Definition

IUD-induced menorrhagia is a regular menstrual cycle accompanied by heavy bleeding and a longer cycle duration than usual, caused by the use of an intrauterine device (IUD) or spiral contraceptive.

An intrauterine device (IUD) is one of the most widely used contraceptive methods worldwide. About 14.3% of women of reproductive age use this contraceptive method globally, particularly in developing countries. The effectiveness of IUDs in preventing pregnancy is very high, at over 99%. An IUD is a T-shaped contraceptive device that is inserted into the uterus.

There are two types of IUDs, as explained below.

Copper IUD

This type of IUD consists of a T-shaped plastic covered with copper wire and can be used for up to 10 years. There are several types of copper IUDs, depending on the surface area of the IUD structure covered with copper. The larger the copper surface area, the longer the copper IUD will be effective.

Some types of copper IUDs available in Indonesia include CuT-200 (200 mm² copper surface area), Multiload 375 (375 mm²), and CuT380A (380 mm²). These various types of copper IUDs are sold under the brand names Andalan and Nova T in Indonesia.

Hormonal IUD

This type of IUD contains a component that stores progestin, a synthetic form of the hormone progesterone. The progestin used for this IUD is levonorgestrel. Hormonal IUDs are designed to continuously release a low dose of progestin from the IUD's stem. The amount of this hormone will decrease over time. Hormonal IUDs can be used for 3-5 years.

Causes

Mechanism of Action of IUDs

Copper IUDs work by releasing a low dose of copper into the uterus to prevent sperm from entering and fertilizing an egg. Meanwhile, the progestin hormone released by hormonal IUDs prevents egg fertilization by thickening the mucus in the cervix and altering the condition of the uterine lining.

Copper IUDs are effective in preventing pregnancy immediately after insertion and can be used as emergency contraception up to 7 days after intercourse. In contrast, hormonal IUDs take up to 7 days to become effective in preventing pregnancy.

Generally, both copper and hormonal IUDs do not interfere with the release of an egg (ovulation) from the ovaries, so women using IUDs will continue to menstruate. However, due to its hormonal effects, about 20% of hormonal IUD users do not ovulate. This causes some hormonal IUD users to potentially experience menstrual cycle complaints.

Causes of Menorrhagia

Menorrhagia is one of the side effects that can occur with IUD use. This typically happens in the first few months after insertion, when the body is still adjusting to the changes.

Several mechanisms can explain the occurrence of heavier menstrual bleeding in IUD users. One theory suggests that various changes occur in the uterine wall of women using IUDs due to an increase in the production of prostaglandins, which are produced by the body in inflammatory processes.

Increased production of prostaglandins in the body will cause:

• Increased vascularity (blood vessels)
• Molecules move more easily in and out of blood vessels
• Reduced clotting activity by platelets

These mechanisms are considered to cause some women to experience heavier and longer menstrual bleeding.

Risk Factor

Several risk factors may increase the likelihood of experiencing menorrhagia after IUD insertion. Bleeding and abdominal cramps are generally more common in copper IUD users than in hormonal IUD users. Therefore, there are certain conditions where the use of copper IUDs is not recommended, including:

• Heavy or irregular menstrual bleeding
• Severe cramps during menstruation
• Anemia, or a decrease in the body's red blood cell count
• Valvular heart disease
• Copper allergy
• Blood clotting disorders

Both copper and hormonal IUDs are not recommended for women with the following conditions:

• History of pelvic inflammatory disease
• Abnormal pap smear results
• Abnormalities in the structure of the uterus, cervix, fallopian tubes, or ovaries
• Certain medical conditions, such as leukemia or HIV/AIDS
• History of drug abuse

Symptoms

IUDs can cause side effects of heavy or irregular menstrual bleeding in some women within the first 3-6 months after insertion. Specifically, you may experience pain and bleeding for several hours or days after insertion. Some women may also experience mild bleeding that happens in the interval between two menstrual cycles (spotting).

The appearance of more specific side effects depends on the type of IUD used.

Copper IUDs are generally associated with heavier menstrual bleeding. Cramps and back pain during menstruation may also be more pronounced with copper IUDs. You do not need to worry if these side effects occur, as they are not unusual or alarming. Your menstrual period will return to normal, and the side effects will disappear after 6 months of IUD insertion.

Hormonal IUDs have side effects that are the opposite of copper IUDs. Menstrual bleeding will become lighter, and menstrual pain will decrease over time. Research shows that women who previously experienced heavy menstrual bleeding will experience a reduction in menstrual bleeding by 80–90% after hormonal IUD insertion.

Diagnosis

Menorrhagia is defined as heavy menstrual bleeding in regular intervals or menstrual bleeding lasting more than 7 days. Specifically, bleeding that exceeds 80 mL per cycle. Typically, a menstrual period lasts an average of 7 days, and the amount of blood lost is 25-80 mL. However, because the volume of blood lost is difficult to measure precisely, your doctor will assess whether you have menorrhagia based on the following symptoms:

• Changing pads every 2 hours or less because they are quickly soaked with blood
• Needing to use two layers of pads to control menstrual blood
• Waking up at night to change pads
• Release of blood clots that are larger than the size of a coin.
• Activities disrupted due to heavy menstrual flow
• Experience symptoms of anemia, such as fatigue, weakness, dizziness, or shortness of breath

Menorrhagia after IUD insertion is usually due to the side effects of the IUD itself. However, your doctor may consider other medical conditions that can also cause heavy menstrual bleeding.

To confirm the diagnosis of the cause of menorrhagia, your doctor may perform several types of tests. A physical examination is performed to examine the external and internal genitalia. Your doctor may also perform additional tests, such as:

• Blood tests to determine if you have anemia or a bleeding disorder.
• Ultrasound (USG) to determine the position of the IUD in the uterus and to detect any abnormalities in the uterus.

If your doctor suspects a tumor or malignancy in the uterus, additional tests such as a pap smear and a biopsy of a uterine tissue sample might be performed.

Management

If your doctor determines that menorrhagia is caused by the insertion of an IUD, they may suggest removing the IUD. This can stop the side effects you are experiencing, including menorrhagia. You can switch to another contraceptive after consulting your doctor. You may also be prescribed iron supplements to treat any anemia you are experiencing.

However, if the doctor determines that menorrhagia is caused by a specific disease and not the IUD, you may receive treatment tailored to address that medical condition.

Complications

The bleeding that occurs with menorrhagia can lead to iron-deficiency anemia. This happens because the bleeding reduces the amount of iron in your body, making it harder for the blood to carry oxygen throughout the body. Symptoms that may occur include:

• Fatigue and weakness
• Increased breathing rate
• Rapid heartbeat
• Dizziness or lightheadedness
• Headache

Prevention

Avoid using copper IUDs if you have risk factors as described above. The use of hormonal IUDs can be an option in such conditions. If you have risk factors that may increase the risk of menstrual disorders due to the use of either hormonal or copper IUDs, avoid using IUDs and choose other contraceptive methods.

When to See a Doctor?

Generally, the longer an IUD is used, the fewer side effects users will experience, such as menorrhagia and cramps. However, if the IUD shifts or falls out of place in the uterus, new complaints may arise. See a doctor immediately if you experience severe pain or heavy bleeding from the vagina.

You should also see a doctor if, after IUD insertion, you continue to experience menorrhagia for more than 6 months and it disrupts your activities. Symptoms such as dizziness, weakness, drowsiness, and shortness of breath may indicate anemia, so consult your doctor to treat this.

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