How should I manage removal and replacement of a three‑year‑expired intrauterine device in a patient who has not had recent gynecologic care and who reports dyspareunia due to vaginal dryness?

Management of Expired IUD with Dyspareunia

Remove the expired IUD and replace it with a new device at the same visit, while simultaneously addressing the vaginal dryness with non-hormonal vaginal moisturizers and lubricants as first-line therapy. 1

IUD Removal and Replacement Strategy

Immediate Removal is Indicated

An IUD that has been expired for three years should be removed promptly. While the device may still provide contraceptive protection beyond its FDA-approved duration, continuing use of an expired device is not recommended practice. The removal procedure itself is straightforward:

• Remove by pulling gently on the strings if they are visible or can be retrieved safely from the cervical canal 1
• If strings are not visible, perform or refer for ultrasound to locate the device before attempting removal 1
• Most IUD removals (approximately 82%) are uncomplicated and require no special instruments 2

Same-Day Replacement Protocol

You can insert the new IUD immediately after removing the expired one 1. This approach:

• Eliminates the need for backup contraception if the patient has been sexually active, as the old IUD was still in place
• Prevents any gap in contraceptive coverage
• Requires no waiting period between removal and insertion 1

Important timing consideration: Since she is switching from one IUD to another and has had recent intercourse, theoretically residual sperm might be present. Consider one of these options 1:

• Insert the new IUD immediately (preferred, given continuous IUD coverage)
• Alternatively, advise emergency contraceptive pills at time of removal if there is concern about residual sperm

Addressing the Dyspareunia

First-Line Treatment: Non-Hormonal Options

Recommend vaginal moisturizers and lubricants as the primary treatment for vaginal dryness and dyspareunia 3, 4. These should be:

• Water-based or hyaluronic acid-containing products for regular use 4
• Silicone-based lubricants may last longer than water-based products 3
• Can be used alone or in combination with other therapies 4

Pain Management for IUD Insertion

Given her dyspareunia and vaginal dryness, consider pain management strategies for the insertion:

• Offer prescription-strength naproxen 550 mg taken 1-2 hours before the procedure 5
• Consider topical anesthetics (4-5g EMLA cream) applied to the cervix 5-10 minutes before insertion 5
• Alternatively, consider intracervical block with 6 mL of 2% lidocaine immediately before insertion 5

Escalation if Non-Hormonal Therapy Fails

If moisturizers and lubricants are insufficient after 4-6 weeks:

Vaginal estrogen is the most effective treatment for vaginal dryness leading to dyspareunia 6, 3. Options include:

• Low-dose estrogen vaginal tablets
• Estradiol vaginal ring
• These have minimal systemic absorption and are generally safe 6

Alternative: Vaginal DHEA (prasterone) can be considered for dyspareunia 6, 7:

• Effective at reducing dyspareunia in postmenopausal individuals
• One RCT showed significant improvements in sexual pain and overall function 6

Pre-Procedure Considerations

No Routine Examinations Required

Before IUD insertion, no examinations or tests are needed in healthy women 1. However, given the lack of recent gynecologic care:

• Perform bimanual examination to determine uterine position and size 8
• Sound the uterus to determine cavity depth 8
• Consider STI screening if she is at risk, but do not delay IUD insertion - you can screen on the day of insertion and treat subsequently without removing the new IUD 9

Common Pitfalls to Avoid

1. Do not delay IUD replacement - there is no need to wait for menses or schedule a separate visit 1
2. Do not assume the expired IUD needs complex removal - most removals are straightforward 2
3. Do not prescribe misoprostol for cervical priming unless there is a history of failed insertion or known cervical stenosis 5
4. Do not overlook the dyspareunia - address it proactively rather than waiting for the patient to bring it up again 3

Post-Procedure Counseling

Advise the patient to:

• Begin using vaginal moisturizers regularly (2-3 times weekly) and lubricants with sexual activity
• Return if she experiences heavy bleeding, cramping, severe pain, abnormal discharge, or fever 1
• Follow up in 4-6 weeks to assess IUD position and response to dyspareunia treatment
• Expect that treating the vaginal dryness may take several weeks but should improve her sexual comfort significantly 4