Post-Insertion Follow-Up Visit (3 to 6 Weeks)

1. Ask how the client is doing with the method and whether she is satisfied. Ask if she has any questions or anything to discuss.

2. Ask especially if she is concerned about bleeding changes. Give her any information or help that she needs (see Managing Any Problems, below).

3. Ask her if she has:

• Increasing or severe abdominal pain or pain during sex or urination
• Unusual vaginal discharge
• Fever or chills
• Signs or symptoms of pregnancy (see for common signs and symptoms)
• Not been able to feel strings (if she has checked them)
• Felt the hard plastic of an IUD that has partially come out

4. A routine pelvic examination at the follow-up visit is not required. It may be appropriate in some settings or for some clients, however. Conduct a pelvic examination particularly if the client’s answers lead you to suspect:

• A sexually transmitted infection or pelvic inflammatory disease
• The IUD has partially or completely come out

1. Ask how the client is doing with the method and about bleeding changes (see Post-Insertion Follow-Up Visit, Items 1 and 2, above).

2. Ask a long-term client if she has had any new health problems. Address problems as appropriate. For new health problems that may require switching methods, see below.

3. Ask a long-term client about major life changes that may affect her needs—particularly plans for having children and STI/HIV risk. Follow up as needed.

4. Remind her how much longer the IUD will protect her from pregnancy.

Removing the Intrauterine Device

Important: providers must not refuse or delay when a woman asks to have her IUD removed, whatever her reason, whether it is personal or medical. All staff must understand and agree that she must not be pressured or forced to continue using the IUD.

If a woman is finding side effects difficult to tolerate, first discuss the problems she is having (see Managing Any Problems, below). See if she would rather try to manage the problem or to have the IUD removed immediately.

Removing an IUD is usually simple. It can be done any time of the month. Removal may be easier during monthly bleeding, when the cervix is naturally softened. In cases of uterine perforation or if removal is not easy, refer the woman to an experienced clinician who can use an appropriate removal technique.

1. The provider inserts a speculum to see the cervix and IUD strings and carefully cleans the cervix and vagina with an antiseptic solution, such as iodine.

2. The provider asks the woman to take slow, deep breaths and to relax. The woman should say if she feels pain during the procedure.

3. Using narrow forceps, the provider pulls the IUD strings slowly and gently until the IUD comes completely out of the cervix.

These guidelines ensure that the client is protected from pregnancy without interruption when switching from a copper-bearing IUD or a hormonal IUD to another method. See also When to Start for each method. 

Managing Any Problems

Problems Reported As Side Effects or Complications

May or may not be due to the method.

• Problems with side effects or complications affect women’s satisfaction and use of IUDs. They deserve the provider’s attention. If the client reports any side effects or complications, listen to her concerns, give her advice, and, if appropriate, treat.
• Offer to help her choose another method—now, if she wishes, or if problems cannot be overcome.

• Reassure her that many women using IUDs experience heavy or prolonged bleeding. It is generally not harmful and usually becomes less or stops after the first several months of use.
• For modest short-term relief she can try (one at a time):

– Tranexamic acid (1500 mg) 3 times daily for 3 days, then 1000 mg once daily for 2 days, beginning when heavy bleeding starts.

– Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (400 mg) or indomethacin (25 mg) 2 times daily after meals for 5 days, beginning when heavy bleeding starts. Other NSAIDs—except aspirin—also may provide some relief of heavy or prolonged bleeding.

• Provide iron tablets if possible and tell her it is important for her to eat foods containing iron (see Possible anemia, p. 150).
• If heavy or prolonged bleeding continues or starts after several months of normal bleeding or long after the IUD was inserted, or if you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use (see Unexplained vaginal bleeding, below).

