Treatment for bleeding disorders

The use of progestin preparations occasionally leads to breakthrough bleeding or spotting. This is usually temporary and does not require treatment. Even after insertion of the first hormonal IUS, irregular bleeding often occurs in the first 3-6 months, which then becomes much less frequent. At the end of the first year, most women only bleed 1-2 days per month and almost half of women have no bleeding at all. This aspect should be discussed in detail during the consultation before insertion. (If the IUS is removed after 3-5 years and a new one is placed immediately, the existing bleeding pattern is retained, with no increased bleeding.)

Occasionally, the bleeding is longer lasting or stronger after inserting a first hormonal IUS. However, it is not possible to predict the individual risk of prolonged or increased bleeding because there are no known risk factors. Therapy should be offered if either the patient’s quality of life is impaired or there is a medical reason for the prolonged loss of blood. No standard therapy is currently available for these situations, but the following options are available:

  • Exclusion of myomas or a wrong position of the IUD/IUS either by ultrasound or hysteroscopy. (The IUS/IUD can remain in place after hysteroscopy).
  • Additional intake of a combined oral contraceptive, or administration of oral or transdermal estradiol or ethinyl estradiol for 3 months.
  • Provision of Mifepristone (progesterone receptor antagonist), which blocks the progesterone receptor and stimulates the formation of the estrogen receptor in the endometrium. This can be enhanced by the addition of 20 mcg ethinyl estradiol per day 2-5. The endometrium can thicken again and bleeding stops.
  • 100mg Doxycycline, twice daily for 5 days. The effect of doxycycline or tetracycline is to inhibit the effect of the matrix metalloproteinases on matrix degeneration in connective tissue. Matrix metalloproteinases are important in the endometrium for the formation of the mucous membrane. A changed pattern of matrix metal proteinases has been proven in users of long-term progestin preparations.
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Tranexamic acid

A summary procedure for treatment of bleeding due to pure gestagen-containing contraceptives can be found in:

  • Bleeding disorders under pure progestin long-term contraception with subdermal implants Part 2: Management of additional bleeding under subdermal implants, Der Frauenarzt, 2011, Hans-Joachim Ahrendt, Christian Egarter
  • M. Ludwig: Hormonal Contraception – A Handbook for Practice, 2009
  • Bleeding pattern changes with progestogen-only long-acting reversible contraceptives, Sexual Health & Family Planning Australia
  • Treatment of vaginal bleeding irregularities induced by progestin only contraceptives. Abdel-Aleem H, d’Arcangues C, Vogelsong KM, Gülmezoglu AM. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003449