What are the signs that an intrauterine device (IUD) has dislodged in a woman?

Signs of IUD Dislodgement

The most important sign of IUD dislodgement is inability to visualize or palpate the IUD strings at the cervical os, which should prompt immediate ultrasound evaluation to determine if the device has been expelled, is malpositioned within the uterus, or has perforated the uterine wall. 1, 2

Primary Warning Signs

String-Related Changes

• Missing or non-visible IUD strings at the external cervical os is the most common presenting sign of dislodgement 1, 3
• Strings that feel longer than usual may indicate partial expulsion 4
• Strings that feel shorter or stiffer may indicate the device has moved upward or rotated 4

Symptomatic Indicators

• Persistent or worsening pelvic pain, especially if it develops after initial placement or worsens over time 5, 6
• Heavy bleeding or abnormal vaginal discharge 1
• Severe cramping beyond the typical adjustment period 1
• Pain during intercourse 3

High-Risk Presentation

• Pregnancy occurring with IUD in place is a critical sign that the device is not properly positioned, as a correctly positioned IUD provides effective contraception 1
• Fever or signs of infection may indicate perforation with intra-abdominal migration 3, 7

Clinical Assessment Algorithm

Step 1: Initial Evaluation

• Perform speculum examination to visualize the cervix and attempt to locate IUD strings 1
• If strings are not visible, attempt gentle retrieval from the cervical canal using appropriate instruments 1

Step 2: When Strings Are Not Visible

• Order pelvic ultrasound immediately to determine IUD location - the device may still be in the uterus, may have been expelled, or may have perforated the uterine wall 1, 2
• If ultrasound cannot locate the IUD within the uterus, obtain abdominal X-ray to identify extra-uterine location 3, 8

Step 3: Management Based on Location

• If IUD is malpositioned (low-lying, extending into cervix, or embedded in myometrium): Remove as soon as possible without requiring updated ultrasound if previous imaging confirmed malposition and patient has persistent symptoms 5, 2, 6
• If IUD has perforated the uterus: The device must be removed as soon as possible, typically requiring laparoscopic surgery 6, 3
• If IUD is properly positioned but strings are not visible: The device can remain in place if the patient is asymptomatic 2

Critical Pitfalls to Avoid

Do Not Assume Expulsion Without Imaging

• Many patients with uterine perforation are asymptomatic at the time of diagnosis 3
• A "lost" IUD may have migrated to unexpected locations including the bladder wall, appendix, or abdominal wall 7, 9, 8
• A patient with non-visible strings is not protected against pregnancy until proper IUD position is confirmed 3

Do Not Delay Removal of Malpositioned Devices

• Malpositioned IUDs should be removed promptly when strings are visible or can be safely retrieved, as studies show higher rates of symptom recovery with removal compared to retention 1, 5
• Do not replace an embedded or perforated IUD on the same day - wait at least 4-6 weeks to allow myometrial healing 6

Do Not Perform Blind D&C

• Attempting dilatation and curettage to remove a "lost" IUD without imaging confirmation of location can cause uterine perforation and device migration 8
• Unless the IUD can be recovered by simple traction on visible strings, refer to a trained specialist for removal 8

Post-Assessment Counseling

Immediate Instructions

• Advise the patient to return promptly for heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever 1, 2
• Counsel about need for alternative contraception until proper IUD position is confirmed 1, 3

Follow-Up Planning

• If IUD is removed, discuss alternative contraceptive methods and offer another method if desired 1, 6
• Schedule follow-up to ensure symptom resolution 5, 2
• For embedded devices requiring removal, plan for 4-6 week healing period before considering reinsertion 6