Managing Menstrual Irregularities After Mirena Insertion: A Patient's Journey

Metrorrhagia and Hysteroscopy Examination

I am 46 years old and had a Da Vinci surgery eight years ago to remove 7 cm and 5 cm uterine fibroids, but the results were not satisfactory; I still experience heavy menstrual bleeding that lasts 9 to 10 days.
Last year, the amount of menstrual blood increased compared to previous years, so in January of this year, I consulted a doctor at a large hospital.
The doctor recommended that I get a Mirena IUD.
After the insertion of the Mirena, my first menstrual period had about half the usual flow, but I have been experiencing continuous light bleeding since then.
By April, during my third menstrual period, I had heavy bleeding with large blood clots, which lasted for four days.
Although the bleeding decreased afterward, the amount remained significant.
On the 17th day, I returned to the clinic, and the doctor confirmed that the Mirena was in the correct position.
The doctor then prescribed me Dydrogesterone, Tranexamic Acid, and Naproxen.
After taking the medication, my first menstrual period was lighter and ended on the 7th day, followed by only brown discharge.
However, my subsequent menstrual periods have again been characterized by light bleeding that does not stop.
Until my menstrual period on July 15, the flow was not heavy, but I experienced continuous bleeding every day.
I returned for a follow-up on July 27, and the doctor prescribed the same medications again, stating that my condition would stabilize after a year.
However, my understanding is that the adjustment period is typically three to six months, and I have already had the Mirena for eight months with ongoing bleeding.
Even while taking Dydrogesterone, I still experience daily light bleeding.
I am very concerned that there may be other underlying issues.
Should I have the Mirena removed, or should I continue to wait for my uterus to adapt? Alternatively, can I undergo a hysteroscopy before removing the Mirena?

Ms. Wu, 40~49 year old female. Ask Date: 2022/08/16

Dr. Huang Yuande reply Obstetrics and Gynecology

Generally, a hysteroscopy is not performed when a Mirena IUD is in place.
One of the issues with Mirena is that it may not completely stop bleeding, leading to intermittent spotting.
Treatment options may include hormone supplementation or the use of medications to promote uterine contraction.
It is important to discuss the benefits and risks of these approaches with your physician.

Reply Date: 2022/08/16

More Info

Managing menstrual irregularities after the insertion of a Mirena IUD can be a challenging experience, especially for women who have previously undergone significant gynecological procedures, such as myomectomy for uterine fibroids. Your situation, characterized by prolonged and heavy menstrual bleeding, is not uncommon among women who have had similar medical histories.
The Mirena IUD, which releases levonorgestrel, is often used to treat heavy menstrual bleeding and can help regulate menstrual cycles over time. However, it is important to understand that the adjustment period after insertion can vary significantly from person to person. While some women may experience a reduction in bleeding and a more regular cycle within a few months, others may continue to experience irregularities for a longer period.

In your case, it appears that while the initial insertion of the Mirena led to a reduction in menstrual flow, you have since experienced persistent light bleeding and significant episodes of heavy bleeding with clots. This can be concerning, especially given your history of fibroids and the surgical interventions you have undergone.
It is essential to communicate openly with your healthcare provider about your ongoing symptoms. The fact that your doctor has already ruled out displacement of the IUD is a positive step, but it does not eliminate the possibility of other underlying issues. The medications you have been prescribed, including Diane-35 (a combination of estrogen and progestin), Tranexamic acid (an antifibrinolytic), and Naproxen (an anti-inflammatory), are commonly used to manage heavy menstrual bleeding and may help in stabilizing your cycle. However, if you continue to experience irregular bleeding, it may be necessary to explore further diagnostic options.

Regarding your concerns about whether to remove the Mirena or continue waiting for your body to adjust, this is a decision that should be made in consultation with your healthcare provider. If your symptoms persist or worsen, it may be advisable to consider removal, especially if you are experiencing significant discomfort or anxiety about the situation.
Additionally, performing a hysteroscopy (a procedure that allows direct visualization of the uterine cavity) could provide valuable information about the state of your uterus and help identify any potential abnormalities, such as polyps or residual fibroid tissue, that may be contributing to your symptoms. This procedure can often be done in an outpatient setting and may provide clarity on the next steps in your treatment plan.

In summary, while the Mirena IUD can be an effective treatment for heavy menstrual bleeding, it is crucial to monitor your symptoms closely and maintain open communication with your healthcare provider. If you continue to experience irregular bleeding beyond the expected adjustment period, further evaluation may be warranted to rule out other potential causes and to determine the best course of action for your health and well-being.

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