What could be causing vaginal bleeding in a patient with an Intrauterine Device (IUD) every time she squats down?

Vaginal Bleeding with IUD During Squatting: Differential Diagnosis and Management

This patient requires immediate evaluation for IUD displacement, which is the most likely cause of position-dependent vaginal bleeding, along with assessment for other underlying gynecological pathology including pregnancy, infection, and structural uterine abnormalities. 1

Primary Differential Diagnosis

IUD Displacement (Most Likely)

• Position-dependent bleeding (specifically with squatting) strongly suggests partial IUD expulsion or malposition 1
• The mechanical movement during squatting may cause the displaced IUD to traumatize the endometrium or cervix, triggering bleeding 1
• IUD expulsion occurs in 5-10% of cases within 5 years, and recurs in approximately 30% of women who experience it once 2
• Partial expulsion can cause intermittent bleeding that worsens with position changes or physical activity 3

Other Critical Considerations

Pregnancy (Must Rule Out First)

• Any abnormal bleeding in a reproductive-age woman with an IUD must be evaluated for pregnancy complications 1, 4
• Ectopic pregnancy occurs in approximately 1 in 20 pregnancies that happen with an IUD in place 2
• Intrauterine pregnancy with IUD in situ can present with bleeding 2

Pathologic Uterine Conditions

• New-onset bleeding after stable IUD use warrants evaluation for polyps, fibroids, or other structural abnormalities 1
• These conditions can cause bleeding that varies with position or physical activity 1

Sexually Transmitted Infections/Pelvic Inflammatory Disease

• PID risk is slightly elevated in the first 20 days after insertion but remains low overall (approximately 6 cases per 1000 woman-years) 1
• STDs should be considered, particularly if accompanied by pain, discharge, or fever 1

Cervical Pathology

• Cervical polyps, erosion, or other lesions can cause bleeding with mechanical stimulation 4
• Unexplained vaginal bleeding requires evaluation to exclude serious conditions including malignancy 1

Immediate Clinical Evaluation Required

Essential Assessment Steps

• Pregnancy test - mandatory first step 1, 4
• Pelvic examination to check for:
  • IUD string visibility and position 1
  • Signs of partial expulsion or malposition 1
  • Cervical lesions or pathology 4
  • Signs of infection (cervical motion tenderness, discharge) 1
• Pelvic ultrasound to confirm IUD location and evaluate for structural abnormalities 1
• STI testing (gonorrhea, chlamydia) if clinically indicated 1

Management Algorithm

If IUD Displacement Confirmed

• Remove the displaced IUD 1
• Offer alternative contraception immediately 1
• Consider emergency contraception if recent unprotected intercourse 1

If Pregnancy Identified

• Intrauterine pregnancy: Remove IUD after initiating antibiotics to reduce infection risk; 90% live birth rate if removed vs. 25% if left in place 2
• Ectopic pregnancy: Immediate gynecologic referral 2

If Infection Present

• Treat according to CDC STD treatment guidelines 1
• IUD does not need immediate removal if patient desires continued contraception 1
• Reassess in 24-48 hours; if no clinical improvement, continue antibiotics and consider IUD removal 1

If No Pathology Found

• For copper IUD: Consider NSAIDs (5-7 days during bleeding episodes) 1
• For levonorgestrel IUD: Reassurance that irregular bleeding typically improves with time 1, 5
• If bleeding persists and unacceptable to patient, counsel on alternative contraceptive methods 1

Critical Pitfalls to Avoid

• Never assume bleeding is "normal IUD side effects" without evaluation when the pattern is new or position-dependent 1
• Do not delay pregnancy testing - this is the most critical diagnosis to exclude 1, 4
• Position-specific bleeding is NOT a typical IUD side effect and warrants thorough investigation 1
• While bleeding irregularities are common in the first 3-6 months of IUD use, they should not be consistently triggered by specific physical positions 1