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Disclosures: Gillian Dean, MD, MPH Nothing to disclose. Alisa B Goldberg, MD, MPH Consultant/Advisory Boards: Bayer (IUD - Mirena) Mimi Zieman, MD Speaker’s Bureau: Teva (women's health). Consultant/Advisory Boards: Teva; Bayer Healthcare (women's health). Vanessa A Barss, MD Employee of UpToDate, Inc. Equity Ownership/Stock Options: Merck; Pfizer; Abbvie.
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INTRODUCTION — Intrauterine contraception is generally well-tolerated, but side-effects and complications sometimes occur. This topic will review management of the most common problems related to intrauterine contraception with the copper T380A intrauterine device (IUD) (called TCu380A) and the IUD containing 52 mg levonorgestrel (called LNg20 because of an initial release-rate of levonorgestrel 20 mcg daily). At this time, there are sparse data on the newer IUD containing 13.5 mg levonorgestrel (called LNg14 because of an initial release-rate of levonorgestrel 14 mcg daily).
General issues related to intrauterine contraception and insertion and removal of IUDs are discussed separately. (See "Intrauterine contraception (IUD): Overview" and "Insertion and removal of an intrauterine contraceptive device".)
Several terms are used to describe intrauterine contraception, including intrauterine device (IUD) and intrauterine contraceptive (IUC); the LNg20 is also referred to as an intrauterine system (IUS). In this topic, we use the term IUD for all types of intrauterine contraception.
EXPULSION — In the first year of use, expulsion occurs in 3 to 10 percent of women with the TCu380A and 6 percent of women with the LNg20 IUD [1-4]. The manufacturer of the LNg14 IUD reports an expulsion rate of 3.2 percent; however, data are limited. Risk factors for expulsion include [1,5,6]:
●Age less than 20 years
●Insertion immediately after a second trimester abortion or postpartum
Symptoms suggesting partial or complete expulsion include cramping, vaginal discharge, intermenstrual or postcoital bleeding or spotting, male or female dyspareunia, or lengthened or absent strings. The woman may palpate all or part of the IUD in the vagina. However, some IUD expulsions are asymptomatic. Because women who experience asymptomatic IUD expulsion may not present for evaluation, it is important to teach all IUD users to check their IUD strings periodically. If complete expulsion occurs and the woman does not become pregnant, she may notice that her periods are changing back to their pre-IUD insertion pattern.
Any woman with symptoms suggestive of expulsion should be evaluated promptly. If the IUD is visible in the endocervical canal or vagina, it should be removed and should not be re-used or re-inserted.
If the IUD or its strings are not visible, complete expulsion may have occurred. The diagnosis of complete expulsion requires ultrasound confirmation that the IUD is not in the uterus, followed by x-ray documentation that the IUD is not in the abdomen or pelvis (see 'Strings not visible' below).
A new IUD can be inserted after expulsion if desired; standard criteria for insertion of an IUD should be met (eg, pregnancy excluded, no active infection). It is unknown whether changing the IUD type (copper or levonorgestrel) at reinsertion will reduce the risk of recurrent expulsion. (See "Insertion and removal of an intrauterine contraceptive device".)
Recurrent expulsion — The risk of re-expulsion appears to be higher than the risk of expulsion after initial insertion, but minimal data are available. In one study, 124 women had a TCu-200B intrauterine device inserted following an expulsion: the cumulative re-expulsion rates after 6 and 12 months were 21.7 and 31.4 per 100 women .
Data on risk factors for repeat expulsion are sparse. Recurrent expulsion may be due to faulty technique or uterine factors (eg, severe flexion, abnormally shaped uterine cavity, patulous internal cervical os) [7,8].
When replacing an IUD after an expulsion, assuming the initial placement was not immediately postabortion or postdelivery, we recommend performing the placement under sonographic guidance to ensure that the IUD is placed at the uterine fundus. If a second expulsion occurs and the woman wishes to try a third IUD insertion, we recommend sonographic or hysteroscopic evaluation of the endometrial cavity to exclude anomalies or pathology that may be responsible for the expulsions (eg, adhesions, obstructing fibroids). If the cavity is abnormal, we recommend not attempting a third insertion. If the cavity is normal, a third IUD insertion can be attempted after counseling the women that she is at high risk for repeat expulsion. Furthermore, we counsel these patients that women with a history of past expulsions may be at increased risk of subsequent IUD failure even when the replaced IUD remains in situ .
MALPOSITION — The proper placement of an IUD is in the fundal portion of the uterine cavity (image 1). An IUD is malpositioned if any part of it extends into the myometrium or endocervical canal (image 1 and image 2 and image 3 and image 4), if it is rotated, or if it is located distant from the fundus and within the lower uterine segment. Approximately 10 percent of IUDs are malpositioned , but not all malpositioned IUDs require removal (as discussed below).
A copper IUD is relatively easy to detect with ultrasound, as it gives a strong echo. The LNg20 IUD is more difficult to identify because only the proximal and distal ends of the vertical arms produce a detectable echo; this may or may not be enough to confirm the location of the device in the uterus. The LNg20 IUD produces a dark sonographic shadow, particularly on transvaginal ultrasound, that can also aid in its localization . The LNg14 IUD contains a silver ring located at the top of the vertical stem near the horizontal arms to facilitate detection by ultrasound.
