The Law of Bleeding Caused by an IUD

by HaRav Eliezer Melamed
Rosh HaYeshiva, Har Bracha

The important principle set by our Sages concerning the law of menstrual stains is to be lenient * Doctors are doubtful if the bleeding caused by the intrauterine device is the result of a wound or inflammation * The practical halakha: a woman with an IUD in her uterus should minimize bedikot as much as possible, and not wear white undergarments * In contrast to claims by stringent poskim, it is doubtful whether to attribute the bleeding to the device, consequently, when not during menstruation, halakha follows the lenient opinion

This column is intended for lamdanim (well-educated Torah scholars), and yet I chose to publish it here in my weekly column because it deals with an important halakhic question that has a great impact on the lives of many married couples, and every man and woman with an average or higher capability should know these issues as part of their Torah learning.

One way to prevent pregnancy is by inserting an IUD (intrauterine device) into the uterus. A small, often T-shaped device is inserted into the uterus, and in a way that is not entirely clear, prevents pregnancy. The problem is that usually, after the insertion of the device into the uterus, a woman’s veset (the day a woman expects her period) is prolonged by a day or two, and even after that, light bleeding commonly comes out of the uterus, especially during the shivah neki’im (seven blood-free days). A very practical question is: does this bleeding render a woman ritually impure?

Since this halakha, which I explained in my new book ‘Peninei Halakha: Taharat Ha-Mishpacha’ (chapter two, footnote 14), aroused questions, I will clarify its reasoning.

Which Blood Renders Impure
The impure blood that comes out of the uterus rendering a woman tameh (ritually impure) from the Torah is on the condition that it came out with a bodily sensation similar to that of niddah blood. However, if it comes out without a bodily sensation, even if it certain that it came out of the uterus and its color is similar to the color of impure blood, it does not render her ritually impure.

However, our Sages also decreed impurity on blood that came out of the uterus without a bodily sensation, and, this blood in halakha is called “ketem” (stain), and they decreed that it is tameh only if it meets three conditions: 1) it is more than two centimeters in diameter. 2) It is found on something white. 3) It is found on something that receives tumah (impurity). In other words, a stain at least two centimeters in diameter on a cloth or white object – renders impure. Why did our Sages determine to render stains impure? Because in the times when taharot (pure items) were practiced in Israel, blood that came out of the uterus without a bodily sensation, even though it did not forbid a wife to her husband, he himself was tameh, and rendered taharot that he touched, tameh. Therefore, our Sages decreed that at any time he is liable to render taharot impure, his wife is forbidden to him, provided that the three aforementioned conditions are met, without which he would not have made taharot impure (Tosafot Niddah 58a, “ke’Rebbe“; Rashba, in the name of his Rav, Rabbeinu Yona; Ran and Meiri, Niddah 57b; Chatam Sofer, Niddah 58a; Sho’el U’Mashiv 141 Kama, 1: 153; Hitorarut Teshuvah 3: 22).

However, our Sages declared a great principle, namely, that whenever there is a safek (doubt) in the law of ketamim, we go according to the lenient ruling, and as Rabbi Akiva said: “The Sages did not state the matter of the impurity of blood stains in order to be stringent; rather, they instituted this impurity in order to be lenient” (Mishna, Niddah 58b).

Blood Found in the Vagina
A woman who performed a bedika (examination) deep in her vagina, even if the bedika was with a colored cloth that does not receive tumah, and found a little blood like the size of a mustard seed, is ritually impure. Since it is in the depths of the vagina near the opening of the uterus, there is concern that it came out with a bodily sensation at the time, or in previous hours. And although the chances are that there was no bodily sensation, our Sages determined that if the blood was in the depths of the vagina, as long as there is no explanation for it being there, it is presumed to be blood that came out with bodily sensation, and it renders her impure (Peninei Halakha: Taharat Ha-Mishpacha: 2, 12).
Blood of a Wound is Pure

However, if the blood comes out of a wound in the vagina or even in the uterus – it does not render a woman tameh, as our Sages said: “A woman is faithful to say: I have a wound in my makor (uterus) from which blood comes out …” and then, even if blood came out of the uterus, she is ritually pure (Niddah 16a). However, there is a difference between two situations. 1) If the woman knows that the blood she saw came out of a wound in her uterus or vagina, even if the blood is found in a bedika peni’mit (self-performed internal examination) during the time of onat ha-veset (the time when her period is expected to appear), she is pure. 2) If the woman knows that she has a wound in her uterus that sometimes bleeds, and she has a doubt whether the blood she has just found in a bedika peni’mit is from the same wound, in the ona of her kavuah veset (fixed menses), she is rendered ritually impure, but at other times, ritually pure (Tosafot, Niddah 16a, ‘u’mar savar’; R’ma, YD 187:5-6, Shach 26). And then there are poskim who are even more lenient, and this is the opinion of Rashba and Shulchan Aruch (according to most of his commentators), that even when a woman is not sure whether the wound in her uterus occasionally bleeds, it is sufficient that she knows she has a wound to her uterus that is liable to bleed. And although this opinion is important, and in principle, since the foundation of this law is from Divrei Chachamim (rabbinical ordinance), I could have been lenient as Shulchan Aruch, but in practice, regarding blood that is found in a bedika peni’mit, I wrote according to the strictest opinion, that only when a woman knows that the wound in her uterus can sometimes bleed, can she be lenient with a bedika peni’mit, and not when she has a safekthe wound in her uterus bleeds. There are two reasons for this: 1) since many of the Achronim were machmir (stringent) in this matter. 2) Nowadays it is possible to go to a doctor to check if she has a wound in her uterus that is liable to bleed, and therefore, instead of relying on a woman’s safek whether she has a wound that bleeds, it is preferable for her to go to a doctor (Peninei Halakha: Taharat Ha-Mishpacha 2: 13, footnote 14).

