What is the assessment and plan for a female patient with an intrauterine device (IUD) presenting with vaginal bleeding upon squatting?

Assessment and Plan: Female Patient with IUD and Vaginal Bleeding Upon Squatting

Assessment

This patient requires immediate evaluation to rule out IUD displacement, perforation, pregnancy, infection, or other underlying gynecological pathology before attributing bleeding to benign causes. 1, 2

Key Differential Diagnoses to Consider:

• IUD displacement or partial expulsion – The mechanical trigger of squatting suggests possible device malposition 1, 3
• Uterine perforation – Though rare (0.12-0.68/1000 insertions), can present with bleeding and pain, or be asymptomatic 4, 5
• Pregnancy (intrauterine or ectopic) – Must be ruled out first, as IUD failure occurs and carries significant morbidity risk 1
• Pelvic inflammatory disease (PID) – Risk is highest in first 20 days post-insertion but can occur anytime 1
• New pathologic uterine conditions – Polyps, fibroids, or other structural lesions 1, 2
• Normal IUD-related bleeding – Common in first 3-6 months, especially with Cu-IUD 1, 3

Critical Initial Workup:

• Pregnancy test (uCG) – Mandatory first step to rule out pregnancy complications including ectopic 1, 2
• Pelvic examination with speculum – Visualize IUD strings, assess for displacement, check cervical/vaginal pathology 1
• Bimanual examination – Assess for uterine tenderness, adnexal masses, cervical motion tenderness 1
• STI screening – Test for gonorrhea and chlamydia if clinically indicated 1, 2
• Pelvic ultrasound – If strings not visible or concern for perforation/displacement, use transvaginal ultrasound to locate IUD 1, 5

Plan

If IUD Strings Are Visible and Properly Positioned:

1. Rule out pregnancy and infection first 2

2. Assess timing of IUD insertion:

   • If <6 months: Counsel that unscheduled bleeding is common and generally not harmful 1, 3
   • If >6 months: Higher suspicion for new pathology (polyps, fibroids, displacement) 1

3. Medical management for persistent bleeding:

   • First-line: NSAIDs for 5-7 days during bleeding episodes (mefenamic acid 500mg TID or indomethacin) 1, 2, 6
   • Second-line (if NSAIDs fail): Consider combined oral contraceptives or estrogen for 10-20 days 2, 3
   • Avoid tranexamic acid if any thrombotic risk factors 1

4. If bleeding persists despite treatment: Counsel on alternative contraceptive methods and offer removal if desired 1, 3

If IUD Strings Are Not Visible:

1. Perform transvaginal ultrasound immediately to locate device 1

2. If IUD is intra-abdominal (perforation confirmed):

   • Refer for laparoscopic removal – most perforations have minimal surgical findings, but adhesions occur in 30% and pregnancy risk exists 5
   • Provide alternative contraception immediately, as patient is not protected 4, 5
   • Note: 29% of perforations are asymptomatic; pregnancy occurs in 15% of cases 5

3. If IUD location unclear: Consider X-ray or hysteroscopy to definitively locate device 5

If Pregnancy Test Is Positive:

1. Evaluate immediately for ectopic pregnancy with ultrasound and serial β-hCG 1

2. If intrauterine pregnancy confirmed and strings visible:

   • Counsel that IUD removal is strongly recommended as soon as possible to reduce risk of spontaneous abortion (including life-threatening septic abortion) and preterm delivery 1
   • Remove IUD by gently pulling strings 1
   • Advise patient to return promptly for heavy bleeding, cramping, pain, abnormal discharge, or fever 1

3. If intrauterine pregnancy but strings not visible:

   • Ultrasound to locate IUD 1
   • Counsel about increased risks and warning signs 1

If Signs of PID Present:

1. Treat PID per CDC STD Treatment Guidelines 1
2. IUD does not need immediate removal – can remain if patient desires continued contraception 1
3. Reassess in 24-48 hours:
   • If no clinical improvement: Continue antibiotics and consider IUD removal 1
   • Remove IUD after antibiotics started if patient desires discontinuation 1

Common Pitfalls to Avoid:

• Never dismiss bleeding without ruling out pregnancy, infection, or structural pathology 2
• Do not assume normal IUD-related bleeding without checking string position 1, 3
• Do not delay ultrasound if strings are not visible – perforation requires surgical management 4, 5
• Do not leave IUD in place if pregnancy confirmed and strings visible – removal significantly improves outcomes 1

Follow-Up:

• Return precautions: Heavy bleeding, severe cramping, fever, abnormal discharge, or inability to feel strings 1
• Routine follow-up not required unless symptoms persist or worsen 2
• Re-evaluate if bleeding continues beyond 3-6 months or worsens over time 1, 3