Bleeding
Give information about expected bleeding patterns as they can change with Cu-IUD use. Although unscheduled bleeding may be caused by the Cu-IUD itself, other causes (e.g. pregnancy, infection, pathology) should be considered and investigated in line with CoSRH Clinical Guideline: Problematic Bleeding with Hormonal Contraception.
Options for HMB include:
Tranexamic acid, NSAIDs or a 3-month trial of COC or switch to LNG-IUD (if medically eligible).
New Onset Pelvic Pain
This should be assessed, and pregnancy excluded. Causes may or may not be related to the Cu-IUD. A clinical history and physical examination will identify the differential diagnoses and guide the investigation and management. Where alternative causes have been excluded and the individual wishes Cu-IUD removal and replacement, 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.
Table Three: Possible causes if new onset pelvic pain [from CoSRH Clinical Guideline: Intrauterine contraception (March 2023)]
Pregnancy
The risk of any pregnancy, including ectopic pregnancy, during use of Cu-IUD and after insertion of a Cu-IUD for EC is very low. However, among pregnancies that occur with a Cu-IUD in situ, the proportion that is ectopic is greater than among pregnancies occurring without IUD in situ.
A previous ectopic pregnancy is not a contraindication to use of Cu-IUD.
Cu-IUD in situ and a positive pregnancy test: follow local assessment pathways.
Pregnancy less than 12 weeks gestation and threads visible: removal may improve pregnancy outcome
Pregnancy after 12 weeks gestation: refer to obstetric team
Infection
The risk of PID appears to increase in the first 3 weeks after Cu-IUD insertion but overall, the risk is very low (<1% of all IUD users). Instrumentation of the uterus can lead to ascending infection and PID.
If symptoms are suggestive of PID manage as per PID guideline (see guideline, insert link)
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 are used for cervical screening.
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
Overall risk of approximately 1–2 per 1000, greater if breastfeeding and postpartum at the time of insertion.
If identified at the time of insertion: Stop procedure: remove Cu-IUD; monitor blood pressure and pulse rate and level of discomfort until stable. Consider broad-spectrum antibiotics to 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.