What is the best course of treatment for a female patient of reproductive age with an Intrauterine Device (IUD) placed last week, now experiencing intermittent pelvic pain?

Treatment of Intermittent Pelvic Pain After Recent IUD Placement

Start scheduled NSAIDs immediately—specifically naproxen 500-550 mg orally every 12 hours with food for 24-72 hours—as this is the first-line treatment for post-IUD insertion pain. 1

Immediate Management

First-Line Pharmacologic Treatment

• Prescribe scheduled NSAIDs rather than as-needed dosing for the first 24-72 hours post-procedure 1
• Naproxen 500-550 mg orally every 12 hours is preferred, taken with food to prevent gastric irritation 1
• Alternative: ibuprofen 600-800 mg every 8 hours if naproxen is contraindicated 1
• Ketorolac can be used for breakthrough pain if NSAIDs alone are insufficient 1

Non-Pharmacologic Adjuncts

• Apply heating pad to lower abdomen for comfort 1
• Consider bilateral acupressure at LI4 (dorsum of hand at midpoint of second metacarpal) and SP6 (four fingers above medial malleolus) for several minutes 1, 2
• Reassure the patient that mild-to-moderate cramping is normal in the first week after insertion 1

Critical Assessment for Complications

Before attributing pain solely to normal post-insertion cramping, you must rule out malposition or perforation, especially if pain is severe, persistent, or worsening. 3, 4, 5

Red Flags Requiring Urgent Evaluation

• Severe or progressively worsening pain that doesn't respond to NSAIDs 5, 6
• Pain accompanied by fever, abnormal vaginal discharge, or signs of infection 3
• Inability to visualize IUD strings on speculum exam 3, 5
• Associated symptoms: dyspareunia, hematuria, or bowel symptoms 4, 5

Diagnostic Workup if Concerning Features Present

• Perform pelvic ultrasound with 3D coronal view reconstruction to visualize the entire IUD and confirm proper positioning within the uterine cavity 6
• 3D ultrasound detects malpositioned IUDs (embedded in myometrium or cervix) that cause pain and bleeding in 16.8% of cases, which standard 2D views miss 6
• If IUD is not visible on ultrasound and strings cannot be located, obtain abdominal and pelvic X-rays to rule out perforation and migration 3, 4

Expected Pain Timeline and Patient Counseling

Normal Post-Insertion Pain Pattern

• Most patients experience cramping that peaks during insertion and gradually improves over 5-15 minutes 1
• Intermittent cramping for 24-72 hours post-insertion is expected and should respond to NSAIDs 1
• Pain beyond 72 hours or increasing in severity warrants re-evaluation 5, 6

When to Remove the IUD

• If 3D ultrasound confirms malposition (IUD arms embedded in myometrium or extending into cervix), removal is indicated 6
• 75% of patients with abnormally located IUDs present with pain or bleeding, and 95% (20/21) report symptom improvement after removal 6
• Perforation with migration requires surgical removal, typically via laparoscopy 3, 4, 5

Common Pitfalls to Avoid

• Providers consistently underestimate patient pain levels (agreement between patient and provider pain assessment is only slight, k=0.167), so take patient reports seriously 7
• Do not assume the IUD is properly positioned just because strings are visible—malposition can occur even with visible strings 5
• Failing to obtain imaging when pain is severe or persistent delays diagnosis of perforation or malposition 3, 5, 6
• Attempting IUD removal without proper training when complications are suspected can worsen outcomes 3