Why Periods Become Heavier and More Painful After Paragard IUD
Heavy, prolonged, and painful periods after Paragard (copper IUD) insertion are a normal, expected side effect caused by the copper's inflammatory effect on the uterine lining, which increases prostaglandin production and local bleeding. 1
Mechanism of Increased Bleeding and Pain
The copper IUD triggers a local inflammatory response in the endometrium that leads to:
- Increased prostaglandin synthesis in the uterine lining, which promotes bleeding and uterine cramping 2
- Enhanced fibrinolytic activity that prevents normal clot formation and prolongs menstrual flow 3
- Local tissue inflammation that increases both blood loss volume and pain perception 4
These changes are generally not harmful and represent the device's normal physiologic effect rather than a complication 1.
Expected Timeline
Most bleeding and pain side effects decrease significantly over the first 3–6 months of use as the uterus adapts to the device 1. Specifically:
- Menstrual bleeding volume and pain during menses typically improve with continued use 5
- Intermenstrual spotting may persist or even increase in frequency over the first year, though this varies 5
- Women who develop new-onset heavy bleeding after several months of stable use require clinical evaluation to exclude underlying pathology 1, 6
When to Investigate Further
If you've had the Paragard for several months and suddenly develop worsening bleeding, your provider should evaluate for 1, 6:
- IUD displacement or malposition (check string position and consider ultrasound)
- Sexually transmitted infections (perform appropriate screening)
- New uterine pathology such as polyps, fibroids, or endometrial abnormalities
- Pregnancy (though rare with IUD in place)
Treatment Options
First-Line: NSAIDs During Bleeding Days
Take NSAIDs for 5–7 days during menstruation when bleeding is heaviest 1, 6. The evidence is strong:
- Nine randomized trials demonstrated that NSAIDs (mefenamic acid, ibuprofen, indomethacin, diclofenac, naproxen) significantly reduce menstrual blood loss in copper IUD users 6, 2
- All but one study showed statistically significant benefit 6
- NSAIDs work by inhibiting prostaglandin synthesis, directly addressing the mechanism of IUD-related bleeding 2, 4
Important caveat: Prophylactic NSAID use (taking ibuprofen every month preventively for the first 6 months) does NOT reduce IUD removal rates and is not recommended 7, 2, 4. Only use NSAIDs when you're actually bleeding.
Second-Line: Tranexamic Acid
If NSAIDs fail, tranexamic acid can markedly reduce menstrual blood loss 6, 4. However:
- It is contraindicated if you have any history of blood clots or high thrombosis risk (FDA warning) 6
- Safety data are limited in this population 6
- Consider this only after NSAID failure and appropriate screening 6
What NOT to Use
Avoid aspirin – it showed no benefit and actually increased bleeding in some women 6
When to Consider IUD Removal
If bleeding persists despite NSAID therapy and remains unacceptable to you, discuss alternative contraceptive methods with your provider 1, 6. Quality of life matters, and no contraceptive method is worth tolerating intolerable side effects.
Common Pitfalls
- Don't assume all heavy bleeding is "normal IUD bleeding" – established users with new symptoms need evaluation 6
- Don't prescribe prophylactic NSAIDs for months on end – they don't prevent discontinuation and waste medication 7, 2
- Don't forget to counsel patients BEFORE insertion that these changes are expected and usually temporary – proper counseling reduces discontinuation rates 1