INTRODUCTION — Intrauterine contraception (IUC) 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 TCu380A and the levonorgestrel-releasing (LNg) IUCs. General issues related to IUC are discussed separately. (See "Approach to 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 LNg IUCs [1-4]. Risk factors for expulsion include [1,5,6]:

• Nulliparity
• Menorrhagia
• Severe dysmenorrhea
• Prior expulsion (30 percent chance of repeat expulsion)
• 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 patient may palpate all or part of the IUC in the vagina.

However, some IUC expulsions are asymptomatic. Because women who experience asymptomatic IUC expulsion may not present for evaluation, it is important to teach all IUC users to check their IUC strings.

Woman with symptoms suggestive of expulsion should be evaluated promptly. If the IUC is visible in the endocervical canal or vagina, it should be removed and should not be re-used or re-inserted. A new IUC can be inserted, if desired; standard criteria for insertion of an IUC should be met (eg, pregnancy excluded, no active infection). (See "Insertion and removal of an intrauterine contraceptive device".)

If the IUC or its strings are not visible, complete expulsion may have occurred. This diagnosis requires ultrasound confirmation that the IUC is not the uterus, followed by x-ray documentation that the IUC is not in the abdomen or pelvis (see 'Strings not visible' below.

DISPLACEMENT — The proper placement of an IUC is at the uterine fundus. If ultrasound performed for any reason reveals that the IUC is not in this position, the patient should be asked whether she is experiencing any symptoms of a displaced IUC, such as new or especially bothersome cramping, heavy menstrual bleeding, or intermenstrual bleeding or spotting. If the woman is symptomatic, the IUC should be removed and a new IUC may be placed at the same visit. We often perform replacements under ultrasound guidance to be sure of proper fundal positioning.

There are no data to guide the management of an incidental finding of a displaced IUC in a woman who is asymptomatic. We consider its distance from the fundus, the size of the uterus, and the type of IUC. If the IUC is located near the fundus, we tend to leave it in place. If the IUC approaches the level of the internal cervical os, we recommend removal because expulsion may follow, and may not be detected. Theoretically, a small change in position should not affect the contraceptive effects of the progestin or copper that are released; however, there are no data to support this hypothesis.

STRINGS NOT VISIBLE — If the IUC strings are not visible on speculum examination, possible explanations are:

• The IUC is in situ, but the strings are curled and retracted into the endocervical canal or uterine cavity, or they are broken
• The IUC has been expelled
• The IUC has perforated the uterus and is in the myometrium or abdomen

The first step is to perform a pregnancy test. If the woman is pregnant, an ultrasound should be performed to determine the location of the IUC and the pregnancy. Management depends upon the location of the IUC, 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 IUC is in the process of being expelled. Usually the strings become more visible in this situation, but they can also become twisted and not visible outside of the cervix. If the IUC is in the cervix, we remove it using an alligator forceps, IUC hook, or Kelly clamp, and, if the woman desires, we replace it with a new IUC. Prophylactic antibiotics are unnecessary when removing the IUC from the uterus or cervix.

If these maneuvers do not locate the strings, we order an ultrasound examination to localize the IUC [7]. Interim contraception should be provided if ultrasonography is scheduled for a later date. If ultrasound examination shows that the IUC is in the proper position within the uterine cavity, the woman may continue to use it for contraception (despite the strings not being accessible). We suggest performing an ultrasound annually for the first several years to ensure that the IUC has remained in place. After several years, the risk of expulsion is so low that the use of confirmatory ultrasound may be discontinued; the patient should be instructed to return if she develops symptoms suggestive of IUC expulsion or displacement.

If she wishes to discontinue the IUC, an alligator forceps or an IUD hook can be used to grasp and remove it. Ultrasound guidance can be helpful if blind attempts to grasp the IUC 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 [8]. The IUC can also be removed using suction: a suction cannula is attached 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.

