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Referral and warning signs
When to refer
Referral needed for: IUD insertion/removal. Management of complications (perforation, difficult removal, PID, suspected ectopic pregnancy). Persistent unacceptable side effects.
Red flags
- Signs/symptoms of PID (severe pelvic pain, fever, discharge)
- Signs/symptoms of ectopic pregnancy (amenorrhoea + pain + bleeding)
- Missing strings with suspected pregnancy or pain
- Signs of uterine perforation (severe pain during insertion, subsequent severe pain/bleeding)
Signs and symptoms
- Common Side Effects:
- - Copper IUD: Heavier, longer, or more painful menstrual periods, especially initially. Spotting between periods.
- - LNG-IUD: Irregular bleeding/spotting initially, often leading to lighter periods or amenorrhoea over time. Hormonal side effects possible (headache, acne, mood changes - less common than systemic methods).
- - Both: Mild cramping during/after insertion.
- Warning Signs (Complications - require prompt evaluation): Severe lower abdominal pain, Pain during intercourse, Fever/chills/unusual vaginal discharge (PID risk highest near insertion), Missed period/Symptoms of pregnancy (esp. rule out ectopic), Missing strings/Feeling hard part of IUD.
Risk factors
- Contraindications (MEC Category 4): Pregnancy, Puerperal sepsis, Immediately post-septic abortion, Unexplained vaginal bleeding suspicious for serious condition (initiation), Current PID, Current purulent cervicitis/Chlamydia/Gonorrhoea, Cervical/Endometrial cancer, Distorted uterine cavity, Malignant gestational trophoblastic disease.
- Relative Contraindications (MEC Category 3 - Copper IUD): AIDS (if not well on ART), High individual risk of STIs (initiation). (LNG-IUD): Past breast cancer >5yrs ago, Severe liver disease, SLE with antiphospholipid antibodies.
- Copper IUD caution: Wilson's disease, Copper allergy.
Diagnosis
Clinical assessment
Eligibility assessment based on medical/reproductive history, pelvic exam (assess uterine size/position, rule out infection/pregnancy), and MEC guidelines.
Investigations
- Rule out pregnancy before insertion.
- Pelvic examination (essential).
- Consider STI screening based on risk factors.
- Cervical cancer screening as per guidelines.
Diagnostic criteria
Client meets medical eligibility criteria for IUD use and has suitable uterine cavity.
Management
Non-pharmacological management
- Counseling: Explain types (Copper vs Hormonal), mechanism, high effectiveness, duration, insertion/removal procedure, expected side effects (bleeding changes specific to type), warning signs, lack of STI protection.
- Skilled Insertion: Requires trained provider using sterile technique.
- Skilled Removal: Requires trained provider.
Pharmacological treatment
- Insertion: Timed during menstruation (less bleeding, cervix softer, pregnancy unlikely) or any time if reasonably sure not pregnant. Prophylactic antibiotics generally not needed.
- Management of Side Effects:
- - Cramping after insertion: NSAIDs.
- - Increased bleeding/pain (Copper IUD): NSAIDs during menses. Tranexamic acid if severe. Reassure often improves. Check Hb if persistent. Remove if unacceptable.
- - Irregular bleeding (LNG-IUD): Reassure often improves/leads to amenorrhoea. NSAIDs or short course hormones rarely needed. Rule out other causes.
- - Missing Strings: Rule out pregnancy. Try to locate strings in vagina/cervix. Ultrasound to confirm presence/position in uterus. Refer if expulsion suspected or perforation possible.
- - Suspected PID: Treat with appropriate antibiotics covering gonorrhea/chlamydia/anaerobes. Usually no need to remove IUD immediately unless severe or no improvement.
- - Suspected Pregnancy: Remove IUD if strings visible and pregnancy <12 weeks (reduces miscarriage/sepsis risk). If strings not visible or >12 weeks, leave IUD in situ and monitor closely (high risk ectopic/preterm birth). Counsel patient. Rule out ectopic pregnancy urgently.
Monitoring
Follow-up visit 3-6 weeks post-insertion (check strings, assess side effects/concerns). Routine checks during other visits or if problems arise. Patient taught to check strings monthly (optional).
Complications
- Pain/cramping after insertion.
- Changes in menstrual bleeding (heavier - Cu-IUD; irregular/amenorrhoea - LNG-IUD).
- Expulsion (partial or complete - ~2-10% in first year).
- Uterine Perforation (rare, usually occurs at insertion - ~1-2 per 1000).
- Pelvic Inflammatory Disease (PID - risk slightly increased in first few weeks after insertion, related to insertion process/pre-existing infection, not IUD itself long-term).
- Pregnancy (rare - if occurs, higher relative risk of ectopic pregnancy).
- Actinomyces-like organisms on Pap smear (usually asymptomatic, treatment controversial).
Prevention
- Careful patient selection using MEC.
- Screening/treatment for STIs before insertion if high risk.
- Sterile insertion technique by trained provider.
- Patient education on string checks and warning signs.
Patient education
- How IUD works, effectiveness, duration.
- Type chosen (Copper vs Hormonal) and expected bleeding pattern.
- Insertion procedure.
- How to check strings (optional).
- Warning signs requiring medical attention.
- Does not protect against STIs/HIV.
- Fertility returns promptly after removal.
- Emergency IUD option.
Uganda-specific notes
Copper IUDs are widely available and promoted as effective LARC. Hormonal IUDs less common/available. Requires trained providers for insertion/removal. Counseling on bleeding changes crucial for acceptance.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 15, Section 15.2.8