• Reassure her that many women using IUDs experience irregular bleeding. It is not harmful and usually becomes less or stops after the first several months of use.
• For modest short-term relief she can try NSAIDs such as ibuprofen (400 mg) or indomethacin (25 mg) 2 times daily after meals for 5 days, beginning when irregular bleeding starts.
• If irregular bleeding continues or starts after several months of normal bleeding, or you suspect that something may be wrong for other reasons, consider underlying conditions unrelated to method use (see Unexplained vaginal bleeding, below).

• She can expect some cramping and pain for the first day or two after IUD insertion.
• Explain that cramping also is common in the first 3 to 6 months of IUD use, particularly during monthly bleeding. Generally, this is not harmful and usually decreases over time.
• Suggest aspirin (325–650 mg), ibuprofen (200–400 mg), paracetamol (325–1000 mg), or other pain reliever. If she also has heavy or prolonged bleeding, aspirin should not be used because it may increase bleeding.

If cramping continues and occurs outside of monthly bleeding:

• Evaluate for underlying health conditions and treat or refer.
• If no underlying condition is found and cramping is severe, discuss removing the IUD.

– If the removed IUD looks distorted, or if difficulties during removal suggest that the IUD was out of proper position, explain to the client that she can have a new IUD that may cause less cramping.

• The copper-bearing IUD may contribute to anemia if a woman already has low iron blood stores before insertion and the IUD causes heavier monthly bleeding.
• Pay special attention to IUD users 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 brittle nails.

– If blood testing is available, hemoglobin less than 9 g/dl or hematocrit less than 30.

• Provide iron tablets if possible.
• Tell her it is important to eat foods containing iron, such as meat and poultry (especially beef and chicken liver), fish, green leafy vegetables, and legumes (beans, bean curd, lentils, and peas).

• Explain that this happens sometimes when strings are cut too short.
• If partner finds the strings bothersome, describe available options:

– Strings can be cut even shorter so they are not coming out of the cervical canal. Her partner will not feel the strings, but the woman will no longer be able to check her IUD strings.

– If the woman wants to be able to check her IUD strings, the IUD can be removed and a new one inserted. (To avoid discomfort, the strings should be cut so that 3 centimeter hang out of the cervix.)

• Some common signs and symptoms of PID often also occur with other abdominal conditions, such as ectopic pregnancy. If ectopic pregnancy is ruled out, assess for PID.
• If possible, do abdominal and pelvic examinations (see Signs and Symptoms of Serious Health Conditions, for signs from the pelvic examination that would indicate PID).
• If a pelvic examination is not possible, and she has a combination of the following signs and symptoms in addition to lower abdominal pain, suspect PID:

– Unusual vaginal discharge

– Fever or chills

– Pain during sex or urination

– Bleeding after sex or between monthly bleeding

– Nausea and vomiting

– A tender pelvic mass

– Pain when the abdomen is gently pressed (direct abdominal tenderness) or when gently pressed and then suddenly released (rebound abdominal tenderness)

• Treat PID or immediately refer for treatment:

– Because of the serious consequences of PID, health care providers should treat all suspected cases, based on the signs and symptoms above. Treatment should be started as soon as possible. Treatment is more effective at preventing long-term complications when appropriate antibiotics are given immediately.

– Treat for gonorrhea, chlamydia, and anaerobic bacterial infections. Counsel the client about condom use and, if possible, give her condoms.

– There is no need to remove the IUD if she wants to continue using it. If she wants it removed, take it out after starting antibiotic treatment. (If the IUD is removed, see Switching from an IUD to Another Method, above.)

• Many conditions can cause severe abdominal pain. Be particularly alert for additional signs or symptoms of ectopic pregnancy, which is rare but can be life-threatening (see Question 11).
• In the early stages of ectopic pregnancy, symptoms may be absent or mild, but eventually they will become severe. A combination of these signs or symptoms should increase suspicion of ectopic pregnancy:

− Unusual abdominal pain or tenderness

− Abnormal vaginal bleeding or no monthly bleeding—especially if this is a change from her usual bleeding pattern

− Light-headedness or dizziness

− Fainting

• If ectopic pregnancy or other serious health condition is suspected, refer at once for immediate diagnosis and care. (See Female Sterilization, Managing Ectopic Pregnancy, for more on ectopic pregnancies.)
• If the client does not have these additional symptoms or signs, assess for pelvic inflammatory disease (see Severe pain in lower abdomen, above).