If ultrasound examination does not visualize the IUC, we obtain anteroposterior and lateral upright plain radiographs of the abdomen and pelvis [7]. Both the TCu380A and the LNg IUC are radiopaque; therefore, if one of these IUCs 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. A new IUC can be inserted, if desired.

If x-ray shows that the IUC is located outside the uterine cavity, a perforation has occurred.

PERFORATION — Uterine perforation occurs during IUC insertion and complicates one in 1000 IUC procedures [4]. Risk factors include clinician inexperience in IUC 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 IUC 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 IUC insertion to look for signs and symptoms of perforation, such as shortening of string length. Perforations diagnosed after the insertion procedure have been attributed to spontaneous IUC migration; although difficult to disprove, we think this is implausible.

Ultrasound is used to determine the location of a perforated IUC (x-ray can be used if ultrasound is not available). As discussed above, if ultrasound examination does not reveal the location of the IUC, the IUC 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, the woman should be treated with antibiotics as for pelvic inflammatory disease [9]. (See "Treatment of pelvic inflammatory disease".) Although serious complications following perforation are rare, most experts, but not all, recommend that any perforated IUC be removed unless the surgical risk is excessive [10-13]. If the IUC 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. If laparoscopy is unsuccessful due to extensive adhesions, the procedure should be converted to a laparotomy [14,15].

If the IUC is embedded in the myometrium, operative hysteroscopy may be required for removal [16]. The IUC 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) [13,15,17-21]. There are case reports of IUC perforation into bladder; intravesical migration can cause urinary tract symptoms. Perforation into the rectum has also been reported, but modern IUCs, including the LNg IUC and various forms of the TCu380A, have not been associated with intestinal injury.

Patients whose IUCs have perforated and been recovered may be offered another IUC, but we recommend placing future IUCs in such patients under ultrasound guidance.

Uterine perforation is discussed in detail separately. (See "Uterine perforation during gynecologic procedures".)

PARTNER FEELS STRINGS — IUC strings should be trimmed to approximately 2.5 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 IUC.

PAIN — If a woman with a longstanding IUC develops new severe cramping or abdominal tenderness, she should be evaluated for pelvic inflammatory disease, ectopic pregnancy, spontaneous abortion, and IUC expulsion or perforation.

Dysmenorrhea is more common with the TCu380A IUC than the LNg IUC. It is often worse in the first few cycles after insertion and, along with unscheduled bleeding, is one of the primary reasons for discontinuation [1,22]. 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 TCu380A IUC can be managed by removing the copper IUC and substituting a LNg IUC, or they can use another method of contraception [16].

ABNORMAL BLEEDING — The TCu380A and the LNg IUC are associated with changes in uterine bleeding patterns, which may include intermenstrual bleeding (both IUCs), increased volume of menstrual bleeding (primarily TCu380A), prolonged menstrual bleeding (primarily LNg IUC), or amenorrhea (primarily LNg IUC). 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 IUCs 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) [9,23]. (See "Management of unscheduled bleeding in women using contraception", section on 'Intrauterine contraception', [24].

Women over age 40 or with risk factors for endometrial cancer who develop new abnormal bleeding should undergo evaluation of the endometrium [9,25]. Although some clinicians remove the IUC before sampling the uterus, an endometrial biopsy using a pipelle may be performed with the IUC in place. When the IUC is left in situ, it is important to exclude IUC displacement, infection, and pregnancy as possible causes of the abnormal bleeding. If an adequate tissue sample cannot be obtained, the IUC should be removed before resampling. We do not send the IUC for culture since colonization without infection is common [26].

Chronic endometritis is a common finding in endometrial biopsies of women who have used an IUC for more than five years [25]. 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 IUC — The copper IUC is associated with increased menstrual flow both in length of menses and in amount of blood loss. A prospective analysis of over 1900 Copper T380A users in Chile found that many side effects related to bleeding and pain decreased over time [22]. However, most of the improvement was in symptoms occurring during menses, whereas most intermenstrual complaints (such as unscheduled bleeding) did not decrease with time.

