How should I manage a woman with a copper intrauterine device who is experiencing prolonged heavy menstrual bleeding?

Management of Prolonged Heavy Menstrual Bleeding with Copper IUD

For a woman with a copper IUD experiencing prolonged heavy menstrual bleeding, first rule out underlying gynecological problems (IUD displacement, STD, pregnancy, or new pathologic uterine conditions), then treat with NSAIDs for 5-7 days during bleeding episodes; if bleeding persists and is unacceptable to the patient, counsel on alternative contraceptive methods. 1

Initial Assessment and Timing Considerations

Determine duration of IUD use. Heavy or prolonged bleeding is common and generally not harmful during the first 3-6 months of copper IUD use, typically decreasing with continued use. 1 This represents a normal adaptation period rather than a pathological condition. 1

If the patient has been using the copper IUD for several months or longer and develops new-onset heavy or prolonged bleeding, clinical evaluation is indicated to exclude underlying problems. 1

Diagnostic Evaluation

Evaluate for the following conditions when clinically indicated: 1

• Copper IUD displacement - Check for proper positioning
• Sexually transmitted disease - Screen as appropriate
• Pregnancy - Rule out intrauterine or ectopic pregnancy
• New pathologic uterine conditions - Consider polyps or fibroids

If any underlying gynecological problem is identified, treat the condition or refer for appropriate care. 1

Medical Management

If no underlying gynecological problem is found and the woman requests treatment:

First-Line Treatment: NSAIDs

Prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) for short-term treatment (5-7 days) during days of bleeding. 1

The evidence supporting NSAIDs is substantial: 1

• Nine studies demonstrated that various oral NSAIDs (indomethacin, mefenamic acid, flufenamic acid, diclofenac sodium, suprofen) produced statistically significant or notable reductions in mean total menstrual blood loss compared to placebo or baseline. 1
• All but one NSAID study showed benefit for heavy or prolonged menstrual bleeding. 1

Alternative Treatment: Tranexamic Acid

Tranexamic acid can significantly reduce mean blood loss in copper IUD users with heavy bleeding, but has important safety limitations. 1

Critical contraindication: Tranexamic acid is contraindicated in women with active thromboembolic disease or with a history or intrinsic risk for thrombosis or thromboembolism per FDA warning. 1 Data regarding overall safety are limited. 1

Avoid Aspirin

Do not use aspirin for treatment. Aspirin demonstrated no significant benefit in women with pretreatment menstrual blood loss >60 mL and actually resulted in a significant increase in blood loss among women whose baseline loss was <60 mL. 1

When Medical Management Fails

If bleeding persists despite treatment and the woman finds it unacceptable, counsel her on alternative contraceptive methods and offer another method if desired. 1 This represents the definitive management when conservative measures fail, prioritizing the patient's quality of life over IUD retention.

Counseling and Reassurance

Provide reassurance that bleeding irregularities are generally not harmful. 1 Enhanced counseling about expected bleeding patterns has been shown to reduce method discontinuation in clinical trials with other contraceptives. 1

Common Pitfalls to Avoid

• Do not assume all bleeding is benign - Always consider underlying pathology, especially in established users with new-onset symptoms. 1
• Do not delay evaluation - Pelvic inflammatory disease risk is slightly higher in the first 3 months after insertion, with about 6 pelvic infections per 1000 woman-years of IUD use. 2
• Do not use routine antibiotic prophylaxis - It is unnecessary for bleeding management. 2
• Recognize that evidence for specific drug regimens is limited - While general recommendations exist, evidence for specific doses and durations is lacking. 1