New Attention to the IUD

• Heavier or longer menstrual bleeding compared with menstrual bleeding before IUD insertion

• Reassure her that heavier and longer menstrual bleeding is common, especially in the first 3 to 6 months of IUD use. Generally this is not harmful and bleeding usually becomes lighter over time.
• If she wants treatment, tranexamic acid and/or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can help reduce the bleeding (34, 35, 83, 129, 241, 243, 269, 280). NSAIDs also help ease pain from uterine cramps (see below). Aspirin should not be used because it may increase bleeding.
• If heavier or longer menstrual bleeding began long after the IUD was first inserted, check for gynecological problems. If a gynecologic problem is found or suspected, treat or refer. She can continue using her IUD while her condition is being evaluated.
• To avoid anemia, give her iron supplements and/or name foods containing iron (such as meat—especially beef and chicken liver, eggs, green leafy vegetables, potato with the skin, and nuts), and advise the woman to eat more of them if possible.
• If the client wishes or if bleeding continues to be heavy or prolonged—and especially if she shows signs of severe anemia—remove the IUD and help her choose another method. Counsel her about the LNG-IUD if available.

Cramping

• Perform speculum and bimanual exams to check for underlying conditions that may cause cramping, such as PID, partial expulsion, perforation, or ectopic pregnancy. If any of these conditions are suspected or found, see instructions for these problems below.
• If no underlying condition is found and cramping is not severe, reassure the client that she can expect some cramping pain for the first day or two after insertion and that some copper-IUD users report more cramps or pain during monthly bleeding. If she wants treatment, NSAIDs, such as ibuprofen, can help ease pain from uterine cramps.
• If no underlying condition is found and cramping is severe, remove the IUD.
  • If the IUD looks abnormal or if difficulties during removal suggest that it was or had become improperly placed, explain to the client that she can have a new IUD inserted which may alleviate the cramping. If she does not want another IUD, help her choose another method.
  • If the IUD looks normal, help her choose a different contraceptive method that suits her body better. Counsel her about the LNG-IUD if available.

Partner can feel IUD strings

• Explain to woman (and partner, if possible) that this happens sometimes when the strings are cut too short. If partner finds strings to be bothersome, describe available options:
  • Strings can be cut even shorter so they are not coming out of the cervical canal and her partner will not feel the strings.  The woman will no longer be able to check her IUD strings.
  • Otherwise, the IUD can be removed and a new one inserted if the woman wants to be able to check her IUD strings. (The strings should be cut 3 cm from the cervix to avoid discomfort.)

Anemia

• The copper-bearing IUD may make the condition worse in a woman who already has anemia. Pay special attention to IUD users coming to the clinic with any of the following signs and symptoms:
  • Inside of eyelids or underneath fingernails looks pale, pale skin, fatigue or weakness, dizziness, irritability, headache, ringing in the ears, sore tongue, and/or brittle nails.
  • If blood testing is available, hemoglobin less than 9 grams per liter or hematocrit less than 30.
• Provide iron tablets if possible.
• Name foods containing iron (such as meat—especially beef and chicken liver, eggs, green leafy vegetables, potato with the skin, and nuts) and advise her to eat more of them if possible.
• If her condition does not improve or she shows signs of severe anemia, remove the IUD and help her choose another method. Consider the LNG-IUD if available.
• Refer for diagnosis and care as necessary.

Lower abdominal pain that suggests pelvic inflammatory disease (PID)

May also have:

• Painful intercourse
• Bleeding after sex or between periods
• Pain associated with periods (if this symptom was absent during the first few months after IUD insertion but developed later)

1. Diagnose.

Take history and do abdominal and pelvic exams.

Diagnose as PID if she has any of the following signs and no other cause(s) for the illness can be identified:

• Lower abdominal, uterine or adnexal tenderness (tenderness in the ovaries or fallopian tubes)
• Evidence or signs of cervical infection (yellowish cervical discharge containing mucus and pus, bleeding easily when the cervix is touched with a swab, or a positive swab test)
• Tenderness or pain when moving the cervix and uterus during pelvic exam

She may also have the following signs and symptoms:

• Abnormal vaginal discharge
• Painful urination
• Fever
• Nausea and vomiting
• Enlargement or hardening of one or both fallopian tubes
• A tender pelvic mass
• Pain when the abdomen is gently pressed or when gently pressed and then suddenly released

Note:
Diagnosis can be difficult. PID signs and symptoms may be mild or absent. Also, some common signs and symptoms of PID often also occur with other abdominal conditions, such as ectopic pregnancy or appendicitis. If ectopic pregnancy and appendicitis are ruled out, clinicians should suspect PID.

Because of the serious consequences of PID, health care providers should treat all suspected cases. Treatment should be started as soon as the presumptive diagnosis has been made, because prevention of long-term complications is more successful if appropriate antibiotics are given immediately.

2. Treat or immediately refer for treatment. Treat for gonorrhea, chlamydia, and anaerobic infections.

3. She can continue using the IUD if she wants to keep it (4, 242). If she wants it removed, take it out 2 to 3 days after antibiotic treatment has been started.

