What management options are available for a patient experiencing pelvic pain one week after intrauterine device (IUD) placement, with visible strings, and no other concerning symptoms?

Management of Pelvic Pain One Week After IUD Placement

Reassure the patient that pelvic pain one week after IUD insertion with visible strings is most likely normal adjustment cramping, and prescribe naproxen 500-550 mg every 12 hours or ibuprofen 600-800 mg every 6-8 hours with food for pain relief. 1

Understanding the Timeline

• Cramping and pelvic discomfort are expected during the first 3-6 months after IUD placement and typically decrease with continued use 1
• The presence of visible strings during examination is reassuring and suggests the IUD is likely in proper position 1
• Pain at one week post-insertion falls well within the normal adjustment period 1

Recommended Pain Management

First-line pharmacologic options:

• Naproxen 500-550 mg orally every 12 hours with food is the preferred NSAID for menstrual-type cramping 1, 2
• Alternatively, ibuprofen 600-800 mg every 6-8 hours with food can be used 1, 2
• For faster onset, ketorolac 20 mg orally taken 40-60 minutes before anticipated pain episodes may be considered 1, 2

Non-pharmacologic approaches to complement pain medication:

• Apply a heating pad to the lower abdomen or back to reduce cramping 2
• Cold, wet towels on the forehead may provide additional comfort 2
• Acupressure at the LI4 (between thumb and index finger) and SP6 (inner ankle) points bilaterally 2, 3
• Slow-rhythm music and yoga-based breathing techniques during acute pain episodes 2
• Aromatherapy with lavender or peppermint essential oil may help reduce discomfort 2

When to Seek Further Evaluation

The patient should return for assessment if:

• Pain becomes severe or progressively worsens rather than improving 1
• Pain persists beyond 3-6 months despite appropriate analgesia 1
• New symptoms develop, including fever, abnormal vaginal discharge, or heavy bleeding 1

Important Caveats

• Do not use misoprostol for pain management – it is not indicated for post-insertion pain and actually causes increased cramping 1
• While visible strings are reassuring, they do not completely exclude malposition, particularly if pain becomes severe or unremitting 4
• If pain is unacceptable to the patient despite appropriate treatment after ruling out other causes, IUD removal and counseling on alternative contraceptive methods should be offered 1

What to Avoid

• Delaying evaluation beyond 3-6 months if pain is severe or progressively worsening, as this exceeds the expected adjustment period 1
• Assuming all pain with visible strings is benign – rare cases of partial perforation or myometrial embedment can occur even with visible strings 4