What is the next step for a 47-year-old female with an Intrauterine Device (IUD) in place for 9 years, where the strings are not visible during a Pap smear?

Management of Non-Visible IUD Strings After 9 Years

Perform a transvaginal ultrasound to confirm the IUD location within the uterine cavity, and if confirmed to be intrauterine, the IUD should be removed immediately given it has exceeded its approved duration of use. 1

Initial Assessment Steps

The first priority is determining whether the IUD is still present and where it is located:

• Obtain a transvaginal ultrasound to confirm the IUD position within the uterine cavity, as this is the CDC-recommended first step when strings are not visible 1
• Rule out pregnancy before proceeding with any intervention, as management differs entirely if the patient is pregnant 2, 1

Interpretation Based on Ultrasound Findings

If IUD is Confirmed Intrauterine

The device must be removed because after 9 years, it has exceeded the FDA-approved duration for all currently available IUDs (copper IUDs are approved for 10-12 years maximum, LNG-IUDs for 3-8 years depending on type) 1

• Even though the CDC states an IUD can remain in place if appropriately positioned and the patient is asymptomatic, this applies only to devices within their approved timeframe 1
• Arrange for removal, which may require:
  • Ultrasound-guided retrieval if strings cannot be grasped from the cervical canal 3
  • Hysteroscopic removal if standard retrieval attempts fail
  • Use of specialized instruments like alligator forceps under ultrasound guidance 3

If IUD Cannot Be Located on Ultrasound

Obtain an abdominal X-ray to rule out uterine perforation and locate the device 1, 4

• If the X-ray shows the IUD outside the uterus, this confirms perforation and requires laparoscopic removal as soon as possible 1, 4
• If no IUD is visualized on either ultrasound or X-ray, expulsion is the most likely explanation, though perforation with migration should still be considered if the patient has had abdominal pain 4, 5

Post-Assessment Counseling

• Advise the patient to return promptly for heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever 2, 1
• Discuss alternative contraceptive options if ongoing contraception is desired 2
• If pregnancy is detected during evaluation, removal should be attempted if strings are visible or can be safely retrieved, as leaving the IUD in place substantially increases risks of spontaneous abortion, septic abortion, preterm delivery, and infection 2, 1

Common Pitfalls to Avoid

• Do not assume expulsion without imaging confirmation, as uterine perforation can present with minimal or atypical symptoms that may be dismissed 4, 5
• Do not leave an expired IUD in place even if asymptomatic and well-positioned, as efficacy cannot be guaranteed beyond the approved duration
• Do not skip the X-ray if ultrasound fails to locate the device, as this is a relatively cheap and non-invasive way to identify perforation 4