Managing Clinical Complexities of Long-Term Contraception

, Planned Parenthood Federation of America, Inc.

Disclosures

Medscape General Medicine. 1998;1(3) 

In This Article

Potential Concerns When the LTC is an IUD

A missing IUD string, partial expulsion of the device, a woman's complaint of a change in menstrual pattern, colonization with actinomycosis, and whether to remove an IUD to treat vaginosis or a sexually transmitted disease are among the issues clinicians who had nothing to do with the original IUD insertion may be called on to evaluate and manage.

Missing IUD String

Many women are able to verify that their IUD remains in position by touching the strings; they are instructed to check them regularly and to report to their clinician the absence or lengthening of the strings. To evaluate a missing string, start with the obvious: take a look by performing an examination with a vaginal speculum. Often, the string will be curled up alongside the cervix and easily visible. Sometimes, it's easier to feel the string digitally, particularly if it is curled up in the cervical canal. In either case, if you see or feel the string, the woman can be reassured. It helps to know how long the string was originally. Lengthening of the string may be a sign of partial IUD expulsion, so you should chart the length of the string each time you insert an IUD. Most practitioners cut the string to the same length each time unless there's a special indication, so the practitioner who inserted the IUD may be able to tell you how long the string should be, even if records are not accessible.

If the string is not visible or palpable, it may be curled up in the cervical canal. A cytobrush or cotton swab may tease it out, but be careful not to pull on the string enough to dislodge the IUD. If the string is not demonstrable by any of the previous steps, the next step is ultrasonography or radiography. IUDs are easy to see on a plain film: The copper on the ParaGard is easily visible. A plain film will quickly tell you if the IUD is missing completely; however, if it shows the IUD, it does not provide sufficient information as to its precise location. Ultrasound, particularly vaginal ultrasound, can demonstrate IUD position within the uterus (Fig. 1). If the IUD is in the proper intrauterine location, then no further investigation is necessary, and the IUD may remain in place until there is another indication for removal or replacement.

Figure 1. Transvaginal ultrasonography of a ParaGard IUD in situ.

Partial Expulsion

If part of the IUD can be visualized during speculum examination, the IUD is no longer effective and should be removed. Removal in this circumstance is usually very easy: Simply grasp the visible part with a spongestick or clamp and pull gently. Removal is not urgent unless the woman is pregnant, so if you are uncomfortable with performing the procedure, there is time to refer her to another provider. Women with partial IUD expulsion should be counseled regarding using an alternative contraceptive method.

Vaginal Discharge

Some clinicians feel that bacterial vaginosis appears to be more frequent in some IUD users (possibly related to either an increased amount or extended duration of menstrual bleeding); it should be evaluated and treated. The frequency of other forms of vaginitis does not appear to change. Mild cervicitis may be associated with IUD use, possibly from the presence of the string, and, if symptomatic, should be treated. Chronic vaginal discharge may also be a sign of cervicitis or of endometritis.

Change in Bleeding Patterns

Menses occur less frequently in some Progestasert users. However, for most women, the major menstrual changes are a generally lighter amount of bleeding and less dysmenorrhea. It may take several cycles for the maximum effect to become apparent. Amenorrhea may also result. New-onset amenorrhea should be evaluated to rule out pregnancy, but once ruled out, the amenorrhea does not require treatment. Some women have intermenstrual spotting, particularly if menses are light. If the woman is otherwise asymptomatic, treatment is not necessary. She should be treated if there are signs of endometritis or severe cervicitis, or if she finds the spotting unacceptable. Evaluation may include a visual inspection, wet mount preparation, tests for sexually transmitted diseases, and/or a Pap smear to rule out cervicitis.

The ParaGard (copper) IUD may result in heavier menstrual bleeding, lengthier menses, and intensified dysmenorrhea. The increases are usually less than were seen previously with the larger, nonmedicated IUDs, and usually diminish after several months. Dysmenorrhea is usually treated with a variety of any of the nonsteroidal anti-inflammatory drugs (NSAIDs). Some clinicians recommend routine use of NSAIDs during the first several menstrual cycles. Treatment during menses appears to be sufficient, and treatment throughout the month is not indicated. Despite the increase in menstrual blood loss associated with non-progestin-containing IUDs, anemia is uncommon.

Some clinicians feel that midcycle bleeding associated with ovulation seems to be more prevalent in IUD users. One or 2 days of spotting associated with mittleschmertz does not require treatment. Irregular intermenstrual bleeding, or a sudden increase in menstrual cramping or flow should prompt an evaluation for cervicitis or endometritis. If there is no clinical evidence of endometritis or cervicitis, bleeding may respond to NSAIDs.

Persistent or increasing menstrual flow may be a symptom of mild sterile endometritis, and may respond to a trial of NSAIDs. If NSAIDs are not effective, a course of doxycycline or other broad spectrum with antibiotic anaerobic coverage may be therapeutic. If prolonged or intermenstrual bleeding persists, the woman should be evaluated for other possible causes of bleeding, based on her age and any other relevant history. The presence of an IUD does not interfere with ultrasound. Some clinicians perform endometrial biopsies with the IUD in place.

Actinomycosis

Colonization with actinomycosis occurs in a small percentage of IUD users and is very rare in nonusers of IUDs in the absence of immunosuppression. There is no evidence that colonization per se presents an increased risk of upper genital tract disease. Most commonly, actinomycosis is an incidental finding on Pap smear. Women with a Pap smear reading of actinomycosis should be evaluated for the presence of pelvic inflammatory disease (PID)/adnexal pathology. If they are asymptomatic, treatment is not necessary, although many clinicians choose to treat with a 1- or 2-week course of penicillin. It is not necessary to remove the IUD, and colonization may recur. If, however, there is evidence of upper tract infection, such as salpingitis or adnexal abscess, the IUD should be removed promptly, and the patient treated with penicillin for a month or more. A history of PID due to actinomycosis contraindicates further IUD use.

Concurrent Sexually Transmitted Infections

Women using IUDs may seek medical help for a sexually transmitted infection (STI). Treatment of asymptomatic colonization with gonorrhea or chlamydia should be the same whether or not a woman has an IUD. Although the presence of an STI indicates that the woman is not in a mutually monogamous relationship, there is no evidence to suggest that removal of the IUD is necessary, but safe sexual practices, including condom use, should be recommended by the clinician to reduce exposure to future STIs. Barrier contraceptives alone have a higher pregnancy rate than IUDs. Hormonal contraceptive methods, however, may offer some additional protection against upper genital tract infection, possibly by changing the character of cervical mucus.

If PID is present, the consensus among clinicians is that the IUD should be removed. Many physicians prefer to institute antibiotics treatment first, removing the IUD 12 to 48 hours later, although there are no data to indicate that results are better with delayed removal compared to immediate removal.

Although "conventional wisdom" holds that IUDs are a cofactor in causing pelvic infections, there is little evidence that they do so after the first month. It is thought, however, that the insertion itself may be responsible for a small but significant rise in pelvic infections seen during the first month after insertion. Beyond the first month, there is no elevation in the prevalence of pelvic infections in IUD users matched with non-IUD users of similar parity.

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