If ultrasound performed for any reason reveals that the IUD is malpositioned, the patient should be asked whether she is experiencing any symptoms of a displaced IUD, such as new or especially bothersome cramping, heavy menstrual bleeding, or intermenstrual bleeding or spotting [10,12]. If the woman is symptomatic, the IUD should be removed and, ideally, a new IUD is placed at the same visit to avoid a gap in contraception. We often perform replacements under ultrasound guidance to be sure of proper fundal positioning.
There are limited data to guide the management of an incidental finding of a displaced IUD in a woman who is asymptomatic. Theoretically, a small change in position should not affect the contraceptive effects of the progestin or copper that is released. Data from a randomized trial of a LNg IUD support this hypothesis, showing no difference in pregnancy rates between devices located in the endocervix and those located in the fundus . A case report described secondary infertility resistant to fertility therapy in a patient with an unrecognized intraabdominal LNg IUD; the patient conceived spontaneously in the first cycle after removal of the device .
There are no similar studies of copper IUDs. Pregnancy appears to be more common in women with malpositioned copper IUDs than correctly positioned copper IUDs, but it is unknown whether the malpositioned IUD is the cause or the result of pregnancy [15,16].
The extent of malposition (eg, low intrauterine displacement versus arms embedded in myometrium) is also a probable factor affecting the risk of contraceptive failure. In a series of 28 women with malpositioned IUDs left in situ and followed for two years, there were no unintended pregnancies . In contrast, women who had malpositioned devices removed or expelled often did not initiate another highly effective method of contraception and became pregnant.
As a general rule, if the IUD is located in the lower uterine segment or near (but not at) the fundus, we tend to leave it in place as most IUDs will not be expelled, and some migrate to a more fundal position [17-19]. If an IUD is below the internal cervical os, we recommend removal because expulsion may follow, and may not be detected. Ideally, a new IUD will be placed or another highly effective contraceptive method will be initiated at the same visit in order to avoid an interruption in contraception.
In a case series of 18 women in whom a LNg20-releasing IUD was displaced towards the cervical canal on sonographic examination, the IUD was easily repositioned toward the fundus using an alligator forceps in 17 patients; however, in 3 of these patients, it became malpositioned again within two months . At present, we do not attempt to reposition malpositioned IUDs; instead, we follow the management plans described above. However, if the success of repositioning IUDs is confirmed in other studies, it may prove to be an effective method of managing a symptomatic malpositioned IUD.
Malposition may be more likely when placement is difficult, such as in women with a distorted uterine cavity, adenomyosis or obesity. In these cases, placement by an experienced clinician and use of ultrasound guidance may reduce the risk of malposition.
STRINGS NOT VISIBLE — If the IUD strings are not visible on speculum examination, possible explanations from most to least common are:
●The IUD is in situ, but the strings are curled and retracted into the endocervical canal or uterine cavity, or they are broken. Uterine enlargement secondary to fibroids or pregnancy, or rotation of the IUD can also cause retraction of strings;
●The IUD has been expelled;
●The IUD has perforated the uterus and is in the myometrium or abdomen.
The first step is to exclude pregnancy. If the woman is pregnant, an ultrasound should be performed to determine the location of the IUD and the pregnancy. Management depends upon the location of the IUD, the trimester of pregnancy, and the patient's desire to continue or terminate the pregnancy (see 'Pregnancy' below).
If the woman is not pregnant, we twist a cytobrush in the endocervical canal to try to draw the string out of the canal. If the string becomes visible with this maneuver, no additional action is required.
If this maneuver is unsuccessful, we examine the endocervical canal with a uterine sound or an endocervical speculum to determine if the IUD is in the process of being expelled. Usually the strings become visible in this situation, but they can also become twisted and remain hidden from view. If the IUD is in the cervix, we remove it using a grasping forceps (eg, Bozeman uterine packing forceps or alligator forceps), IUD hook, IUD thread retriever, or Kelly clamp, and, if the woman desires, we replace it with a new IUD. Prophylactic antibiotics are unnecessary when removing the IUD from the uterus or cervix.
If these maneuvers do not locate the strings, we obtain an ultrasound examination to localize the IUD . Interim contraception should be provided if ultrasonography is scheduled for a later date. If ultrasound examination shows that the IUD is in the proper position within the uterine cavity, the woman may continue to use it for contraception (despite the strings not being accessible). The risk of IUD expulsion is low (approximately 2 percent) in women with non-visible strings after an initial ultrasound confirms correct IUD placement. Therefore, it is not necessary to perform routine periodic ultrasounds to confirm correct IUD placement in women who are asymptomatic . A patient with non-visible strings should be instructed to return if she develops symptoms suggestive of IUD expulsion or displacement, such as changes in bleeding patterns, pain, partner feeling the IUD during intercourse, or pregnancy symptoms. For women who might have difficulty distinguishing a change in menstrual pattern suggestive of expulsion, periodic or annual ultrasound surveillance for one to two years is a reasonable option .
