What is the recommended treatment for pain due to a malpositioned Intrauterine Device (IUD)?

Treatment for Pain Due to Malpositioned IUD

The primary treatment for pain due to a malpositioned IUD is removal of the device, as this provides the highest rate of symptom resolution. 1

Immediate Assessment and Diagnostic Approach

When a patient presents with pain and a suspected malpositioned IUD, perform the following evaluation:

• Check for visible IUD strings on speculum examination to determine if the device can be safely removed 1
• Order pelvic ultrasound if strings are not visible or malposition is suspected, as this can reveal low-lying, endocervical, or intraperitoneal positioning 2, 3
• Consider 3-dimensional ultrasound for better visualization of IUD position relative to uterine anatomy 4
• Evaluate for uterine perforation, particularly if the patient has chronic pelvic pain, as approximately 80% of perforated IUDs migrate to the peritoneal cavity 5

Definitive Management: IUD Removal

When Strings Are Visible or Retrievable

Remove the IUD immediately by pulling gently on the strings, as this is the definitive treatment that resolves symptoms 1, 2

When Strings Are Not Visible

• Perform or refer for outpatient vaginoscopic hysteroscopy to locate the device and potentially remove or reposition it during the same procedure 2
• If hysteroscopy reveals the IUD is correctly positioned but causing symptoms, removal is still recommended 2
• If uterine perforation is confirmed, surgical removal via laparoscopy is indicated, even in asymptomatic patients with intraperitoneal migration 5

Symptomatic Pain Management During Evaluation

While arranging for IUD removal or repositioning, provide the following pain control:

Pharmacological Management

• NSAIDs are first-line: Prescribe naproxen 440-550 mg every 12 hours OR ibuprofen 600-800 mg every 6-8 hours, taken with food 1
• Continue NSAID therapy on a scheduled basis (not as-needed) for 24-72 hours 1
• Ketorolac 20 mg orally can be considered for more severe pain, taken 40-60 minutes before anticipated peak discomfort 1

Non-Pharmacological Adjuncts

• Apply heat to the lower abdomen or back to reduce cramping pain 1
• Acupressure at Large Intestine-4 (LI4) point on the dorsum of the hand or Spleen-6 (SP6) point above the medial malleolus, applied bilaterally for several minutes 1
• Cold compresses on the forehead may provide comfort 1
• Encourage slow-rhythm music or yoga-based breathing techniques for anxiety and pain reduction 1

Critical Pitfalls to Avoid

• Do not delay removal in symptomatic patients—the evidence shows higher symptom resolution rates with removal compared to conservative management 1
• Do not assume normal positioning based on initial imaging interpretation alone; malpositioned IUDs (particularly low-lying or endocervical) are frequently misread as normal 3
• Do not dismiss chronic pelvic pain in IUD users without imaging evaluation, as uterine perforation can present with minimal or delayed symptoms 5, 4
• Missing IUD strings at presentation are strongly associated with malposition (OR 3.58) and warrant immediate ultrasound evaluation 4

Special Considerations

Certain anatomical factors increase malposition risk and should prompt closer monitoring:

• Retroflexed uterine position (7.6% malposition rate vs 1.8% in normal position) 4
• Uterine anomalies including septate/bicornuate uteri (31.9% malposition rate) 4
• Submucosal fibroids or increased total fibroid burden 4
• Patients presenting with vaginal bleeding (OR 2.25) or pain (OR 2.85) have significantly higher malposition rates 4

Hysteroscopy offers the advantage of potentially repositioning rather than removing a malpositioned IUD, which may preserve contraceptive efficacy if the patient desires to continue using the device 2. However, if the patient has lost confidence in the IUD or symptoms persist after repositioning, removal remains the definitive solution 2.