Intrauterine Device
Now we come to the question of an IUD placed inside the uterus. In practice, as mentioned, the presence of an intrauterine device in the uterus often causes prolongation of menstruation, and additional bleeding. It is not clear to doctors what the exact reason is; is it because the presence of the device in the uterus causes injury to the uterine lining, or does it cause an inflammatory response designed to remove the foreign body, and causes bleeding, or uterine dilation, which is somewhat similar to what happens during menstruation.

Some poskim are machmir, and are concerned that these hemorrhages are considered bleeding of the uterine dilation, similar to menstruation (Nishamat Avraham 194:5, 6 in the name of Risha and Rabbi Neuwirth; Be’Ohala shel Torah 1: 24; Rabbi Yonatan Blass, Techumin 31).

Then, there poskim who are lenient, since there is a possibility that this bleeding is due to a wound (Rabbi Eliyahu Abergel in Debrot Eliyahu 6:36, Rabbi Kapach, also implied by Taharat HaBayit 1:5; Vol. 1, pg. 267; Rabbi Dr. Halperin ‘Refuah, Mitziyut, ve’Halakha 21).

The Practical Halakha
In practice, I wrote in my book ‘Taharat Ha-Mishpacha’ (2: 14): “After menstruation has ended and a woman became taharah, even if blood is found in a bedika peni’mit, as long as it is not as much as usual from menstruation, it can be assumed that it is blood that came out of a wound caused by the device.” However, in order to absolve the safek, it is correct for a woman who has a device that causes bleeding, to avoid performing bedikot penimi’ot that are not necessary for her purification, rather, be satisfied with two bedikot for all the seven days (ibid. 4:8), and avoid wearing white undergarments (see, ibid. 4, footnote 9).

This is because as long as doctors are doubtful about whether the bleeding caused by the device came out due to a minor wound caused by the device injuring the uterus or an inflammatory response, and even if caused by an inflammatory response, maybe this reaction is considered to be somewhat similar to a wound, then it is a situation in which the blood found in a bedika peni’mit may have come from a wound, and as long as it is not her onat ha-veset, it does not render her ritually impure.

The Claim of the Machmirim, and My Answer
Some rabbis argued against me that they have asked several doctors, and since the doctors do not know how to explain why the device causes bleeding, we should be machmir. My answer is that the law is the exact opposite. Only when doctors say with certainty that blood that came out because of the device is not considered blood of a wound, should we be machmir. In other words, because there was no bodily sensation of menstruation, as long as the doctors are doubtful, even if there is only a ten percent chance that the blood found in a bedika peni’mit is due to a wound that the device caused uterine dilation, a woman is ritually pure. Moreover, as we have learned, that when a woman thinks she has a wound in her uterus and does not know if the blood came out from the wound, as long as it is not in her onat ha-veset, she is ritually pure.

These rabbis asked: previous poskim were only lenient when a woman knows that there is a wound in her uterus, whereas in this situation, when there is an IUD, it is not certain that there is a wound. My answer: if in the past when there was no means to know what happens inside the uterus, a woman who said ‘I have a wound in my uterus’ was trusted, i.e., she felt a type of pain, or saw bleeding of a different kind, kal ve-chomer (all the more so) that when an IUD was inserted into the uterus, which is known to millions of women that it can cause bleeding, it should be considered as a wound which sometimes bleeds.

Therefore, as long as it is not the onat ha-veset, and it is blood that came out without a clear bodily sensation, since there is a ten percent or more chance that it came out of a wound caused by the device, it does not render her ritually impure.

Conditions of the Halakha
However, one can be lenient in this matter provided it is clear that it is bleeding caused by the device. For example, before she had a device, menstruation lasted only six days, and even now, she was able to become taharah at the end of the sixth day and thus remove herself from the presumption of tumah,however, atypically, she found blood during the shiva niki’im in a bedika peni’mit, and presumably, it was caused by the device. However, if due to the prolongation of menstruation, she was unable to perform a hefsek taharah, then it is a relatively heavy bleeding and should be considered a continuation of menstruation, and only after she performs a hefsek taharah, if she finds blood on the bedika peni’mitbeyond the days she normally saw, can she assume that it came from a wound caused by the device. Additionally, if after she performs a hefsek taharah, she sees a large amount of blood, similar to the blood she finds towards the end of her veset, she should be machmir, since sometimes the majority of menstrual blood comes out continuously, and then stops, and comes out again, until its completion.

Hormonal IUD
I also added (ibid, 2: 16) that even if it is an IUD with hormones, one can be lenient in this matter. For indeed, although the hormones cause the uterine lining to become thin and tend to bleed, we also find that taking hormonal pills sometimes causes bleeding; nevertheless, in the latter case, a woman should not be lenient (ibid. 2: 8). This is because seeing as the device was actually inserted into the uterus, there is a possibility that the device wounded the uterus, or provoked an inflammatory reaction that caused bleeding due to the wound, and consequently, the law concerning such a woman is similar to that of a woman who has a wound that is liable to bleed, and the blood she found in a bedika peni’mit is pure. This, provided it is a light bleeding that is clearly not in the framework of her veset, nor is it a light menstruation, which is sometimes made light due to the effect of the hormones.