If she wishes to discontinue the IUD, an alligator forceps, Bozeman uterine packing forceps, or an IUD hook can be used to grasp and remove it. Ultrasound guidance can be helpful if blind attempts to grasp the IUD are unsuccessful . Analgesia, if needed, can be provided by infusing a local anesthetic (eg, 5 mL of 2 percent lidocaine) into the uterine cavity with an angiocatheter  or by paracervical block, either alone or in combination with conscious sedation . The cervix can be softened, if needed, with misoprostol in order to facilitate the procedure . Dilating the cervix with a 7 to 9 French or 21 to 27 mm Pratt dilator can facilitate opening the forceps for grasping the IUD. The IUD can also be removed using suction: attach a small cannula to a manual uterine aspirator (eg, IPAS syringe) or an electric vacuum aspirator. Hysteroscopic removal is rarely necessary, but is the next step if other methods have been unsuccessful. (See "Pudendal and paracervical block" and "Procedural sedation in adults".)
If ultrasound examination does not locate the IUD, we obtain anteroposterior and lateral upright plain radiographs of the entire abdomen and pelvis . The TCu380A, LNg20, and LNg14 IUDs are radiopaque; therefore, if the IUD is not visualized on x-ray examination, expulsion has occurred. Expulsion cannot be diagnosed without x-ray documentation unless the expulsion was noted by the user. It is usually impossible to detect an IUD that is located outside the uterus with ultrasound. A new IUD can be inserted, if desired.
If x-ray shows that the IUD is located outside the uterine cavity, a perforation has occurred.
BROKEN IUD — Case reports have described IUD breakage during removal or expulsion. Most cases occurred during removal when the IUD string broke or the device fractured . There are no data on the consequences of not removing the retained fragment(s). Potential consequences include infection, infertility, pelvic pain or cramping, abnormal uterine bleeding or vaginal discharge.
If the location of the fragment is unknown, ultrasound imaging, hysteroscopy, or an X-ray may indicate its position. To remove the fragment, options include manual vacuum extraction, use of alligator or Bozeman uterine packing forceps, hysteroscopy, and curettage.
PERFORATION — Uterine perforation occurs during IUD insertion and complicates about 1 in 1000 insertion procedures . Risk factors include clinician inexperience in IUD placement, an immobile uterus, a retroverted uterus, and the presence of a myometrial defect (pre-existing or created during the procedure by the uterine sound or the IUD inserter). (See "Insertion and removal of an intrauterine contraceptive device".)
Since perforation may not be recognized immediately, many clinicians re-examine the patient six weeks after IUD insertion to look for signs and symptoms of perforation, such as shortening of string length. Mild abdominal pain and/or uterine bleeding may occur . Perforations diagnosed after the insertion procedure have been attributed to spontaneous IUD migration; although difficult to disprove, we think this explanation is implausible.
Ultrasound is used to determine the location of a perforated IUD (x-ray can be used if ultrasound is not available). As discussed above, if ultrasound examination does not reveal the location of the IUD, the IUD may have been expelled. An x-ray of the pelvis and abdomen should be obtained since expulsion cannot be diagnosed reliably without x-ray documentation.
Once perforation has been identified, experts recommend treating the woman with antibiotics as for pelvic inflammatory disease . (See "Treatment of pelvic inflammatory disease".) Although serious complications following perforation are uncommon, most experts, but not all, recommend that any perforated IUD be removed unless the surgical risk is excessive [29-32]. The major concerns of nonintervention are adhesion formation and their sequelae, and perforation into bowel, bladder, or blood vessels .
If the IUD is in the abdomen or perforating through the myometrium, operative laparoscopy is the preferred method of removal and can be performed electively in asymptomatic patients, and is usually successful . If laparoscopy is unsuccessful due to extensive adhesions, the procedure should be converted to a laparotomy [35,36].
If the IUD is embedded in the myometrium, operative hysteroscopy may be required for removal . An IUD that has migrated completely through the myometrium may be anywhere in the pelvis. Most frequently, it is found encased in adhesions, adherent to the sigmoid colon or omentum, or freely floating in the posterior cul de sac (pouch of Douglas) [27,32,36,38-42]. There are case reports of IUD perforation into the bladder; intravesical location of an IUD may cause urinary tract symptoms. Perforation into the rectum has also been reported, but modern IUDs, including the LNg20 IUD and various forms of the TCu380A, have not been associated with intestinal injury. IUDs embedded in the omentum can be hard to find because radiographically they appear to be located in the pelvis, but when the patient is placed into Trendelenburg position for laparoscopy, the omentum and IUD can shift into the upper abdomen . An intraoperative x-ray can help localize the IUD.
Patients whose IUDs have perforated and been recovered may be offered another IUD, but we recommend placing future IUDs in such patients under ultrasound guidance.
IUD perforation is not a contraindication to future labor and vaginal delivery, as the uterine defect is small. A literature review did not identify any case reports of rupture of a pregnant uterus associated with prior IUD perforation.
Uterine perforation during insertion is discussed in detail separately. (See "Uterine perforation during gynecologic procedures".)
