How should cyclical pelvic pain be evaluated and managed in a woman using an intrauterine device (copper or levonorgestrel‑releasing)?

Evaluation and Management of Cyclical Pelvic Pain in IUD Users

For cyclical pelvic pain in women with IUDs, first rule out pregnancy, pelvic inflammatory disease, and IUD malposition, then treat symptomatically with NSAIDs for 5-7 days; if pain persists or is unacceptable despite treatment, counsel on alternative contraceptive methods and offer IUD removal. 1

Initial Evaluation: Rule Out Serious Pathology

When a woman with an IUD presents with cyclical pelvic pain, immediately assess for:

• Pregnancy (including ectopic) - This is the first priority as IUD failure with pregnancy carries significant morbidity risk including septic abortion and preterm delivery 1
• Pelvic inflammatory disease (PID) - Evaluate for fever, abnormal vaginal discharge, cervical motion tenderness, and adnexal tenderness 1
• IUD malposition or expulsion - Perform speculum exam to check for visible IUD strings 1
• Other underlying pathology - Rule out ovarian cysts, endometriosis, or other pelvic pathology if clinically warranted 1

Management Algorithm Based on Findings

If PID is Diagnosed:

• Treat with appropriate antibiotics per CDC STD Treatment Guidelines 1
• The IUD does not need immediate removal if the woman desires continued contraception 1
• Reassess in 24-48 hours; if no clinical improvement, continue antibiotics and consider IUD removal 1
• Counsel about condom use for comprehensive PID management 1

If Pregnancy is Confirmed:

• Evaluate for ectopic pregnancy first 1
• If intrauterine pregnancy and IUD strings are visible, remove the IUD as soon as possible by pulling gently on the strings to reduce risks of spontaneous abortion and preterm delivery 1
• Counsel the patient about pregnancy options 1

If No Serious Pathology is Found (Simple Cyclical Pain):

For Copper IUD users with cyclical pain:

• Prescribe NSAIDs for 5-7 days of treatment during symptomatic periods 1
• Naproxen 500-550 mg orally is preferred, or other NSAIDs if unavailable 1
• Always take NSAIDs with food 1

For LNG-IUD users with cyclical pain:

• First-line: NSAIDs for 5-7 days of treatment 1
• Second-line (if medically eligible): Hormonal treatment with combined oral contraceptives or estrogen for 10-20 days 1

Understanding the Mechanism

Cyclical pelvic pain with IUDs occurs through several mechanisms:

• Copper IUDs commonly cause increased dysmenorrhea and menstrual bleeding, which may continue even with long-term use 2
• Endometrial prostaglandin release secondary to the foreign body contributes to cramping and pain 3
• Localized endometrial inflammation from devices that don't conform well to the uterine cavity can produce pain 3
• Menstrual problems are frequent with both copper and levonorgestrel IUDs, with one-third of devices removed within the first year, primarily for menstrual problems 4

When Conservative Management Fails

If bleeding or pain persists despite treatment, or if the woman finds it unacceptable:

• Counsel on alternative contraceptive methods 1
• Offer another method if desired 1
• Consider IUD removal 1

Special Consideration: LNG-IUD as Treatment for Underlying Pain Conditions

If the patient has underlying endometriosis or severe dysmenorrhea causing the cyclical pain:

• The LNG-IUD is Category 1 (benefits clearly outweigh risks) for both endometriosis and severe dysmenorrhea per CDC guidelines 5
• The LNG-IUD decreases dysmenorrhea, pelvic pain, and dyspareunia in women with endometriosis 5, 6
• Up to 85% of LNG-IUD users experience 70-90% reduction in monthly blood loss after the first year, with 20-30% achieving amenorrhea 6, 7
• The device has proven effective in relieving pelvic pain from peritoneal and rectovaginal endometriosis and reducing recurrence of dysmenorrhea after conservative surgery 6, 7

Critical Pitfalls to Avoid

• Never assume pain is benign - Always rule out pregnancy and PID first, as these carry significant morbidity and mortality risks 1, 3
• Don't delay evaluation - Women should be advised to return at any time to discuss side effects or problems 1
• Don't force continuation - If pain persists and is unacceptable to the patient despite appropriate treatment, respect her autonomy and offer alternative contraception 1
• Screen for anatomical abnormalities - Women with uterine cavity distortion are poor IUD candidates and may experience more pain 5

Follow-Up Recommendations

• No routine follow-up visit is required for asymptomatic IUD users 1
• Advise women to return promptly if they develop heavy bleeding, cramping, pain, abnormal discharge, or fever 1
• Consider performing an examination to check for IUD string presence at routine visits 1
• Assess satisfaction with the method and any concerns about use 1