What are the management options for symptoms experienced with a copper T (intrauterine device) IUD?

Management of Copper IUD Symptoms

For women experiencing symptoms with a copper IUD, reassurance and expectant management are appropriate for the first 3-6 months, as bleeding and cramping typically improve with time; however, if symptoms persist beyond this period or are unacceptable to the patient, NSAIDs during menses can be offered, and if symptoms remain intolerable, removal and alternative contraception should be discussed. 1

Common Expected Symptoms

Bleeding Changes

• Increased menstrual bleeding and unscheduled spotting are the most common side effects during the first 3-6 months of copper IUD use 1
• These bleeding irregularities are generally not harmful and decrease with continued use 1
• Research confirms that most bleeding and pain symptoms during menses decrease over time, though intermenstrual spotting may persist with increased number of days affected 2

Pain and Cramping

• Cramping and dysmenorrhea are common, particularly in the first several months 1
• Nulliparous women report more dysmenorrhea requiring analgesics (72%) compared to parous women (47%) 3
• Pain symptoms during menses generally improve over time 2

Management Algorithm

Step 1: Initial Counseling (Before Insertion)

• Provide pre-insertion counseling about expected bleeding patterns and cramping, emphasizing that symptoms are typically most prominent in the first 3-6 months 1
• Enhanced counseling about expected side effects reduces discontinuation rates 1

Step 2: Symptom Assessment (When Patient Reports Problems)

If clinically indicated, evaluate for underlying gynecological problems: 1

• IUD displacement - check for visible strings
• Sexually transmitted infection
• Pregnancy - particularly if bleeding pattern changes abruptly
• New pathologic uterine conditions (polyps, fibroids) - especially in women who have been using the IUD for months and develop new-onset heavy bleeding 1

Step 3: Treatment Options for Persistent Symptoms

For Bleeding and Pain During Menses:

• NSAIDs for short-term treatment (5-7 days) during days of bleeding 1
• Specific dosing: Naproxen 500-550 mg orally or ketorolac 20 mg orally, taken with food 1
• Important caveat: Prophylactic ibuprofen (1200 mg daily during menses for 6 months) does NOT reduce IUD removal rates, so continuous prophylactic use is not recommended 4

If No Underlying Problem Found:

• Provide reassurance that symptoms are expected and typically improve 1
• Offer NSAIDs during symptomatic days only 1

Step 4: When to Consider Removal

If bleeding or pain persists beyond 3-6 months and the woman finds it unacceptable: 1

• Counsel on alternative contraceptive methods
• Offer another method if desired 1
• The 12-month continuation rate for copper IUD is approximately 94%, with increased bleeding and menstrual disturbances being the main reasons for discontinuation 5

Special Circumstances

Pelvic Inflammatory Disease (PID)

If PID is diagnosed: 1

• Treat with appropriate antibiotics per CDC STD Treatment Guidelines
• The IUD does NOT need to be removed immediately if the woman wants ongoing contraception 1
• Reassess in 24-48 hours
• Consider removal only if no clinical improvement occurs after 24-48 hours of antibiotics 1
• Treatment outcomes do not generally differ between women who retain versus remove the IUD 1

Pregnancy with IUD in Place

If pregnancy is diagnosed: 1

• Immediately evaluate for ectopic pregnancy 1
• If intrauterine pregnancy confirmed and strings visible: remove the IUD as soon as possible by gently pulling on strings 1
• Advise that IUD retention increases risk of spontaneous abortion (including life-threatening septic abortion) and preterm delivery 1

Key Clinical Pitfalls

• Do not prescribe prophylactic NSAIDs for months - evidence shows this does not reduce removal rates 4
• Do not immediately remove IUD for PID - treat with antibiotics first and reassess 1
• Do not dismiss persistent heavy bleeding - evaluate for displacement, infection, pregnancy, or new uterine pathology, especially after the initial 3-6 month period 1
• Expulsion rates are higher in nulliparous women (12.2%) versus parous women (3.5%), though not statistically significant 3