PARTNER FEELS STRINGS — IUD strings should be trimmed to approximately 3 to 4 cm from the external os. If the strings are cut too short, the partner may experience irritation during intercourse. If this occurs, we suggest trimming the strings flush with the cervix, or replacing the IUD and leaving longer strings. Some women do not want their partners to know that they are using contraception for fear of violence or birth control sabotage. The IUD may be used in these patients by trimming the string flush with the cervix so that it cannot be detected.
PAIN — If a woman with a longstanding IUD develops new severe cramping or abdominal tenderness, she should be evaluated for pelvic inflammatory disease, ectopic pregnancy, threatened or incomplete miscarriage, and IUD expulsion or perforation.
Dysmenorrhea is often worse in the first few cycles after insertion of a copper IUD, and along with unscheduled bleeding, is one of the primary reasons for copper IUD discontinuation. However, discontinuation rates for pain are low (0.1 to 2.4 percent) in both copper and LNg20 IUD users [1,44-48]. Moreover, the LNg20 and LNg14 have both been found to reduce rates of dysmenorrhea [49,50]. Mild to moderate dysmenorrhea can be treated with nonsteroidal antiinflammatory drugs (NSAIDs) begun at the onset of menses and maintained for the first three days of each menstrual cycle (table 1). Women with severe dysmenorrhea and a copper IUD should consider the LNg20 or LNg14 IUD or choose another method of contraception.
ABNORMAL BLEEDING — The TCu380A, LNg20, and LNg14 IUDs are associated with changes in uterine bleeding patterns, which may include episodes of intermenstrual bleeding (all IUDs), increased volume of menstrual bleeding (primarily TCu380A), prolonged menstrual bleeding (primarily LNg14 and LNg20 IUDs), or amenorrhea (primarily LNg20 IUD). Counseling women about the expected changes in bleeding patterns prior to insertion may enhance adherence to the method. Unexpected changes in bleeding patterns or changes that are not tolerable to the patient should be evaluated.
Possible causes of new onset abnormal bleeding after prolonged use of IUDs include displacement of the device, pregnancy (intrauterine or ectopic), and infection, as well as gynecologic disorders of the cervix or uterus (eg, leiomyomas, polyps, endometrial cancer) [28,51]. (See "Management of unscheduled bleeding in women using contraception", section on 'Intrauterine contraception (IUD)'.) .
Women over age 40 or with risk factors for endometrial cancer who develop new abnormal bleeding should undergo evaluation of the endometrium [28,53]. It is important to first exclude IUD displacement, infection, and pregnancy as possible causes of the abnormal bleeding. Although some clinicians remove the IUD before sampling the uterus, an endometrial biopsy using a Pipelle can be performed with the IUD in place. If an adequate tissue sample cannot be obtained, the IUD should be removed before repeat sampling. We do not send the IUD for culture since colonization without infection is common .
Chronic endometritis is a common finding in endometrial biopsies of women who have used an IUD for more than five years . We do not treat this histological diagnosis unless the patient also has pain. (See "Endometritis unrelated to pregnancy", section on 'Intrauterine foreign objects, intrauterine growths, and radiation therapy'.)
TCu380a IUD — The copper IUD is associated with increased menstrual flow both in length of menses and in amount of blood loss. A prospective study of over 1900 Copper T380A users found that many side effects related to bleeding and pain decreased over time . However, most of the improvement was in symptoms occurring during menses, whereas most intermenstrual complaints (such as unscheduled bleeding) did not decrease with time. NSAIDs appear to decrease menstrual blood loss and bleeding duration, particularly in women with heavy or prolonged bleeding. (See "Management of unscheduled bleeding in women using contraception", section on 'Intrauterine contraception (IUD)'.)
We remove the IUD if the woman complains of menorrhagia and experiences a clinically significant fall in hemoglobin. These patients may consider another method of contraception or insertion of a LNg20 IUD since the mean per cycle blood loss for the LNg20 IUD is 5 mL versus 55 mL for the copper IUD [4,55]. Alternatively, a LNg14 IUD could be used with expected reduction in menstrual blood loss.
LNg20 IUD — The LNg20 IUD is associated with a reduction in menstrual blood loss; LNg20 IUD users report fewer bleeding or spotting days per month compared with noncontraceptors and users of copper IUDs . However, many LNg20 IUD users experience episodes of unscheduled bleeding, which may be limited to spotting. The incidence of unpredictable bleeding is greatest in the initial six months of use, although episodes may occur throughout usage.
The proportion of users with amenorrhea increases with duration of use . At six months of use, 44 percent of users have amenorrhea, 25 percent experience oligomenorrhea, and 25 percent experience unscheduled spotting; the remainder have either normal or heavy bleeding. At 24 months of use, 50 percent have amenorrhea, 25 percent have oligomenorrhea, and 11 percent have spotting; again the remainder report either normal or heavy bleeding . Amenorrhea in LNg20 IUD users is due to endometrial decidualization and atrophy; at one year, the majority of women have ovulatory cycles [45,56,58]. The decrease in uterine bleeding that occurs in most LNg20 IUD users is associated with a corresponding increase in hemoglobin levels [3,45].
