Patients with Bleeding Disorders Report IUD Expulsion Rates Similar to Others
The results of recent research suggest clinicians should not hesitate to insert a hormonal intrauterine device (IUD) in patients with a bleeding disorder because their IUD expulsion rate is similar to that of other women with heavy bleeding but without a bleeding disorder diagnosis.1
“There have been a few small studies in adult women with bleeding disorders that had provided conflicting results,” says Sarah O’Brien, MD, MSc, study co-author and an associate professor of pediatrics on the hematology/oncology team at Nationwide Children’s Hospital in Columbus, OH. “Some studies suggested women with bleeding disorders had higher IUD expulsion rates than the general public, and some found there were similar expulsion rates. There was fear among clinicians that this population may be at a higher rate of expulsion.” Research revealed a range of IUD expulsion rates from 3% to 10% among all people with IUDs, she adds.
O’Brien and colleagues studied all IUD adverse events, including expulsion and malposition, among a population of adolescent and young women with heavy menstrual bleeding. Some were diagnosed with a bleeding disorder, such as Ehlers-Danlos syndrome, von Willebrand disease, qualitative platelet disorders, and others.
Heavy Bleeding Can Cause Expulsions
Ninety percent of the youths enrolled in the study had tried another method to control heavy bleeding. These methods, which included combined oral contraceptive pills, nonhormonal medications, and depot medroxyprogesterone acetate injections, had failed. Among both groups, the IUD expulsion rate was about 10%, O’Brien says.
Expulsions may have been caused by their heavy bleeding. “Women with heavy menstrual bleeding, in general, may be at a bit of a higher rate of expulsion, but whether they have a defined bleeding disorder does not impact the risk,” O’Brien explains.
Up to one-third of adolescent females can experience heavy menstrual bleeding. Sometimes, they can experience anovulatory bleeding or bleeding due to an infection, a thyroid disorder, or polycystic ovary syndrome.
The study included adolescents who visited the hematology clinic because of their heavy menstrual bleeding. They underwent evaluation for a bleeding disorder. About half of the population of 78 adolescent females were diagnosed with a bleeding disorder. Researchers compared symptoms and IUD expulsions between those with heavy bleeding vs. those with a bleeding disorder.
Symptoms of heavy bleeding include:
- menses that lasts more than seven days;
- needing to change the tampon after one to two hours;
- getting up at night to change the pad;
- passing blood clots larger than a quarter or the size of a grape;
- developing iron-deficiency anemia.
Any patient with those symptoms may need a referral to a hematologist to test for a bleeding disorder.
Despite a 10% expulsion rate, patients with heavy menstrual bleeding and bleeding disorders can benefit from a hormonal IUD, such as levonorgestrel IUDs.
“These are really the best choice for women with bleeding disorders because they’re the most effective at really suppressing the menstrual blood flow,” O’Brien says. Copper IUDs would not be a good fit for these patients, she adds.
“As a pediatrician, I see a lot of barriers to IUDs in young women,” O’Brien says. “One of our hopes of our paper is to show that girls are getting IUDs and can be young.”
For instance, the mean age of IUD insertion for this adolescent and young adult population is 15 years, and the age range was 11 years to 21 years.1
“Most of our patients were not sexually active, and that’s another barrier,” O’Brien notes. “People have the misconception that you should only get it when you’re sexually active.”
Levonorgestrel IUDs now can be kept in place safely and effectively for eight years, which is another benefit to patients who select that contraceptive method. “We talk about how they’re not only wonderful treatments for controlling heavy menses, but they’re also the most effective form of contraception,” O’Brien says.
When an adolescent who started the hormonal IUD to stop heavy bleeding decides to become sexually active, they will already have a safe and effective contraceptive in place, she adds.
Physicians sometimes hear a patient say that they do not want a contraceptive method that lasts for eight years because they may wish to get pregnant before then. “I make the point that we can always remove the IUD early; it’s a simple procedure to remove it,” O’Brien says.
The study was small and involved a chart review. “We were not calling patients at regular times to learn about their experience,” O’Brien notes. “I think and hope our study shows it can help guide IUD counseling for these patients. We can let patients know the risk for expulsion, in general, seems to be 10%, and I think it is always helpful to let people know up front that sometimes expulsion occurs.”
But clinicians also can counsel patients that if this happens, the IUD can easily be reinserted. “In my experience, most people who have it replaced really do well moving forward,” O’Brien says.
Clinicians should keep in mind when counseling patients for whom an IUD is their first choice that breakthrough bleeding is common. “Give counseling on what we expect to see with breakthrough bleeding. If it’s more problematic than a few days of spotting, they should call us, and we’ll likely prescribe a hormone pill,” O’Brien says.
A combined hormonal contraceptive pill or a progestin-only option could serve as a bridge for patients, getting them through the first months of irregular bleeding and discomfort.
“As a provider, the last thing I want to see is the patient coming back six weeks later to say they are miserable with their breakthrough bleeding,” O’Brien says. “Remember to counsel patients and families about how breakthrough bleeding is very common and may require intervention in the first few months after IUD placement.”
REFERENCE
- Kendel NE, Zia A, Rosenbaum LE, et al. Intrauterine device outcomes in young women with heavy menstrual bleeding: Comparing patients with and without inherited bleeding disorders. J Pediatr Adolesc Gynecol 2022;35:653-658.
The results of recent research suggest clinicians should not hesitate to insert a hormonal IUD in patients with a bleeding disorder because their IUD expulsion rate is similar to that of other women with heavy bleeding but without a bleeding disorder diagnosis.
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