We remove the IUC 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 LNg IUC since the mean per cycle blood loss for the LNg IUC is 5 mL versus 55 mL for the copper IUC [4,27].

• LNg IUC — The LNg IUC is associated with a reduction in menstrual blood loss; LNg IUC users report fewer bleeding or spotting days per month compared with noncontraceptors and users of copper IUCs [28]. However, many LNg IUC 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 of the LNg IUC.

The proportion of users with amenorrhea increases with duration of use [29]. 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 [30]. Amenorrhea in LNg IUC users is due to endometrial decidualization and atrophy; at one year, the majority of women have ovulatory cycles [28,29,31]. The decrease in uterine bleeding that occurs in most LNg IUC users is associated with a corresponding increase in hemoglobin levels [3,28].

Changes in bleeding patterns, primarily unscheduled spotting and bleeding and prolonged bleeding episodes, are the main reasons for premature LNg IUC 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 [28,32,33]. Complaints of menstrual problems, including amenorrhea and spotting, decline with use beyond one year and with patient age greater than 30 years [28,33]. Options for treatment are discussed separately. (See "Management of unscheduled bleeding in women using contraception", section on 'Intrauterine contraception'.)

Any LNg IUC user presenting with new onset of amenorrhea should have a pregnancy test; once pregnancy is excluded, further pregnancy tests are not required.

INFECTION

Pelvic inflammatory disease — Although some women report increased vaginal discharge with the IUC, this is usually normal leukorrhea and not a sign of infection [16]. Pelvic inflammatory disease is most strongly associated with the insertion process and with the user's risk of acquiring a sexually transmitted disease (STD) [34,35]. The risk of infection is greatest in the first 20 days after insertion (range 1 to 10 per 1000 women undergoing insertion [34,36]) and is rare thereafter (1.4 per 1000 women undergoing insertion [34]), and does not increase with prolonged IUC use. Pelvic inflammatory disease following insertion is due to a polymicrobial infection, usually involving anaerobic bacteria from the cervix and vagina [16]. Risk factors include bacterial vaginosis, cervicitis, and contamination of the endometrial cavity at insertion [9,16].

Infections more than one month after insertion are generally due to a newly acquired STD [16,37]. The LNg IUC is probably protective against pelvic inflammatory disease from newly acquired STDs because of the effect of progestin on cervical mucus [38]. Although the copper IUC does not offer this same protection, it does not appear to increase the risk of pelvic inflammatory disease or of serious infection [39].

If a woman has clinical signs and symptoms of pelvic inflammatory disease, standard antibiotic treatment should be initiated. The World Health Organization (WHO) has stated that the IUC does not have to be removed if the provider feels the advantages of continuing the method outweigh the risks [40,41]. However, this recommendation was based upon data from three retrospective series [42-44]. The only randomized trial (published after the WHO statement [40]) showed that removing the IUC before initiating medical therapy increased the rate of clinical improvement of mild to moderate pelvic inflammatory disease compared with patients in whom the IUC was left in situ during treatment [45]. Therefore, in settings where a replacement IUC is readily available, we recommend administering appropriate antibiotics followed immediately by removal of the IUC, as well as use of an alternative method of contraception [45,46]. Antibiotics should be administered before IUC removal because bacteremia may occur with removal of an IUC in the setting of pelvic inflammatory disease [46]. We send the IUC for culture, as microbiology results can be helpful if the patient does not respond to empiric therapy.

If the woman wants the IUC replaced, a new IUC may be inserted three months after the infection has resolved if she is no longer at elevated risk of pelvic inflammatory disease. Because infection is associated with insertion, clinicians should avoid premature replacement of IUCs unless replacement is clinically indicated and a good alternative is unavailable [34,35]. In resource poor settings where a replacement IUC is not available, it may be preferable to treat mild to moderate pelvic inflammatory disease without removal of the IUC. (See "Treatment of pelvic inflammatory disease".)