If puncturing is suspected at the time of insertion or sounding of the uterus, stop the procedure immediately (and remove the IUD if inserted). Observe the client in the clinic carefully:

– For the first hour, keep the woman at bed rest and check her vital signs (blood pressure, pulse, respiration, and temperature) every 5 to 10 minutes.

– If the woman remains stable after one hour, check for signs of intra-abdominal bleeding, such as low hematocrit or hemoglobin, if possible, and her vital signs. Observe for several more hours. If she has no signs or symptoms, she can be sent home, but she should avoid sex for 2 weeks. Help her choose another method.

– If she has a rapid pulse and falling blood pressure, or new pain or increasing pain around the uterus, refer her to a higher level of care.

– If uterine perforation is suspected within 6 weeks after insertion or if it is suspected later and is causing symptoms, refer the client for evaluation to a clinician experienced at removing such IUDs (see Question 6.

If the IUD partially comes out, remove the IUD. Discuss with the client whether she wants another IUD or a different method. If she wants another IUD, she can have one inserted at any time it is reasonably certain she is not pregnant. If the client does not want to continue using an IUD, help her choose another method.

• If the client reports that the IUD came out, discuss with her whether she wants another IUD or a different method. If she wants another IUD, she can have one inserted at any time it is reasonably certain she is not pregnant.
• If complete expulsion is suspected and the client does not know whether the IUD came out, refer for x-ray or ultrasound to assess whether the IUD might have moved to the abdominal cavity. Give her a backup method to use in the meantime.

Ask the client:

– Whether and when she saw the IUD come out

– When she last felt the strings

– When she had her last monthly bleeding

– If she has any symptoms of pregnancy

– If she has used a backup method since she noticed the strings were missing

• Always start with minor and safe procedures and be gentle. Check for the strings in the folds of the cervical canal with forceps. About half of missing IUD strings can be found in the cervical canal.
• If strings cannot be located in the cervical canal, either they have gone up into the uterus or the IUD has been expelled unnoticed. Rule out pregnancy before attempting more invasive procedures. Refer for evaluation. Give her a backup method to use in the meantime, in case the IUD came out.

• Refer or evaluate by history or pelvic examination. Diagnose and treat as appropriate.
• She can continue using the IUD while her condition is being evaluated.
• If bleeding is caused by sexually transmitted infection or pelvic inflammatory disease, she can continue using the IUD during treatment.

• Assess for pregnancy, including ectopic pregnancy.
• Explain that an IUD in the uterus during pregnancy increases the risk of preterm delivery or miscarriage, including infected (septic) miscarriage during the first or second trimester, which can be life-threatening.
• If the woman does not want to continue the pregnancy, counsel her according to program guidelines.
• If she continues the pregnancy:

– Advise her that it is best to remove the IUD.

– Explain the risks of pregnancy with an IUD in place. Early removal of the IUD reduces these risks, although the removal procedure itself involves a small risk of miscarriage.

– If she agrees to removal, gently remove the IUD or refer for removal.

– Explain that she should return at once if she develops any signs of miscarriage or septic miscarriage (vaginal bleeding, cramping, pain, abnormal vaginal discharge, or fever).

– If she chooses to keep the IUD, her pregnancy should be followed closely by a nurse or doctor. She should see a nurse or doctor at once if she develops any signs of septic miscarriage.

If the IUD strings cannot be found in the cervical canal and the IUD cannot be safely retrieved, refer for ultrasound, if possible, to determine whether the IUD is still in the uterus. If it is, or if ultrasound is not available, her pregnancy should be followed closely. She should seek care at once if she develops any signs of septic miscarriage.