Changes in bleeding patterns, primarily unscheduled spotting and bleeding and prolonged bleeding episodes, are the main reasons for premature LNg20 IUD removal. Some early studies reported amenorrhea was the principal cause for removal, but subsequent studies found that amenorrhea was associated with continuation; this change may reflect improved counseling about expected changes in bleeding patterns [45,59,60]. Complaints of menstrual problems, including amenorrhea and spotting, decline with use beyond one year and with patient age greater than 30 years [45,60]. Options for treatment are discussed separately. (See "Management of unscheduled bleeding in women using contraception", section on 'Intrauterine contraception (IUD)'.)
Any LNg20 IUD user presenting with new onset of amenorrhea should have a pregnancy test; once pregnancy is excluded, further pregnancy tests are not required.
LNg14 IUD — The LNg14 IUD is also associated with an overall reduction in menstrual blood loss, although rates of amenorrhea are lower in LNg14 users compared with LNg20 users (12.7 versus 23.6 percent with three years of use) . Any LNg14 IUD user presenting with new onset of amenorrhea should have a pregnancy test; once pregnancy is excluded, further pregnancy tests are not required.
VAGINAL DISCHARGE — Some women report increased vaginal discharge with the IUD; this is usually normal leukorrhea and not a sign of infection .
Pelvic inflammatory disease — Pelvic inflammatory disease (PID) is most strongly associated with the insertion process and with the user's risk of acquiring a sexually transmitted disease (STD) [61,62]. The risk of infection is greatest in the first 20 days after insertion (range 1 to 10 per 1000 women undergoing insertion [61,63]) and is rare thereafter (1.4 per 1000 women undergoing insertion ), and does not increase with prolonged IUD use. PID following insertion is due to a polymicrobial infection, usually involving anaerobic bacteria from the cervix and vagina . Risk factors include bacterial vaginosis, cervicitis, and contamination of the endometrial cavity at insertion [28,37].
Infections more than one month after insertion are generally due to a newly acquired STD [37,64]. The LNg20 IUD is probably protective against PID from newly acquired STDs because progestin thickens cervical mucus, making it less permeable to sperm and bacteria ; it is reasonable to expect that the LNg14 IUD will provide similar protection, but data are lacking. Although the copper IUD does not offer this same protection, it does not appear to increase the risk of PID or of serious infection .
A systematic review including three randomized trials and a prospective cohort study. all of fair quality, concluded that women with PID treated with appropriate antibiotics who retained their IUDs had similar or better outcomes than women who had their IUDs removed . Based on these data, the Centers for Disease Control and Prevention (CDC) US Selected Practice Recommendations for Contraceptive Use recommended that women with an IUD and PID should be started on appropriate antibiotic therapy with the IUD in place (algorithm 1) . (See "Treatment of pelvic inflammatory disease".) Overall, the data on the management of PID with IUDs are limited and inconsistent, with two studies showing lower rates of prolonged hospitalization in women who retain their IUDs, one study showing improved outcomes in women with IUD removal, and a fourth study showing no difference in clinical or laboratory outcomes .
We advise initiating treatment with the IUD in place, as recommended by the CDC. Oral antibiotics are appropriate treatment for mild to moderate PID, with patient reassessment in 48 to 72 hours. If no clinical improvement has occurred within 72 hours (ie, persistent fever, abdominal pain, cervical motion tenderness, or adnexal or uterine tenderness) or if, despite antibiotics, the patient’s clinical status is worsening, then options include hospitalization for parenteral antibiotics, further diagnostic evaluation (including imaging to assess for tuboovarian abscess), and IUD removal. For women with PID resistant to outpatient management, we advise sending the IUD for culture, as microbiology results can be helpful in patients not responsive to standard therapy. Patients with PID should be counseled about condom use for prevention of sexually transmitted diseases.
If a patient with PID wants her IUD removed, we initiate appropriate antibiotics before removing the IUD in order to avoid the potential risk of bacteremia from the removal procedure , and we offer an alternative method of contraception. We also offer emergency contraception if the patient has had sex within the previous five days. (See "Emergency contraception".)
If the woman wants the IUD replaced, a new IUD may be inserted three months after the infection has resolved if she is no longer at elevated risk of PID. Because infection is associated with insertion, clinicians should avoid premature replacement of IUDs unless replacement is clinically indicated and a good alternative is unavailable [61,62].
Asymptomatic women who have laboratory evidence of gonorrhea or chlamydia should receive standard treatment. Although IUD removal is not necessary, the patient's appropriateness for continued use of an IUD should be reassessed  and the use of condoms for protection against sexually transmitted infections should be discussed. (See "Treatment of uncomplicated gonococcal infections" and "Male condoms", section on 'Protection from STIs' and "Treatment of Chlamydia trachomatis infection".)
Counseling, screening, and treatment of sexual partners are reviewed separately. (See "Treatment of pelvic inflammatory disease", section on 'Counseling and screening' and "Treatment of pelvic inflammatory disease", section on 'Sex partners'.)
Vaginitis — Women with bacterial vaginosis, trichomonas vaginalis, or candidiasis should receive standard treatment without IUD removal. Whether women with IUDs are at higher risk of developing bacterial vaginosis is controversial [70,71]. (See "Bacterial vaginosis" and "Trichomoniasis" and "Candida vulvovaginitis".)
