Managing problems associated with IUC

Bleeding

Tranexamic acid or NSAIDs can be offered for management of HMB during use of IUC. A 3-month trial of COC can be offered to medically eligible individuals with problematic bleeding during use of IUC.  

As bleeding patterns will often change with IUC, provision of information about expected bleeding patterns is important. Although unscheduled bleeding may be caused by the IUC itself, other causes (e.g. pregnancy, infection, pathology) should be considered and investigated in line with FSRH Clinical Guideline Problematic Bleeding with Hormonal Contraception. Risk factors for endometrial cancer include older age, raised BMI, early menarche, late menopause, nulliparity, use of HRT, use of tamoxifen, history of polycystic ovary syndrome, diabetes and a family history of endometrial cancer.

New Onset Pelvic Pain 

New-onset pelvic pain in an IUC user should be assessed, and pregnancy should be excluded. There are a number of possible causes for new-onset pelvic pain in an IUC user, many of which are not related to the IUC. A clinical history and physical examination will identify the differential diagnoses and guide the investigation and management. The history will determine the examination and investigations required; however, an abdominal and pelvic examination (speculum ± bimanual examination) and a pregnancy test would usually be required. Due to the potential serious consequences of an ectopic pregnancy, pregnancy should be excluded in all IUC users with new-onset pelvic pain. Other investigations/examinations that may be indicated would be urinalysis, STI screening, measurement of temperature/blood pressure/heart rate, pelvic ultrasound, rectal examination, blood tests. Where alternative causes have been excluded and the individual wishes IUC removal and replacement, that clinicians could consider offering replacement with an alternative device (e.g. switching to a device with a smaller or different-shaped frame). There is, however, insufficient evidence to suggest one particular device over another.

Possible causes if new onset pelvic pain [from FSRH Clinical Guideline: Intrauterine contraception (March 2023)]

Pregnancy

The risk of any pregnancy, including ectopic pregnancy, during use of LNG-IUS is very low. Risk of ectopic pregnancy during use of LNG-IUD is lower than using no contraception. However, among pregnancies that occur with LNG-IUD in situ, the proportion that is ectopic is greater than among pregnancies occurring without LNG-IUD in situ.

A previous ectopic pregnancy is not a contraindication to use of IUC (UKMEC1).

If someone with an LNG-IUD in situ has a positive pregnancy test, follow local assessment pathways

Explain that the risk of adverse pregnancy outcomes (including miscarriage, preterm delivery and septic abortion) is greater than that for pregnancies without an IUC in situ. Removal of the device may improve pregnancy outcomes and is advised when pregnancy is less than 12 weeks’ gestation, as long as the threads are visible or can be easily removed from the endocervical canal. After 12 weeks’ gestation or if  threads are not visible, the decision to remove or retain the device should be considered on an individual basis in conjunction with the obstetric team. When a LNG-IUD IUC is in situ in pregnancy, the individual’s obstetric/maternity team should be made aware of the presence of the device.

 Infection

Pelvic inflammatory disease (PID) occurs as a result of upper genital tract infection, often due to ascending infection from the vagina or endocervix. Chlamydia trachomatis is the commonest causative organism (35% of PID cases). Instrumentation of the uterus for gynaecological procedures, including IUC insertion, can facilitate upward ascent of infection and therefore purulent cervicitis, gonorrhoea and symptomatic chlamydia infection are considered contraindications to IUC insertion (UKMEC4). A sexual history should be taken prior to IUC insertion and screening offered to any individual at risk of an STI. For asymptomatic individuals, testing can be undertaken at the time of IUC insertion. The risk of PID appears to increase in the first 3 weeks after IUC insertion but overall the risk is very low and (<1% of all IUC users)

IUC users with a clinical presentation suggestive of PID should be given antibiotic treatment, managed in accordance with BASHH guidance, and reviewed after 48–72 hours. For individuals with mild-to-moderate PID, whose clinical condition is improving over the first 48–72 hours, the IUC can remain in situ. For individuals whose clinical condition does not improve after 48–72 hours of antibiotics, removal of IUC is normally recommended but should be considered alongside any potential risk of pregnancy if there has been unprotected vaginal sex within the preceding 7 days. An alternative method of contraception should be offered for ongoing contraception, and the need for EC and follow-up pregnancy testing considered. Insertion of IUC when an individual has PID is a UKMEC4. Therefore, for individuals with PID that have their IUC removed but wish another IUC inserted, it is recommended that IUC insertion is delayed until antibiotic treatment has been completed and all signs and symptoms have resolved.

Candida &  Bacterial vaginosis (BV):; IUC users with symptomatic, recurrent, confirmed VVC/BV not controlled by standard management may wish to switch to an alternative method of contraception.

Actinomycosis and presence of actinomyces-like organisms (ALO): Incidental findings of ALO are rare now that liquid-based cytology (LBC) and/or primary human papillomavirus (HPV) testing is now used for cervical screening. For more information refer to FSRH Clinical Guideline: Intrauterine contraception (March 2023)

https://www.fsrh.org/standards-and-guidance/documents/ceuguidanceintrauterinecontraception

Malposition

If malposition is  suspected clinically or detected on a scan refer to senior clinician

Advise use of an alternative method of contraception meantime

Perforation

The rate of uterine perforation associated with IUC use is very low, with an overall risk of perforation in the general population of approximately 1–2 per 1000.

Perforation risk  is greater if breastfeeding and postpartum at the time of insertion

Perforation identified at the time of insertion. Stop procedure: remove IUC; monitor blood pressure and pulse rate and level of discomfort monitored until stable. Consider broad-spectrum antibiotics reduce the risk of peritonitis. Offer alternative contraception and advise to seek review if significant pain or signs/symptoms of infection develop.

Delayed identification of perforation. Lower abdominal pain, non-visible threads or changes in bleeding could indicate uterine perforation but are non- specific.

The presence of threads does not exclude perforation as the IUC could have breached the myometrium/other surrounding tissue or perforated the cervix.

Arrange urgent USS ± plain abdominal and pelvic X-ray should be arranged to locate the device. In the interim, consider EC, and offer alternative contraception.

Morbidity associated with detection and removal of an intraabdominal IUC appears to be low but uterine perforation can  involve damage to the abdominal or pelvic viscera, bladder or bowel. If confirmed perforation liaise with gynaecology to consider laparoscopy

Wait at least 6 weeks after a known or suspected uterine perforation before inserting a subsequent IUD. Refer to a specialist service, where ultrasound is available.