to normal soon after removal, meaning the endometrium rapidly regenerates and may initially produce heavier-than-expected bleeding 5, 6, 7
• Heavy or prolonged bleeding is uncommon during LNG-IUD use, so acute heavy bleeding after removal may represent either normal endometrial recovery or underlying pathology that was masked 2, 1

Management Based on Findings

If Structural Complications Are Identified

• Retained IUD fragments require removal, either in the office or via hysteroscopy depending on location and accessibility 2
• Uterine perforation or significant cervical trauma necessitates immediate referral to gynecology for surgical evaluation 1
• Identified uterine pathology (polyps, fibroids) should be treated according to standard protocols or referred for definitive management 2, 3

If No Structural Cause Is Found

First-line symptomatic treatment consists of NSAIDs for 5-7 days:

• Mefenamic acid, ibuprofen, or naproxen significantly reduce menstrual blood loss by 20-60% in multiple studies 2, 3, 4
• NSAIDs work by reducing prostaglandin synthesis, which decreases both bleeding volume and associated cramping 2
• Treatment can be repeated as needed for subsequent bleeding episodes 2

Alternative pharmacologic options if NSAIDs are insufficient or contraindicated:

• Tranexamic acid (antifibrinolytic) for 5 days may reduce blood loss, though evidence is limited and it carries an FDA warning against use in women with thrombotic risk 2
• Short-course combined oral contraceptives or estrogen for 10-20 days can stabilize the endometrium, though this is typically reserved for persistent rather than acute bleeding 2

Critical Clinical Pitfalls to Avoid

Do not dismiss large clots or soaking through protection as "normal post-removal adjustment." While some increased bleeding is expected as the endometrium recovers from levonorgestrel suppression, baseball-sized clots or severe bleeding requiring same-day evaluation indicate excessive blood loss that demands immediate assessment 1

Do not attribute all post-removal bleeding to the device removal itself without excluding pregnancy. Ectopic pregnancy can occur even shortly after IUD removal and carries significant morbidity and mortality risk 2, 3

Do not overlook the possibility of previously masked pathology. The profound endometrial suppression from levonorgestrel may have concealed underlying conditions (polyps, fibroids, endometrial hyperplasia) that now become symptomatic after removal 2, 3

When to Provide Reassurance Versus Escalate Care

• Mild to moderate bleeding without large clots in the first few days post-removal likely represents normal endometrial recovery and can be managed expectantly with NSAIDs 5, 6, 7
• Severe bleeding with large clots, hemodynamic instability, or severe pain requires same-day evaluation and possible intervention 1
• Persistent heavy bleeding beyond 7-10 days despite NSAID therapy warrants further investigation with pelvic ultrasound and consideration of endometrial sampling 2, 3