What is the management approach for a patient with an Intrauterine Device (IUD) presenting with symptoms suggestive of uterine fibroids or Arteriovenous Malformations (AVMs)?

Management of IUD Patients with Suspected Uterine Fibroids or AVMs

In a patient with an IUD presenting with symptoms suggestive of fibroids or AVMs, immediately perform transvaginal and transabdominal ultrasound with Doppler imaging to differentiate between these entities, as the IUD does not preclude either diagnosis but significantly influences management decisions. 1

Initial Diagnostic Approach

Start with transvaginal and transabdominal ultrasound with Doppler as the primary imaging modality to evaluate both the IUD position and characterize any uterine pathology. 1

Key Imaging Considerations with IUD in Place:

• Doppler ultrasound is essential for diagnosing AVMs, showing low-resistance arterial flow in the myometrium with characteristic high-velocity turbulent flow patterns. 1
• Grayscale ultrasound findings alone are insufficient for AVM diagnosis; Doppler confirmation is mandatory. 1
• The IUD artifact does not prevent adequate visualization of fibroids or vascular lesions in most cases. 1

Critical Diagnostic Pitfall:

Exercise extreme caution before diagnosing an AVM in any patient with recent uterine instrumentation (including IUD placement), as enhanced myometrial vascularity can mimic true AVMs. 1 Many of these "vascular lesions" will resolve spontaneously and are not true arteriovenous malformations. 1

Distinguishing Fibroids from AVMs

If Fibroids are Confirmed:

• Physical examination should reveal an enlarged, irregularly contoured uterus that is typically non-tender on bimanual pelvic examination in uncomplicated cases. 2
• New-onset tenderness should never be attributed to pre-existing fibroids without excluding complications such as degeneration, torsion of pedunculated fibroid, or alternative diagnoses like PID. 2
• The IUD can remain in place if the patient desires continued contraception and is pursuing medical management or minimally invasive treatments. 1

If AVM is Suspected:

• In stable patients, obtain follow-up ultrasound before confirming the diagnosis or initiating treatment, as many vascular lesions resolve with conservative management. 1
• Measure peak systolic velocity in the suspected vascular lesion, as this helps guide management decisions—higher velocities may indicate need for intervention. 1
• Consider MRI without gadolinium for problem-solving if ultrasound findings are equivocal or to better characterize the extent of the AVM. 1

Management Algorithm Based on Diagnosis

For Confirmed Fibroids with IUD:

First-line medical management includes maintaining the progestin-containing IUD if already present, as it reduces bleeding symptoms effectively. 1 If the patient has a copper IUD and desires medical management:

• Replace copper IUD with levonorgestrel-releasing IUD for superior bleeding control in fibroid-related menorrhagia. 1
• Combined oral contraceptives are an alternative if IUD is not desired or contraindicated. 1
• Tranexamic acid provides a nonhormonal option for reducing bleeding symptoms. 1

Second-line medical options include oral GnRH antagonists (elagolix, relugolix) with add-back hormone therapy to mitigate hypoestrogenic effects. 1

For Symptomatic Fibroids Requiring Intervention:

Remove the IUD before any surgical or interventional procedure including:

• Hysteroscopic myomectomy for submucosal fibroids causing bleeding symptoms. 1
• Uterine artery embolization (UAE) for subserosal or intramural fibroids in patients desiring uterus preservation. 1
• Laparoscopic or open myomectomy for fertility preservation with multiple or large fibroids. 1
• MR-guided focused ultrasound (MRgFUS) as a non-invasive alternative with rare complications. 1

For Confirmed Uterine AVM:

Conservative management with observation is appropriate for stable patients with minimal bleeding, as many vascular lesions resolve spontaneously. 1

Uterine artery embolization is the first-choice treatment for symptomatic AVMs causing significant bleeding, particularly in reproductive-age women desiring fertility preservation. 3, 4

Hysterectomy is reserved for life-threatening hemorrhage unresponsive to embolization or in patients with completed childbearing who prefer definitive treatment. 4, 5

Special Clinical Scenarios

If Patient Presents with Acute Heavy Bleeding:

• Stabilize hemodynamically first before pursuing definitive diagnosis. 3, 4
• Perform urgent ultrasound with Doppler at bedside to differentiate fibroid degeneration from AVM. 1
• Angiography remains the gold standard for diagnostic confirmation of AVM if embolization is being considered. 4
• Remove IUD if it is contributing to bleeding or if surgical intervention is planned. 3, 4

If Fibroid Degeneration is Suspected:

Look for severe sudden-onset pain, fever, nausea, and leukocytosis as the classic presentation. 2, 6

Provide supportive care with NSAIDs and observation, as this typically resolves without intervention. 2, 6

The IUD can remain in place during conservative management of fibroid degeneration. 2

If Large Fibroids with Concurrent AVMs:

This rare combination requires multidisciplinary management involving interventional radiology, gynecologic surgery, and potentially cardiology if high cardiac output state develops. 5

Preoperative arterial embolization followed by hysterectomy may be necessary for massive leiomyomatous uteri with multiple large AVMs. 5

Key Management Principles

The presence of an IUD does not contraindicate any imaging modality including ultrasound, MRI, or angiography. 1

Fertility preservation considerations apply equally to IUD users, as many choose IUDs specifically for reversible contraception. 1, 4

Rapid fibroid growth with tenderness in any patient warrants urgent referral to exclude malignant transformation (leiomyosarcoma), though this remains rare. 2, 6

Document IUD location on all imaging studies to ensure it remains properly positioned and is not displaced by fibroids or contributing to symptoms. 1