If it is taken out, consider providing emergency contraceptive pills if needed and help her choose another contraceptive method.

4. Follow up. If the woman’s symptoms of acute infection, such as pain, fever, and chills, do not improve within 2 or 3 days after starting treatment, she should be sent to a hospital. If she improves, however, schedule another follow-up for her just after she has finished taking all of her medicine.

5. Treat sex partner(s). Urge the client to have her sex partner or partners come for treatment of gonorrhea and chlamydia.

6. Counsel the client about condom use to help protect against future sexually transmitted infections. If possible, give her condoms.

Current sexually transmitted infection (STI) or purulent cervicitis (an infection of the cervix with a pus-like discharge from the opening of the cervix)

• Diagnose and treat the STI, or refer.
• The IUD can stay in place during treatment, if the client wants to keep it. If she wants it removed, take it out. If it is taken out, consider providing emergency contraceptive pills if needed and help her choose another contraceptive method.
• Urge the client to have her sex partner or partners come for STI treatment. Counsel the client about STIs and condom use. If possible, give her condoms.

Missing strings (suggesting possible pregnancy, uterine perforation, or expulsion)

Rule out pregnancy. Ask the client:

• When she had her last menstrual period
• If she has any symptoms of pregnancy
• When she last felt the strings
• If she used a back-up method from the time she noticed the strings missing

Conduct a physical exam, use an ultrasound, or use a pregnancy test, if available, to rule out pregnancy. If she is pregnant follow procedure for pregnancy below. If pregnancy is ruled out, continue trying to locate IUD strings.

Locating the IUD:

1. Always start with minor and safe procedures and be gentle. Check for the strings in the folds of the cervical canal with Bozeman or alligator forceps. About half of missing IUD strings can be found in the cervical canal (19).
2. If strings cannot be located in the cervical canal, either they have retracted into the uterus or the IUD has been expelled unnoticed.
   • If the woman wants the IUD removed, a sound can be used to check whether the IUD is in the uterus. Attempt to draw out the strings using Bozeman or alligator forceps and use the strings to remove the IUD. Be careful not to injure the uterus. If strings still cannot be found, follow step 3 below.
   • If she wants to keep the IUD, do not perform any intrauterine manipulations with a sound or forceps because it may dislodge the IUD. Follow step 3 instead.
3. If strings still cannot be found after sounding or if intrauterine manipulations are not performed, obtain an x-ray, or ultrasound if x-ray is unavailable. (An x-ray will show an IUD that is outside the uterus).
   • If the IUD is located in the uterus and the woman wants to keep it, explain that she is protected from pregnancy but that she will not be able to feel the strings.
   • If the IUD is located in the uterus and the woman no longer wants the IUD, remove it using alligator forceps. If it is difficult to retrieve, refer her to a more experienced provider.
   • If perforation or expulsion is suspected or found, see instructions for these problems below.

• 6 weeks or more after insertion 

• Experienced clinicians can use forceps to remove partially perforated IUDs that are stuck in the wall of the uterus or the cervix.
• If complete perforation is discovered 6 weeks or more after insertion and the client has no symptoms, it is best to leave the IUD in place. Copper-bearing IUDs may become partially or completely encased in adhesions (fibrous bands of scar tissue that form between two surfaces inside the body), but the perforated IUD and adhesions rarely cause problems. Removal of the IUD may lead to pelvic abscess (a mass-like collection of pus in the pelvic area) and other complications. Help her choose another contraceptive method.
• If complete perforation is discovered 6 weeks or more after insertion and the client has associated symptoms—for example, abdominal pain (especially if there is associated diarrhea), excessive bleeding—refer to a surgeon experienced at removing such IUDs by laparoscopy or laparotomy.

Partial or complete expulsion

• If the IUD is partially expelled, remove the IUD and insert a new one at once if there are no signs or symptoms of infection, pregnancy is ruled out, and she has not developed any new conditions that make IUD insertion unsafe. If she does not want to continue using an IUD, help her choose another contraceptive method.
• If complete expulsion is suspected, ask the client if she knew the IUD came out and, if x-ray or ultrasound does not show the IUD in the uterus or that it moved to the abdominal cavity, then perforation can be excluded and complete expulsion can be assumed. Discuss with the client whether to insert another IUD or choose a different contraceptive method. If she wants another IUD, she can have one inserted at any time it is reasonably certain she is not pregnant.

• The IUD strings cannot be found and the IUD cannot be safely retrieved

• Where ultrasound is available, it may help determine the location of the IUD. If the IUD is not located, expulsion may have occurred.
• If ultrasound is not possible or if the IUD cannot be safely retrieved because ultrasound determines it to be inside the uterus:
  • Explain that, with the IUD in place, she is at increased risk of preterm delivery or miscarriage, including septic miscarriage during the first or second trimester, which may be life-threatening to her (10, 67, 269). Given this risk, if she does not want to continue the pregnancy, counsel her according to program guidelines.
  • If client wants to or must continue her pregnancy, make clear to her the risks. Her pregnancy should be followed closely by a nurse or doctor. She should see a nurse or doctor at once if she develops vaginal bleeding, cramping, pain, abnormal vaginal discharge, or fever.