Asymptomatic women who have laboratory evidence of gonorrhea or chlamydia should receive standard treatment. Although IUC removal is not necessary, the patient's appropriateness for continued use of an IUC should be reassessed [16]. (See "Neisseria gonorrhoeae infections in women" and "Genital Chlamydia trachomatis infections in women".)

Vaginitis — Women with bacterial vaginosis, trichomonas vaginalis, or candidiasis should receive standard treatment without IUC removal. Whether women with IUCs have an increased incidence of bacterial vaginosis is controversial [47,48]. (See "Bacterial vaginosis" and "Trichomonas vaginalis" 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 [49]. Although there are several case reports of endometritis, pelvic inflammatory disease, pelvic abscess, and retroperitoneal fibrosis associated with actinomyces in IUC users [50,51], 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 [52].

Approximately 7 percent of women using an IUC have actinomyces-like organisms on a Papanicolaou (Pap) test [53]; only about half of these women will have positive actinomyces cultures [52,53]. If the Pap smear report indicates actinomyces-like organisms, then we suggest that the woman be notified of the finding and examined. If she is asymptomatic, the Pap smear finding probably represents colonization. There is no evidence to support antibiotic treatment or IUC removal in asymptomatic women [16,53]. 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 IUC, which is sent for anaerobic culture [9]. The diagnosis can be difficult to make.

Removal of the IUC is important because actinomyces preferentially grows on foreign bodies. Therapy is individualized, depending on the initial burden of disease and the clinical and radiological responses to antibiotics. A 14-day course of penicillin G (500 mg four times per day) or doxyclycline (100 mg twice per day) may be adequate treatment for a very early, local infection [54], but prolonged intravenous therapy (weeks to months) is indicated for tuboovarian abscess or disseminated infection [55]; surgery may also be necessary. Of note, only half of all women with pelvic actinomyces abscesses had actinomyces organisms identified on a prior Papanicolaou smear [53]. We recommend counseling women with a history of actinomyces abcesses against future IUC use. (See "Abdominal actinomycosis", section on 'Diagnosis' and "Abdominal actinomycosis", section on 'Management'.)

The LNg IUC seems to have a lower incidence of actinomyces-like organisms noted on Pap smear than copper IUCs [56].

PREGNANCY — The risk of pregnancy is highest in the first year after IUC insertion [2]. Among women who conceive with an IUC in situ, the spontaneous abortion rate is 40 to 50 percent, a rate more than two-fold higher than that of the general obstetric population. A retained IUC also increases the risk of several late gestational adverse maternal and neonatal outcomes; this risk is reduced, but not eliminated, with early removal of the IUC [57].

If a woman becomes pregnant with an IUC in place, we first determine whether the pregnancy is intrauterine or extrauterine. (See "Clinical manifestations, diagnosis, and management of ectopic pregnancy".) We suggest the following steps in the evaluation and management of intrauterine pregnancy in a patient with an IUC in situ:

• First trimester intrauterine pregnancy

• - If the IUC strings are visible on speculum examination, remove the IUC to decrease the risk of subsequent miscarriage and infection [4]. Antibiotics are unnecessary.
• - If the strings are not visible and the patient wishes to continue the pregnancy, we suggest removing the IUC under ultrasound guidance using an alligator forceps or an IUC hook [58,59]. Removal can also be attempted by hysteroscopy. Data on hysteroscopic removal of IUCs 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 [60,61]. We recommend antibiotic prophylaxis when instrument removals are performed during pregnancy, including when IUC removal is to be followed by pregnancy termination (see below). On the other hand, the IUC may be left in situ if findings on ultrasound examination suggest removal will be difficult or disrupt the pregnancy (eg, IUC embedded in the placenta or membranes).
• - If the woman desires pregnancy termination, IUC removal can be performed at the time of the termination. Manual or electric vacuum aspiration or an instrument such as an IUC hook, alligator forceps, ring forceps, or ovum forceps can be used to remove the IUC.
• - In the setting of spontaneous abortion with IUC in place, we suggest removing the IUC and prescribing antibiotics (eg, doxycycline 100 mg twice a day or ampicillin 500 mg four times a day for seven days).

