May or may not be due to method.

Unexplained vaginal bleeding (that suggests a medical condition not related to the method)

• 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.

Heart Disease due to blocked or narrowed arteries (ischemic heart disease)

• A woman who has this condition can safely start the LNG-IUD. If, however, the condition develops while she is using the LNG-IUD:
  
  • Remove the IUD or refer for removal.
  • Help her choose a method without hormones.
  • Refer for diagnosis and care if not already under care.

Migraine Headaches (see Identifying Migraine Headaches and Auras)

•  If she has migraine headaches without aura, she can continue to use the LNG-IUD if she wishes.
•  If she develops migraine with aura, remove the LNG-IUD. Help her choose a method without hormones.

Certain serious health conditions (blood clots in deep veins of legs or lungs, breast cancer, gestational trophoblast disease, or pelvic tuberculosis). See Appendix B – Signs and Symptoms of Serious Health Conditions.

• Remove the IUD or refer for removal.
• Give her a backup method to use until the condition is evaluated.
• Refer for diagnosis and care if not already under care. 

Suspected pregnancy

• Assess for pregnancy, including ectopic pregnancy.
• Explain that exposure of the fetus to an LNG-IUD does not increase the risk of birth defects. However, 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, a nurse or doctor should follow her pregnancy closely. She should see a nurse or doctor at once if she develops any signs of septic miscarriage.
• If the IUD strings are not visible and cannot be found in the cervical canal, 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.