George Krucik, MD, MBA
An intrauterine device (IUD) is a long-term, rapidly reversible and highly effective form of contraception. The T-shaped IUD device is placed inside the uterus by a medical professional. Two types of IUDs are available in the United States. One emits a low level of copper (ParaGard) and the other gradually releases a synthetic progesterone-like hormone called levonorgestrel (Kyleena, Liletta, Mirena, Skyla). Some women report increased cramping during the first 3 month of IUD use, but it typically is not severe and rarely leads to a woman opting to have the device removed. Thus, severe cramping might indicate a problem, which should be discussed with your healthcare provider.
Cramping, sometimes severe, frequently occurs at the time of IUD insertion. This level of pain wanes after about 15 minutes in most women. Less severe cramps and light bleeding might continue for a few days. An over-the-counter pain reliever, such as aspirin or ibuprofen (Advil, Motrin), often alleviates this discomfort. If you experience persistent severe cramps after having an IUD inserted, contact your healthcare provider immediately. The pain might indicate that the device has perforated the uterine wall, a complication that occurs in approximately 1 out of every 1,000 IUD placements, according to the American College of Obstetricians and Gynecologists.
Pelvic Inflammatory Disease
The Centers for Disease Control and Prevention reports there is a slightly increased risk for pelvic inflammatory disease (PID) in the first 20 days following IUD insertion. PID is an infection of a woman's upper reproductive tract. Researchers believe the cases of PID that develop shortly after IUD insertion occur in women with undiagnosed chlamydia or gonorrhea, or both, when the device is placed. New pelvic or lower abdominal pain, possibly severe, can signal PID. Other possible signs and symptoms include fever, painful intercourse, increased vaginal discharge and irregular bleeding. Immediate medical evaluation is needed if any of these symptoms develop, especially during the first 3 weeks after IUD placement.
Temporary Increase in Menstrual Cramps
A study involving more than 5,000 women tracked changes in cramping and bleeding after IUD placement. The researchers found that 32 percent of hormonal IUD users and 63 percent of copper IUD users reported increased cramping within the first 3 months after device insertion, as reported in the July 2014 issue of the "American Journal of Obstetrics and Gynecology." After 6 months of use, however, only 12 percent of hormonal IUD users and 15 percent of copper IUD users reported increased cramping, compared to before they had an IUD. This study indicates that increased cramping -- potentially severe in some women -- is relatively common in the first 3 months after IUD placement. However, cramping returns to baseline levels in nearly 9 out of 10 women within 6 months.
IUD expulsion refers to partial or complete extrusion of the device from the uterus into the vagina or out of the body. The American College of Obstetricians and Gynecologists states that about 5 percent of women with an IUD experience expulsion in the first year after placement. Expulsion can occur later but is less common after the first year. Women who experience heavy, painful periods may be at increased risk for IUD expulsion. Although expulsion can occur without symptoms, it sometimes causes pelvic pain, pain during sex, excessive bleeding or spotting. Since a properly placed IUD cannot be felt by a woman or her partner, feeling the device at the cervix or in the vagina signals expulsion.
IUDs are more than 99 percent effective in preventing pregnancy, according to CDC. IUDs do not increase a woman's overall risk for ectopic pregnancy, meaning a pregnancy that implants outside the uterus -- usually in one of the ovarian tubes. However, if a pregnancy occurs with an IUD in place, the risk for an ectopic pregnancy is significantly increased. Researchers estimate the risk for ectopic pregnancy is roughly 1 in 1,000 women with 5 years of IUD use. Common symptoms of an ectopic pregnancy include abdominal and pelvic pain and tenderness, and vaginal bleeding. An ectopic pregnancy is a medical emergency, as a rupture could cause life-threatening bleeding.
Malposition and Displacement
A properly positioned IUD sits freely within the uterine cavity, with the horizontal part of the T-shaped device at the top of the uterus and the arms pointed to either side. A malpositioned or displaced IUD refers to a device that is:
-- too low in the uterus
-- rotated such it is oriented front-to-back rather than side-to-side
-- embedded in or protruding through the uterine wall
-- located within the abdomen or pelvis
Malposition or displacement of an IUD can occur at the time of insertion or develop later. An IUD that is out of place may cause symptoms, including cramps, and abdominal or pelvic pain -- although sometimes no symptoms occur. A malpositioned or displaced IUD is a rare occurrence, but it can be potentially life-threatening and requires urgent medical evaluation.
Other Considerations, Warnings and Precautions
Seek medical attention as previously recommended for any of the situations and signs and symptoms described. Also be aware that cramping abdominal or pelvic pain can occur with medical conditions unrelated to having an IUD. Seek immediate medical care if you experience any warning signs or symptoms, including:
-- fever, chills or clammy skin
-- persistent or severe nausea or vomiting
-- severe or worsening abdominal or pelvic pain or tenderness
-- heavy vaginal bleeding
-- progressive abdominal bloating
-- bloody or black stools
-- dizziness, lightheadedness or fainting
Reviewed and revised by: Tina M. St. John, M.D.