• Second trimester pregnancy — We counsel these woman that if the IUC 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 [4,16,23,62]. Removal of the IUC may cause rupture of membranes, bleeding, pregnancy loss, or fetal trauma [63]; however, if the IUC is removed or expelled without complications, there is no increased risk of miscarriage [4,16,64].

• - Given this information, for pregnancies after 12 weeks, we suggest removing the IUC 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 IUC and placenta) [23,59,64-66].
• - If the strings are not visible in the early second trimester, the IUC may be removed under ultrasound guidance if removal appears feasible, the IUC 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 IUC is in the lower uterine segment [64]. If the IUC appears embedded in the placenta, located behind the placenta, or protrudes into the gestational sac, we suggest leaving the IUC in situ.

In the later second trimester, if the strings are not visible, the IUC should be left in place. The patient should be counseled that her risk of spontaneous abortion and premature delivery is increased relative to women whose IUCs may be easily removed [66].

HORMONAL SIDE EFFECTS OF LNg-IUC — Hormonal side effects (including hirsutism, acne, weight change, nausea, headache, mood changes, and breast tenderness) are the most common reasons for elective LNg IUC removal in the first 36 months of use [38]. LNg IUC users also have more discontinuations because of hair and skin changes and headache than users of copper IUCs [28,38,67]. These complaints may be due to the systemic effects of levonorgestrel, even though plasma levonorgestrel levels are low [38]. In the first five years of use, approximately 12 percent of women prematurely discontinue the LNg IUC because of hormone-attributable complaints [28,33,68].

ABNORMAL CERVICAL CYTOLOGY — Women with IUCs 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. However, benign cervical changes, such as cervical inflammation and metaplasia, are more common in IUC users than non-users [28,69-71].

If an ablative or excisional procedure is required for management of CIN, it may be performed with the IUC in situ. For LEEP procedures, 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.

For this reason, we recommend the following approach for LEEP or ablative procedures with an IUC 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 down using a cytobrush. If the strings become damaged during the procedure, the IUC 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 — Educational materials on this topic are available for patients. (See "Patient information: Long-term methods of birth control".) We encourage you to print or e-mail this topic, or to refer patients to our public web site www.uptodate.com/patients, which includes this and other topics.

SUMMARY AND RECOMMENDATIONS

• If the IUC strings are not visible on speculum examination, possible explanations are:

• - The IUC is in situ, but the strings are curled and retracted into the endocervical canal or uterine cavity. The strings may be teased into the correct position. (See 'Strings not visible' above.)
• - The IUC has been expelled. This requires supportive ultrasound and x-ray documentation. (See 'Expulsion' above.)
• - The IUC has perforated the uterus and is in the myometrium or abdomen. We suggest surgical removal rather than expectant management (Grade 2C). (See 'Perforation' above.)
• - The patient is pregnant. The IUC 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.)

• If a woman with a longstanding IUC develops new severe cramping or abdominal tenderness, pelvic inflammatory disease, ectopic pregnancy, spontaneous abortion, and IUC expulsion or perforation should be excluded. (See 'Pain' above.)

• Mild and moderate dysmenorrhea can often be controlled with nonsteroidal antiinflammatory drugs. Women with severe dysmenorrhea and a copper IUC may experience less pain if the IUC is switched to a levonorgestrel releasing IUC. (See 'Pain' above.)

• Possible causes of new onset abnormal bleeding in women after prolonged use of IUCs 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 LNg IUC 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 and removal of the IUC rather than treatment with the IUC in situ (Grade 2B). An alternative method of contraception should be prescribed. (See 'Pelvic inflammatory disease' 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 IUC that remains in situ, the risk of spontaneous abortion is 40 to 50 percent, a rate twice as high as that of the general obstetric population. For most of these patients, we suggest removing the IUC (Grade 2C). (See 'Pregnancy' above.)

• If LEEP or an ablative procedure is to be performed with IUC 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.)