Actinomyces on cervical cytology — Actinomyces, a Gram positive anaerobic bacillus, is part of the normal flora of the gastrointestinal tract and is commonly present in normal vaginal flora . Although there are several case reports of endometritis, pelvic inflammatory disease, pelvic abscess, and retroperitoneal fibrosis associated with actinomyces in IUD users [73,74], the identification of actinomyces in the vagina or cervix by any laboratory technique is not diagnostic of disease and is not predictive of development of disease .
Approximately 7 percent of women using an IUD have actinomyces-like organisms on a Papanicolaou (Pap) test ; only about half of these women will have positive actinomyces cultures [75,76]. If the cervical cytology report indicates actinomyces-like organisms, then we suggest that the woman be notified of the finding and examined. If she is asymptomatic, the cytology finding probably represents colonization. There is no evidence to support antibiotic treatment or IUD removal in asymptomatic women [37,76]. The woman should be informed that she should contact her health care provider if she develops signs of pelvic inflammatory disease. (See "Clinical features and diagnosis of pelvic inflammatory disease".)
On the other hand, if the woman shows signs or symptoms of pelvic infection (pelvic mass or pain, uterine tenderness), antibiotics should be administered followed by removal of the IUD, which is sent for anaerobic culture . Removal of the IUD is important because actinomyces preferentially grow on foreign bodies. The diagnosis can be difficult to make and therapy is individualized, depending on the initial burden of disease and the clinical and radiological responses to antibiotics. Actinomyces is sensitive to penicillin; tetracyclines are used for penicillin allergic patients. Although some experts advocate oral therapy for very early pelvic actinomyces , accurate diagnosis of early stages of infection is difficult given the nonspecific clinical features of even advanced disease. Therefore, actinomyces infection is generally treated with intravenous antibiotics. Prolonged intravenous therapy (weeks to months) is indicated for confirmed actinomyces-related tuboovarian abscess or disseminated infection ; surgery may also be necessary. Infectious disease consultation is important for these cases. We counsel women with a history of actinomyces abscesses against future IUD use. (See "Abdominal actinomycosis", section on 'Diagnosis' and "Abdominal actinomycosis", section on 'Management'.)
Of note, in one review, only 50 percent of women with pelvic actinomyces abscesses had actinomyces organisms identified on a prior Papanicolaou smear .
The LNg20 IUD seems to have a lower incidence of actinomyces-like organisms noted on Pap smear than copper IUDs .
Toxic shock syndrome — Rare cases of staphylococcal and streptococcal toxic shock syndrome attributed to IUD use have been reported [80-82]. (See "Epidemiology, clinical manifestations, and diagnosis of streptococcal toxic shock syndrome" and "Staphylococcal toxic shock syndrome" and "Treatment of streptococcal toxic shock syndrome".)
EXPIRED IUD — Women sometimes present with an IUD that has been retained beyond its ‘expiration’ date. If the string is visible, the IUD should be removed.
If the string is not visible, the location should be determined by ultrasound. If the IUD is confirmed to be intrauterine, we suggest removal in the office or an appropriately equipped ambulatory procedure room using an alligator forceps, Bozeman uterine packing forceps, or IUD hook. Difficult removals should be performed under ultrasound guidance . Analgesia, if needed, can be provided by infusing a local anesthetic (eg, 5 mL of 2 percent lidocaine) into the uterine cavity with an angiocatheter  or by paracervical block, either alone or in combination with conscious sedation . The cervix can be softened, if needed, with misoprostol in order to facilitate the procedure . Dilating the cervix with a 7 to 9 French or 21 to 27 mm Pratt dilator facilitates opening the forceps for grasping the IUD. The IUD can also be removed using suction: attach a small cannula to a manual uterine aspirator (eg, IPAS syringe) or an electric vacuum aspirator. Hysteroscopic removal under anesthesia is the next step if other methods have been unsuccessful.
If removal is unsuccessful and the woman is asymptomatic, premenopausal, and does not currently require contraception, one option is to leave the IUD in place, but there are no data about the safety of this approach. If she develops symptoms (pain, abnormal bleeding), the IUD should be removed, which may require anesthesia and operative hysteroscopy, particularly if the IUD is embedded in the myometrium. The risks and benefits of anesthesia and an operative procedure need to be weighed against those of leaving the IUD in place indefinitely (eg, rare case reports of pelvic actinomycosis [84,85]). These decisions are patient-specific and need to be made on a case by case basis.
If the woman requires contraception, removal and replacement depend on the type of IUD.
●Studies of long-term use of the copper T380A IUD show high contraceptive efficacy and safety for up to 20 years of use, although data for use beyond 15 years are limited .
●For the LNg20 IUD, efficacy decreases after five years; therefore, this IUD should be replaced at five years for most women desiring continued contraception. The LNg20 IUD has not been studied for extended use; however, we can infer from studies of related IUDs that the LNg20 IUD may have efficacy beyond five years. Therefore, in special circumstances for particular patients (such as those delaying replacement while temporarily uninsured, or those very close to menopause), extended use of the LNg20 IUD to no more than seven years may be advised [45,50].
The LNg14 IUD should be replaced after three years of use.
