IUD for Heavy Menstrual Bleeding

The levonorgestrel 52 mg intrauterine device is first-line medical treatment for heavy menstrual bleeding without a structural cause, and gives highly effective contraception at the same time. Local levonorgestrel causes endometrial atrophy, cutting measured menstrual blood loss substantially within the first 3 to 6 months and by about 90% by 12 months. Copper devices worsen heavy bleeding and are not used for this indication.

Mechanism in heavy bleeding. Sustained high endometrial levonorgestrel concentrations cause glandular atrophy and decidualisation of the stroma, with reduced prostaglandin production.

Effect on blood loss and anaemia. Blood loss falls progressively; about 1 in 5 patients are amenorrhoeic by 1 year. Haemoglobin and ferritin rise over 6 to 12 months.

Device choice. Only the 52 mg device is used. The 19.5 mg and 13.5 mg devices give insufficient endometrial suppression for this indication.

Duration and return to fertility. Replace at 5 years. Fertility returns immediately on removal.

Definition. Heavy menstrual bleeding is excessive menstrual loss that interferes with physical, social or emotional quality of life, regardless of measured volume.

History. Bleeding duration, flooding, clots, pad changes at night, symptoms of anaemia, intermenstrual or postcoital bleeding, pelvic pain, pressure symptoms, bleeding disorder history, medicines (anticoagulants, tamoxifen), and endometrial cancer risk factors (obesity, polycystic ovary syndrome, diabetes, unopposed oestrogen, nulliparity).

Examination. Abdominal palpation for a pelvic mass, speculum examination of the cervix, and bimanual examination for uterine size and contour.

Investigations.

• Full blood count in all patients.
• Pregnancy test where pregnancy is possible.
• Pelvic ultrasound if the uterus is palpable abdominally, a mass is felt, examination is inconclusive, or fibroids or adenomyosis are suspected.
• Endometrial sampling if age 45 or over with persistent bleeding, persistent intermenstrual bleeding, risk factors for endometrial hyperplasia, or failure of treatment.
• Coagulation screen if heavy bleeding since menarche or a personal or family bleeding history.
• Cervical screening if due, and STI testing if at risk.

Eligibility. Heavy or prolonged bleeding is category 1 for initiating the levonorgestrel device and category 2 for continuing it if bleeding worsens. It is category 2 for a copper device. Unexplained bleeding suspicious of serious pathology is category 4 for both until evaluated. Fibroids distorting the uterine cavity are category 4.

Expulsion risk. Higher in heavy menstrual bleeding, adenomyosis and an enlarged uterus; counsel the patient and confirm position at follow up.

Regimen line. Levonorgestrel 52 mg intrauterine device; transcervical insertion; insert at any time during bleeding or within 7 days of menses start with no backup, or at other times if reasonably certain not pregnant with backup for 7 days; replace at 5 years; no adjustment for weight, kidney disease or enzyme inducers; avoid initiation with severe decompensated cirrhosis, liver tumours and current breast cancer.

Insertion during bleeding. Insertion is not delayed for heavy flow; heavy bleeding does not prevent placement.

Bridging treatment for the first 3 months.

• Tranexamic acid 1 g orally three times daily for up to 4 days during each heavy bleed; maximum 4 g daily; avoid with past or current venous thromboembolism; reduce dose in kidney impairment.
• Mefenamic acid 500 mg orally three times daily for up to 5 days during bleeding; avoid in kidney impairment, peptic ulcer disease and asthma worsened by nonsteroidal anti-inflammatory medicines.

Iron replacement. Ferrous sulphate 200 mg (65 mg elemental iron) orally once daily, or on alternate days if poorly tolerated, continued for 3 months after haemoglobin normalises. Intravenous iron where oral iron fails or anaemia is severe.

Follow up. Review at 3 to 6 weeks for threads and bleeding, then at 3 and 6 months with haemoglobin. Expect substantial improvement by 3 to 6 months.

Early irregular bleeding. Common for 3 to 6 months. Continue bridging treatment and reassure, after excluding pregnancy, infection and expulsion.

Expulsion. Suspect with a sudden return of heavy bleeding, cramping, or lengthened threads. Confirm by speculum examination and ultrasound and reinsert if appropriate.

Treatment failure at 6 months. Repeat ultrasound for device position, fibroids and adenomyosis; take an endometrial sample; reconsider coagulation disorders. Options include combined hormonal contraception if eligible, progestogens, and surgical treatment (hysteroscopic resection of submucous fibroids or polyps, endometrial ablation once fertility is complete, or hysterectomy).

Hormonal effects. Breast tenderness, acne, mood change and functional ovarian cysts, usually transient.

Referral and escalation. Refer urgently for haemoglobin under 7 g/dL, symptomatic anaemia or haemodynamic compromise. Refer to a gynaecologist for atypical hyperplasia or malignancy on sampling, cavity-distorting fibroids, or bleeding not controlled at 6 months.