• Reassure the woman that menstrual irregularities (spotting, light bleeding, heavy and/or prolonged menstruation) are common in the first 3–6 months but usually subside.
• Consider prescribing mefenamic acid for spotting/light bleeding or tranexamic acid for heavy and/or prolonged bleeding.
• To prevent anaemia, provide an iron supplement and/or encourage consumption of foods containing iron.
• 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.

In depth