How can I manage a patient who experiences heavy menstrual bleeding after IUD insertion?

Management of heavy menstrual bleeding (HMB) following intrauterine device (IUD) insertion:

• First, exclude pregnancy by performing a pregnancy test.
• Consider the possibility of a malpositioned device or underlying gynaecological conditions such as cervical or endometrial cancer; if suspected, refer urgently via a suspected cancer pathway.
• Perform a speculum and pelvic examination if bleeding persists beyond 3–6 months, if new symptoms or changes in bleeding occur after 3 months, or if the woman has not participated regularly in cervical screening.
• If structural abnormalities are suspected, consider transvaginal ultrasound and/or hysteroscopy.
• If no other cause is found and examinations are normal, reassure the woman that irregular bleeding is a common adverse effect of intrauterine contraception.
• Offer pharmacological treatment options for heavy menstrual bleeding, including tranexamic acid, a nonsteroidal anti-inflammatory drug (NSAID), or combined oral contraceptives, depending on suitability and patient preference.
• If heavy bleeding remains unacceptable or if anaemia develops, consider changing to another contraceptive method.
• If the cause of bleeding cannot be determined or managed in primary care, refer to gynaecology for further assessment.

These steps align with the Faculty of Sexual and Reproductive Healthcare (FSRH) clinical guideline and NICE recommendations for managing bleeding related to intrauterine contraception.