• Abnormal bleeding is a particular problem with the levonorgestrel-releasing intrauterine system (IUS):
• Irregular, light, or heavy bleeding is common in the first 6 months.
• About 65% of women have amenorrhoea or reduced bleeding at 1 year.
• Studies have shown that 40% of the levonorgestrel load is still present in the IUS after 5 years of use. It is therefore unlikely that any change in bleeding pattern is a result of hormone 'running out'.
• Consider managing heavy unscheduled bleeding by:
• Treating with a combined oral contraceptive (either cyclically or continuously) for up to 3 months.
• 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.

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