Managing Breakthrough Bleeding

Time will heal most bleeding

When a woman experiences unscheduled bleeding, the differential diagnosis is large:

• Normal in a new user
• Normal, owing to decreased LNG-release over time
• Normal, following an IUC replacement
• Displacement of IUC
• Ectopic pregnancy
• Gynecologic disorders of cervix or uterus, or ovaries (e.g. large cyst)
• Infection
• Pregnancy

Breakthrough bleeding in a new user
Reassure women that the IUC is still effective when unscheduled bleeding is present. Review swab results (if previously done) – if not done, consider STI testing and pelvic examination. An ultrasound may provide reassurance that the IUC is located in the correct position.

Copper IUD users: There is limited evidence that NSAIDS (ibuprofen, naproxen) and Antifibrinolytics (Tranexamic Acid) may reduce bleeding, however prophylactic use of NSAIDS is ineffective. ASA increases bleeding in Copper IUD users. If no contraindications exist, consideration for short-term use of a combined hormonal contraceptive is acceptable (3 months and reassess).

LNG-IUS users: Unscheduled bleeding is common for the first few months following placement and is usually time-limiting. Typically, bleeding patterns at 6 months will remain throughout the use of the IUS. There is limited evidence to support the use of combined hormonal contraception for short-term use (3 months) as well as low-dose doxycycline (50 mg daily). There is no evidence to support the use of NSAIDS among IUS users to reduce bleeding.

When there is a new onset of bleeding following amenorrhea, examination should be performed to rule out lower-genital tract pathology (polyp, infection, ectropion). Women who are using an IUS for menstrual management who experience bleeding in years 4 or 5 may benefit from early replacement.

An endometrial biopsy can be performed with an IUC in situ, however this should be performed by an experienced clinician.

New onset bleeding in prolonged user

Possible causes of new onset abnormal bleeding after prolonged use of IUCs:

• Normal. Some women experience a return of menses after a period of amenorrhea
• Normal. Towards the end of the duration of use of an IUS, menses may return
• Normal, if bleeding recurs after replacing an IUS
• Malpositioning of IUC (embedment, expulsion, and perforation)
• Ectopic pregnancy
• Other gynaecological conditions (e.g. cervix or uterus)
• Genital tract infection
• Pregnancy

More information about Unscheduled Bleedings

Costescu D. and Guilbert E. et al. Preceptorship Program on IUC insertion - Module 4
Royal College of Obstetricians & Gynaecologists - Management of unscheduled bleeding in women using hormonal contraception. 2009