Is All Uterine Bleeding Considered Dam Nidos?

Chukat 5780

The intrauterine device (IUD) is a common method of contraception that can be utilized for an extended period. Broadly speaking, IUDs may be divided into two groups; copper devices and hormone-releasing devices.

 IUDs are T-shaped devices placed into the uterus that have either copper-coated arms[1] or a reservoir that releases a steady amount of hormone[2]. Several copper IUDs available in Europe and Asia (including Israel) have anchoring knots or other mechanisms of securing the IUD to the myometrium, but neither the copper IUD used in the United States nor the hormonal devices invade the uterine wall at all. Multiple theories exist to explain the precise mechanism(s) of contraception but will not be discussed here as they are not germane to the Halachic issues at hand. In order to introduce the IUD, a speculum is placed, the cervix is stabilized by means of a tenaculum, the uterine cavity is measured using a sound[3], and the device is inserted.

In the following paragraphs we will discuss whether bleeding that occurs during the insertion of an IUD – or afterwards – renders a woman a Nidah. We will also examine the possibility that she is a Nidah due to the very nature of the procedure, even if she does not experience any bleeding.

The Poskim disagree as to whether uterine bleeding that occurs due to a wound or disease renders a woman a Nidah. The Shev Yaakov (37) and Chazon Ish (Y.D. 81) hold that the Torah only considers a woman a Nidah when she bleeds due to her menstrual cycle. However, the Chacham Tzvi (46) and Chasam Sofer (154) rule that any uterine bleeding renders a woman a Nidah. This is also a matter of dispute among contemporary Poskim.

Furthermore, even the Poskim who rule leniently in this matter disagree as to whether uterine bleeding that is caused by the insertion of a medical instrument (which pierces the endometrium) renders a woman a Nidah. Rav Shlomo Zalman Auerbach zt”l (Shulchan Shlomo, Erkei Refua 3, p25) and Rav Ovadia Yosef zt”l (Taharas haBayis 3, p25) held that we may be lenient in this case as well and assume that the bleeding is due to an abrasion of the endometrial lining and is not menstrual blood (“Dam Nidos”)[4]. However, the Chazon Ish, in a 1948 exchange of letters with Dr. Moshe Taub[5], ruled stringently.

In his letter to Dr. Taub, the Chazon Ish inquired as to the source of the bleeding that is caused by insufflation of the uterus[6]. In a subsequent letter, he elaborated that Halacha considers three types of uterine bleeding:

1. Menstrual bleeding (Dam Nidos)
2. Non-menstrual bleeding due to an external cause (“Ones”) or injury to the uterus and similar to that which occurs after birth or miscarriage[7]. This also renders a woman a Nidah.
3. Bleeding due to an endometrial abrasion, which is similar to the bleeding of a wound in any area of the body.

The Chazon Ish wanted to ascertain whether the bleeding that occurs due to insufflation was the second type of bleeding and would therefore render a woman a Nidah or if it was bleeding that would occur with a similar injury to any other organ or part of the body.

Dr. Taub replied:

Bleeding that occurs due to insufflation of the uterus should be considered of the third sort, namely, bleeding that is due to an injury or wound similar to that which occurs in other areas of the body…the bleeding that occurs during the said procedure is caused by an external factor – an artificial and mechanical cause, and is not due to any particular characteristic of the uterus.

On the basis of Dr. Taub’s letter, the Chazon Ish was lenient if the bleeding was caused by an abrasion of the endometrium during a medical procedure. However, if the endometrial arteries were disrupted and uterine bleeding occurs, the woman is to be considered a Nidah (as it is Dam Nidos), even though the bleeding was prompted artificially[8].

As stated, the Chazon Ish’s view is that uterine bleeding due to a wound or disease does not render a woman a Nidah. Why then does he rule that bleeding due to an intrauterine procedure does cause her to be a Nidah?

We must say that, according to the Chazon Ish, uterine bleeding only causes a woman to become a Nidah when it takes place in the normal manner (i.e. cyclic shedding of the endometrial lining). If the bleeding is caused by disease or some other external cause, though it may instigate uterine bleeding, it is not the regular process and therefore the woman does not become a Nidah. However, where the bleeding is caused by an invasive intrauterine procedure, any bleeding that occurs is considered to be release of Dam Nidos and the woman is considered a Nidah.

Most contemporary Poskim are stringent regarding uterine bleeding that is caused by medical treatment. Regarding the insertion of an IUD, some are lenient, arguing that the bleeding may not be Dam Nidos, particularly given that the bleeding may even come from the cervix which is stabilized during the process (and which is not considered Halachically to be a part of the uterus in this regard)[9]. The Poskim do differentiate between the copper devices that invade the uterine wall (see above) and the other devices. As described earlier, these devices penetrate the fundus during placement in order to secure the device. Therefore, there is a concern that any bleeding is not merely due to an abrasion but is endometrial bleeding and considered Dam Nidos.

