Persistent Pelvic Pain After IUD Placement

Some cramping occurs for 24 to 48 hours after insertion and settles with analgesia. Pain that is severe, worsens, or continues beyond this period needs evaluation for partial expulsion, malposition, perforation, infection and ectopic pregnancy. When no cause is found and the pain continues, the device is removed and another method offered.

Pattern. Pain timing, whether cyclical or constant, relation to intercourse or menses, bleeding, fever, discharge, dyspareunia, bowel and bladder symptoms.

History. Time since insertion, type of device, pain at insertion, previous dysmenorrhoea, endometriosis, previous pelvic infection, last menses, pregnancy symptoms, partner discomfort.

Examination. Vital signs, abdominal tenderness, speculum examination for threads and device position at the os, bimanual examination for cervical motion tenderness, uterine and adnexal tenderness.

Differential diagnosis.

• Device related: partial expulsion, malposition, embedded device, perforation, device too large for the uterus.
• Infection: pelvic inflammatory disease, endometritis, urinary tract infection.
• Pregnancy: ectopic pregnancy, miscarriage.
• Gynaecological: dysmenorrhoea, fibroid, adenomyosis, endometriosis, ovarian cyst, torsion.
• Non gynaecological: constipation, appendicitis, musculoskeletal pain.

Investigations. Pregnancy test. Pelvic ultrasound. Chlamydia and gonorrhoea testing, full blood count and urinalysis. Plain film if the device is not seen. Laparoscopy for persistent pain with a normal ultrasound, especially with suspected endometriosis.

Red flags. Severe pain with fever, peritonism, haemodynamic instability, positive pregnancy test with pain, or a missing device.

Mild or moderate pain. Paracetamol 1 g orally every 6 hours, maximum 4 g daily (3 g in liver disease or weight under 50 kg), with ibuprofen 400 mg orally every 8 hours with food for up to 5 days, maximum 1.2 g daily. Avoid ibuprofen in creatinine clearance under 30 mL/min, peptic ulcer, anticoagulant use and after 20 weeks of pregnancy. Both are compatible with breastfeeding.

Severe pain. Evaluate for partial expulsion, pelvic inflammatory disease or ectopic pregnancy and treat the cause.

Partial expulsion or malposition. Remove the device and replace it or offer another method.

Pelvic infection. Ceftriaxone 500 mg intramuscularly as a single dose, then doxycycline 100 mg orally twice daily and metronidazole 400 mg orally twice daily, both for 14 days. Avoid doxycycline in pregnancy and reduce metronidazole in severe liver disease. The device may stay if the patient wishes, and is removed if there is no improvement after a few days.

Persistent pain without a cause. If pain and cramping persist and no cause is found, remove the device and counsel the patient to choose another method.

Cyclical pain from dysmenorrhoea. Continue NSAIDs from the day before expected menses for 3 to 5 days, and consider a levonorgestrel intrauterine device or another method if the patient prefers.

Emergency contraception. If sex has taken place unprotected within 120 hours and the device may be displaced, give levonorgestrel 1.5 mg orally as a single dose.

Follow up. Review in 2 to 4 weeks after any change. Remove the device if pain persists beyond 3 months with no cause found.

Method decisions. If the device is removed, offer an implant, injectable or other method. Where endometriosis or adenomyosis is found, a levonorgestrel device or a progestin-only method may relieve pain.

Referral and escalation. Refer suspected perforation, ectopic pregnancy, tubo-ovarian abscess, peritonism and pain that continues after removal.