●Older inert IUDs can be left in place indefinitely, but generally are removed and replaced with newer medicated IUDs due to the lower efficacy of the inert devices.
In general, we would remove any IUD when the woman reaches menopause (ie, amenorrhea for one year). (See "Intrauterine contraception (IUD): Overview", section on 'Menopausal women'.)
If a woman becomes pregnant with an IUD in place, we first determine whether the pregnancy is intrauterine or extrauterine. The diagnosis and management of ectopic pregnancy is reviewed separately. (See "Clinical manifestations, diagnosis, and management of ectopic pregnancy".)
Women who conceive an intrauterine pregnancy with an IUD in place have a greater risk of adverse pregnancy outcomes compared with the general obstetrical population. Risks include miscarriage, septic abortion, chorioamnionitis, and preterm delivery . Among women who conceive with an IUD in situ, the miscarriage rate is approximately 50 percent, a rate more than two-fold higher than that of women who have the IUD removed. In one case series of pregnancy with an in situ LNg20-IUD, 8 in 10 pregnancies ended in spontaneous abortion.
Although the risk of adverse events is highest when the IUD is left in place, women who have the IUD removed still have an increased risk of adverse events throughout pregnancy, including preterm delivery, compared with women who conceived without an IUD . There does not appear to be an increased risk of birth defects in pregnancies conceived and carried with an IUD in situ, although there are insufficient data to draw definitive conclusions about the effect of levonorgestrel exposure on the fetus [88,89].
We suggest the following steps in the evaluation and management of intrauterine pregnancy in a patient with an IUD in situ.
First trimester intrauterine pregnancy — If the IUD strings are visible on speculum examination, remove the IUD to decrease the risk of subsequent miscarriage, infection, and preterm delivery . Antibiotics are unnecessary.
If the strings are not visible and the patient wishes to continue the pregnancy, we suggest removing the IUD under ultrasound guidance using an alligator forceps or a Bozeman uterine packing forceps [90-92]. Removal can also be attempted by hysteroscopy. Data on hysteroscopic removal of IUDs in early pregnancy are limited; therefore, it is not clear whether this technique poses greater or lesser risk of pregnancy loss than instrument removal under ultrasound guidance [93,94]. We recommend antibiotic prophylaxis when instrument removals are performed during pregnancy, including when IUD removal is to be followed by pregnancy termination (see below).
If the IUD cannot be removed by pulling the strings or removed easily using either instruments under sonographic guidance or hysteroscopy, the IUD may be left in situ. The risks of pregnancy loss with aggressive attempts at IUD removal must be weighed against the risks of adverse maternal and fetal outcomes later in pregnancy, including infection and preterm delivery, if the IUD is left in place.
If the woman desires pregnancy termination, IUD removal can be performed at the time of the termination. Manual or electric vacuum aspiration or an instrument such as an IUD hook, Bozeman uterine packing forceps, alligator forceps, ring forceps, or ovum forceps can be used to remove the IUD. However, if strings are visible upon initial diagnosis and there may be a significant delay until pregnancy termination can be performed, we recommend pulling the strings to remove the IUD as soon as possible, since the strings may no longer be visible as the uterus grows and removal may be more difficult later in gestation.
Second trimester pregnancy — We counsel these women that if the IUD remains in situ, there is an increased risk of preterm labor and delivery (fourfold increase), second trimester fetal loss, and infection, but no proven increase in risk of birth defects [4,37,51,95]. In addition, in a LNg20 or LNg14 IUD user, there are theoretical fetal risks associated with intrauterine hormone exposure . Removal of the IUD may cause rupture of membranes, bleeding, pregnancy loss, or fetal trauma ; however, if the IUD is removed or expelled without complications, there is no increased risk of miscarriage [4,37,97].
Given this information, for pregnancies after 12 weeks, we suggest removing the IUD by pulling on the strings if the strings are visible and removal is unlikely to disrupt the placenta or membranes (based upon ultrasound localization of the IUD and placenta) [51,91,97-99].
If the strings are not visible in the early second trimester, the IUD may be removed under ultrasound guidance if removal appears feasible, the IUD is not located behind the placenta, and it does not appear to be incorporated into the gestational sac. In particular, we recommend ultrasound guided removal in these cases if the IUD is in the lower uterine segment . If the IUD appears embedded in the placenta, located behind the placenta, or protrudes into the gestational sac, we suggest leaving the IUD in situ.
In the late second trimester, if the strings are not visible, the IUD should be left in place. The patient should be counseled that her risks of miscarriage and premature delivery are increased relative to women whose IUDs may be easily removed .
HORMONAL SIDE EFFECTS OF LNG20-IUD AND LNG14-IUD — Complaints of hormonal side effects (including hirsutism, acne, weight change, nausea, headache, mood changes, and breast tenderness) are the most common reasons for elective LNg20 IUD removal in the first 36 months of use . LNg20 IUD users also have more discontinuations because of hair and skin changes and headache than users of copper IUDs [45,65,100]. These complaints may be due to the systemic effects of levonorgestrel, even though plasma levonorgestrel levels are low . In the first five years of use, approximately 12 percent of women prematurely discontinue the LNg20 IUD because of hormone-attributable complaints [45,60,101].