We have discussed the status of bleeding that occurred during the insertion of an IUD or soon afterwards. Is there any ground for suspicion that bleeding has occurred when it has not been observed?

The Shulchan Aruch (Y.D. 188) asserts that, “There is no opening of the uterus without bleeding”. If the cervix has been dilated to a certain width (see below), we must assume that there was bleeding, even if it wasn’t been observed.

There is a great controversy among the Poskim as to when this law applies[10]. According to some, we only assume that bleeding must occur during spontaneous dilation, such as during labor, when the uterus is preparing to expel its contents. Others hold that even if the cervix is dilated artificially (e.g. during a medical examination or procedure), bleeding is also inevitable. This is because they assume that the uterus contains menstrual blood at all times that is being held back by the cervix (until menstruation or delivery occurs). If the cervix is opened in any manner, whether spontaneously or artificially, bleeding is therefore bound to take place.

Contemporary Poskim have the same dispute. Rav Ovadia Yosef zt”l (Taharas haBayis 11:7) and others rule leniently and do not consider a woman to be a Nidah following a medical examination unless she sees blood. Rav Shmuel Wosner zt”l (Shevet haLevi 6:129) and Rav Elyashiv zt”l (Mishmeres haTahara 1:13) and others rule stringently.

However, they all agree that if the uterus has only been opened by fewer than three millimeters, one needn’t assume that bleeding has taken place (Nishmas Avraham, Y.D. 194). Some rule that if it has been opened by as much as three millimeters one should be stringent (Shiurei Shevet haLevi 188:3 & Mishmeres haTahara ibid. citing Rav Elyashiv). Others hold that one may be lenient up to a width of 15 or even 19 millimeters (see Igros Moshe, Y.D. 1:89, Levushei Oz 188:3, and Badei haShulchan 188:31 and footnote 55).

Therefore, according to the lenient opinions, when inserting an IUD, a woman is not considered to be a Nidah for we do not assume that bleeding has occurred when the uterus is opened artificially. However, according to those who hold that we always assume that bleeding has occurred and that this occurs when the uterus has opened as little as three millimeters, she would be considered to be a Nidah for even devices that do not have a diameter of three millimeters, the instrument that is used to insert them does. Those who hold that one may be lenient up to a width of 15 or 19 millimeters would not consider a woman who is inserting an IUD to be a Nidah, as neither the device nor the inserter are that wide.[11]

[1] E.g. Paragard (US); Gynefix, Nova-T, and Ballerine in Europe and Asia.

[2] E.g. Kyleena, Mirena, or Skyla

[3] A sterile instrument with a rounded tip used to measure the length and direction of the cervical canal and uterus.

[4] Rav Shlomo Zalman did concede that if the procedure took place shortly before she expected to menstruate, she should be stringent, as it is possible that the procedure prompted early menstruation.

[5] These letters were published in HaPardes v35 no6 (March 1961) and are reproduced in their entirety in the Shulchan Shlomo ibid.

[6] In the early and mid-20^th century, the workup of infertility would often include insufflation of the uterus with air to determine whether the Fallopian tubes were obstructed. This procedure has largely been abandoned due to improved imaging technology and the risk of air embolism with insufflation.

[7] The Chazon Ish distinguished between bleeding that was due to the unique nature of the uterus and its lining and bleeding caused by an injury that would occur if any other tissue or part of the body was similarly injured.

[8] See Shulchan Shlomo ibid. which cites a letter written by the Chazon Ish (to his student and nephew R’ Shaul Barzam zt”l) that declares that it is difficult to rely fully upon the medical opinion that the bleeding following insufflation performed to facilitate conception is due to a wound caused by insertion of the instrument and is not endometrial bleeding. He therefore rules that we should be stringent and perform this procedure prior to Tevila (after waiting a day as a Shomeres Yom k’Neged Yom) but that we can rely upon the physicians’ opinion to permit Tevila without waiting a full Shiva Nikiyim.

[9] The Poskim do differentiate between the Gynefix (see footnote 1 above) and the other devices. As described earlier, the Gynefix has an anchoring knot that penetrates the fundus during placement in order to secure the device. Therefore, there is a concern that any bleeding is not merely due to an abrasion but is endometrial bleeding and considered Dam Nidos.

[10] There is a great deal of Halachic literature on this subject. We will only cite the Chazon Ish (Y.D. 82:3) as an example of those who ruled leniently in this regard and the Noda b’Yehuda (Mahdura Tinyana, Y.D. 120) who ruled stringently.

[11] Some Rabbanim rule stringently even if no bleeding is observed and the cervix has not been dilated beyond 15 millimeters, as they believe that in most cases the endometrium is pierced during the insertion of an IUD.