Management of Embedded IUD in Postmenopausal Patients
An embedded IUD in a postmenopausal patient should be removed, as these devices serve no contraceptive purpose after menopause and can cause complications including postmenopausal bleeding, chronic endometritis, and progressive embedding into the uterine wall. 1, 2, 3
Immediate Assessment
- Obtain pelvic ultrasound to determine the exact location of the IUD and assess whether it remains intrauterine, has partially embedded in the myometrium, or has perforated through to the serosa 4, 5
- Evaluate for complications including postmenopausal bleeding, pelvic pain, infection (including Actinomyces), and degree of uterine wall involvement 1, 2, 3
- Perform speculum examination to check for visible IUD strings 4
Removal Strategy Based on Clinical Findings
If Strings Are Visible or Retrievable from Cervical Canal
- Remove the IUD by pulling gently on the strings during speculum examination 4
- This represents the simplest scenario and should be attempted first 4
If Strings Are Not Visible
Hysteroscopic removal is the preferred approach for embedded IUDs in postmenopausal patients, as it allows direct visualization and controlled extraction even when the device has significantly embedded in the uterine wall 5, 2, 3
- Use hysteroscopy to visualize the uterine cavity and locate the device 4, 5
- If uterine adhesions obscure the IUD, use microscissors to carefully cut through adhesion bands until the device becomes visible 5
- Measure the distance to the serosal surface intraoperatively if the device appears deeply embedded 5
- Be prepared to convert to laparoscopy or laparotomy if the IUD has perforated through the serosa or cannot be safely retrieved hysteroscopically 5
Important Clinical Context
The evidence shows that IUDs retained for decades in postmenopausal women commonly present with:
- Postmenopausal bleeding as the primary symptom 1, 2, 3
- Progressive embedding into the myometrium over time, making removal more challenging 5, 2
- Chronic endometritis and Actinomyces colonization 2
Case reports document successful hysteroscopic removal of IUDs retained for 30-40 years, even when reaching the serosal surface 5, 1, 3. One case demonstrated successful hysteroscopic-only removal of an IUD that had reached the uterine serosa in a patient 12 years postmenopausal 5.
Post-Removal Management
- Prescribe analgesics for cramping and pain 1
- Consider short-course antibiotics (such as doxycycline) if there is evidence of chronic endometritis or Actinomyces on endometrial sampling 1, 2
- Counsel the patient to return promptly for heavy bleeding, severe cramping, pain, abnormal discharge, or fever 4
Critical Pitfall to Avoid
Never attempt forceful removal if strings are not visible, as this risks uterine perforation 4. Always proceed to imaging and hysteroscopic evaluation rather than blind instrumentation of the uterine cavity.