The LNg14 IUD appears to have rates of hormonal side effects comparable to the LNg20 IUD .
ABNORMAL CERVICAL CYTOLOGY — Women with IUDs are not at increased risk of cervical intraepithelial neoplasia (CIN); they should undergo routine assessment in accordance with American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines on cervical cancer screening. Benign cervical changes, such as cervical inflammation and metaplasia, are more common in IUD users than non-users [45,102-104], but cervical cancer is less common in IUD users. (See "Intrauterine contraception (IUD): Overview", section on 'Cancer risk reduction'.)
If an ablative or excisional procedure is required for management of CIN, it may be performed with the IUD in situ. For loop electrosurgical excision procedures (LEEP), some clinicians perform the LEEP in two segments, holding the strings anteriorly while removing the posterior segment of the biopsy and then holding the strings posteriorly for removal of the anterior segment. This approach requires more skill than the usual LEEP and increases the chance that a suboptimal specimen will be obtained. Another cumbersome technique involves tying a suture to the strings and bringing the lengthened strings through a hollow plastic tube, which is placed in the endocervical canal to protect the enclosed strings during the LEEP .
We recommend the following approach for LEEP or ablative procedures with an IUD in situ: push the strings into the cervical canal using a cytobrush and then perform the procedure in the usual fashion. After completing the procedure, tease the strings back out using a cytobrush. If the strings become damaged during the procedure, the IUD may be managed as in a patient with retracted strings (see 'Strings not visible' above). However, some providers find this approach more difficult than the two segment approach.
We do not recommend prophylactic antibiotics for these procedures.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
●Beyond the Basics topics (see "Patient information: Long-term methods of birth control (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●If the intrauterine device (IUD) strings are not visible on speculum examination, possible explanations are:
•The IUD is in situ, but the strings are retracted into the endocervical canal or uterine cavity. The strings may be teased into the correct position. (See 'Strings not visible' above.)
•The IUD has been expelled. This requires supportive ultrasound and x-ray documentation. (See 'Expulsion' above.)
•The patient is pregnant. The IUD may be in situ, but the pregnant uterus has drawn the strings up into the uterine cavity so they are no longer visible. Alternatively, the device may have been expelled or perforated, and thus not protected the women against pregnancy. (See 'Pregnancy' above.)
●Malpositioned (greater than 20 mm from the fundus in a normal uterus) IUDs in symptomatic women should be removed. In asymptomatic women who wish to continue IUD use, the IUD may be left in place if it is located above the internal os and if the woman would not replace it or choose another highly effective method of contraception. We suggest removal of malpositioned IUDs located below the level of the internal os. (See 'Malposition' above.)
●In women with a history of expulsion, perforation, or malposition of a past IUD, the next IUD should be placed under sonographic guidance. (See 'Recurrent expulsion' above.)
●If a woman with a longstanding IUD develops new severe cramping or abdominal tenderness, she should be evaluated for pelvic inflammatory disease, ectopic pregnancy, miscarriage, and IUD expulsion or perforation. (See 'Pain' above.)
●Mild and moderate dysmenorrhea can often be controlled with nonsteroidal antiinflammatory drugs. (See 'Pain' above.)
●Possible causes of new onset abnormal bleeding in women after prolonged use of IUDs include displacement of the device, pregnancy (intrauterine or ectopic), infection, as well as gynecologic disorders of the cervix or uterus (eg, leiomyomas, polyps, endometrial cancer). In women over age 40 or with risk factors for endometrial cancer who develop abnormal bleeding, the endometrium should be evaluated. Any LNg20 or LNg14 IUD user presenting with new onset of amenorrhea should have a pregnancy test. (See 'Abnormal bleeding' above.)
●For women who develop symptomatic pelvic inflammatory disease, we suggest administration of appropriate antibiotics with the IUD in situ rather than removing the IUD and initiating treatment (Grade 2B). If no clinical improvement has occurred within 72 hours or the patient’s clinical status is worsening despite antibiotics, options include hospitalization for parenteral antibiotics, further diagnostic evaluation (including imaging to assess for tuboovarian abscess), and IUD removal. (See 'Pelvic inflammatory disease' above.)
●Standard antibiotic treatment without IUD removal may be offered to asymptomatic women with laboratory evidence of gonorrhea or chlamydia. The patient should be assessed for appropriateness for continued IUD use. (See 'Infection' above.)
●The identification of actinomyces in the vagina or cervix by any laboratory technique is not diagnostic of disease and is not predictive of development of disease. We suggest avoiding treatment of actinomyces in asymptomatic women (Grade 2C). (See 'Actinomyces on cervical cytology' above.)
●Among women who conceive with an IUD that remains in situ, the risk of miscarriage is 40 to 50 percent, a rate twice as high as that of the general obstetric population. Whenever possible, we suggest removing the IUD (Grade 2C). (See 'Pregnancy' above.)
●If loop electrosurgical excision procedure (LEEP) or an ablative procedure is to be performed with IUD in situ, we suggest leaving the IUD in situ and either pushing the strings into the cervical canal to get them out of the way or performing a LEEP in two segments. (See 'Abnormal cervical cytology' above.)
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.