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Contraception - Management
How should I manage vaginal bleeding associated with use of the copper intrauterine device (IUD)?

  • When a woman using the copper intrauterine device (IUD) has:
    • Spotting and light bleeding:
      • Inform her that spotting or light bleeding is common during the first 3–6 months of copper IUD use, that it is not harmful, and that it usually decreases over time.
      • Consider a short course of a nonsteroidal anti-inflammatory drug (e.g. mefenamic acid) to be given during the days of bleeding. For prescriptions, see the CKS topic on Menorrhagia.
    • Heavy and/or prolonged menstruation:
      • Inform her that heavier and longer menstrual bleeding is common during the first 3–6 months of copper IUD use, and that this is not harmful and bleeding becomes lighter over time.
      • Consider prescribing a nonsteroidal anti-inflammatory drug (e.g. mefenamic acid) or an antifibrinolytic (e.g. tranexamic acid); these are taken during the days of bleeding. For prescriptions, see the CKS topic on Menorrhagia.
      • If heavy bleeding remains unacceptable or if there is evidence of anaemia, consider changing to another method, such as the levonorgestrel-releasing intrauterine system.
      • To prevent anaemia, provide an iron supplement and/or encourage consumption of foods containing iron.
      • Aspirin should not be used.
  • Exclude or manage other situations which could result in unscheduled bleeding, such as:
    • Sexually transmitted infections.
      • Risk of STI if the woman is under 25 years, or has a new sexual partner, or more than one partner in the last year.
    • Misplaced device.
    • Pregnancy.
    • Gynaecological conditions such as endometrial polyps, endometrial cancer, cervical cancer, or other gynaecological abnormality.
    • Speculum examination is warranted:
      • For persistent bleeding beyond the first 3–6 months of use.
      • For new symptoms or a change in bleeding after at least 3 months of use.
      • If the woman has not participated in a National Cervical Screening programme.
      • If requested by the woman.
      • If there are other symptoms such as pain, dyspareunia, or post coital bleeding. (Note that these symptoms also warrant pelvic examination.)
  • Refer if the cause of the bleeding cannot be determined or treated in primary care.
Basis for recommendation
  • These recommendations are based on guidelines published by the National Institute for Health and Clinical Excellence (NICE) and the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) and the Department of Health [FFPRHC, 2002; FFPRHC, 2004a; National Collaborating Centre for Women's and Children's Health, 2005; DH, 2010]:
    • On the basis of expert opinion, NICE recommends that if the woman finds the heavy bleeding associated with copper intrauterine device (IUD) use unacceptable, she should consider changing to the levonorgestrel-releasing intrauterine system [National Collaborating Centre for Women's and Children's Health, 2005].
    • The FFPRHC (following the World Health Organization) recommends that for women with spotting or light bleeding between menstrual periods, a short course of nonsteroidal anti-inflammatory drugs (NSAIDs) be given during the days of bleeding [FFPRHC, 2002; WHO, 2004a].
    • The FFPRHC advises that if abnormal bleeding persists for more than 6 months, gynaecological abnormality and infection should be excluded. Although a cohort study found that bleeding was not associated with a misplaced device on ultrasonography, this should still be considered in women with persistent bleeding [FFPRHC, 2004a].

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