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 support, and, if appropriate, treat. Make sure she understands the advice and agrees.
• Offer to help her choose another method—now, if she wishes, or if problems cannot be overcome.

Heavy or prolonged bleeding (twice as much as usual or longer than 8 days)

• 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 (1,500 mg) 3 times daily for 3 days, then 1,000 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. Aspirin could increase bleeding.
• Provide iron tablets if possible and tell her it is important for her to eat foods containing iron (see “Possible anemia,” below).
• 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”).

Irregular bleeding (bleeding at unexpected times that bothers the client)

• 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”).

Cramping and pain

• She can expect some cramping and pain for the first day or two after IUD insertion.
• Explain that some 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 (325–1,000 mg), or other pain reliever. If she also has heavy or prolonged bleeding, aspirin should not be used because it may increase bleeding.
•  If severe cramping continues beyond the first 2 days after insertion, evaluate for partial expulsion or perforation.

Possible anemia

• 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).

Partner can feel IUD strings during sex

• Explain that this happens sometimes when strings are cut too short.
• If her partner finds the strings bothersome, describe and discuss this option:
  
  • Strings can be cut even shorter so they are not coming out of the cervical canal. Her partner will not feel the strings, but it will make the removal procedure somewhat more difficult (may require a specially trained provider).

Severe pain in lower abdomen (suspected pelvic inflammatory disease [PID])

• 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 Appendix B – 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 prevention and treatment of STIs and about condom use. 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, consider emergency contraceptive pills and discuss choosing another method (see Switching from an IUD to Another Method.)
  • If the infection does not improve, consider removing the IUD while continuing antibiotics. If the IUD is not removed, antibiotics should still be continued. In both cases the woman’s health should be closely monitored.

Severe pain in lower abdomen (suspected ectopic pregnancy)

• 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 10).
• 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 Chapter 12 − 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).

Suspected uterine puncturing (perforation)

• 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 or rebound on abdominal examination, 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 or more after insertion based on clinical symptoms, refer the client for evaluation to a clinician experienced at removing such IUDs (see Question 6).

IUD partially comes out (partial expulsion)

• 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 right away if it is reasonably certain she is not pregnant. If the client does not want to continue using an IUD, help her choose another method.

IUD completely comes out (complete expulsion)

• 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 (for example, strings cannot be found on pelvic exam) and the client does not know whether the IUD came out, refer for ultrasound (or x-ray, if pregnancy can be ruled out) to assess whether the IUD might have moved to the abdominal cavity. Give her a backup method to use in the meantime.

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

• Ask the client:
  • Whether and when she saw the IUD come out
  • When she had her last monthly bleeding
  • If she has any symptoms of pregnancy
  • If she has used a backup method since she noticed that the IUD came out
• 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. Refer for ultrasound (or x-ray, if pregnancy can be ruled out). Give her a backup method to use in the meantime, in case the IUD came out.