Heavy Bleeding on Contraception

Heavy or prolonged bleeding during contraceptive use is bleeding lasting more than 8 days or twice as long as the patient’s usual menses, or heavy enough to cause anaemia or interfere with life. It is most often seen with copper intrauterine devices, injectables and implants, and may unmask existing gynaecological disease or a bleeding disorder.

Assessment of severity. Number of pads or tampons and flooding, clots, duration, effect on daily life, symptoms of anaemia (fatigue, dyspnoea, palpitations, pallor), and haemodynamic state.

History. Method and duration of use, bleeding before the method, fibroids, adenomyosis, endometriosis, thyroid disease, easy bruising, family history of bleeding disorder, anticoagulant or antiplatelet use, pregnancy symptoms, pain, discharge and fever.

Examination. Vital signs, pallor, abdominal mass or tenderness, speculum examination for cervical lesions, bimanual examination for uterine size and tenderness, and device threads.

Differential diagnosis. Expected effect of the method, pregnancy complications (incomplete or threatened miscarriage, ectopic pregnancy), pelvic infection, fibroids, adenomyosis, endometrial polyp, device malposition or partial expulsion, cervical or endometrial pathology, coagulopathy, thyroid disease and anticoagulant effect.

Investigations. Pregnancy test. Full blood count and ferritin where available. Pelvic ultrasound. Thyroid function and coagulation screen when history suggests. Cervical screening if due. Endometrial sampling for persistent bleeding over 45 years of age or with risk factors.

Indications for urgent care. Haemodynamic instability, haemoglobin under 7 g/dL, bleeding with pain and a positive pregnancy test, or severe pain with fever.

General. Treat the cause. If no underlying gynaecological problem is found and the patient wishes to continue the method, offer one of the following.

Anaemia. Treat with elemental iron 100 to 200 mg orally daily in divided doses until haemoglobin normalises and for 3 months afterwards. Transfuse for symptomatic severe anaemia with instability.

Device specific. If bleeding persists with a copper intrauterine device and no pathology is found, remove the device when bleeding is unacceptable or anaemia develops, and offer another method.

Injectable specific. If the patient presents 8 weeks or more after the last injection, a repeat injection with a reset return date may speed amenorrhoea.

Life threatening bleeding. Stop the method, give fluids and blood as needed, and refer for emergency evaluation.

Follow up. Review within 3 months, repeat haemoglobin, and continue iron for 3 months after normalisation.

Method decisions. Remove the implant or intrauterine device and choose another method if bleeding persists, becomes a threat to life or is unacceptable. A method that reduces bleeding, such as a levonorgestrel intrauterine device or a progestin-only method, is considered when the cause is a copper device and pathology is excluded.

Referral and escalation. Refer fibroids or adenomyosis needing surgery, suspected neoplasia, coagulation disorders, severe anaemia and haemodynamic instability.