The most important medical reason that women give for requesting removal of an IUD is bleeding and pelvic pain. These symptoms are common in the first few months, but diminish. Nonsteroidal anti-inﬂammatory drugs are usually helpful. When pain and bleeding occur later, the patient should be examined for signs of PID, partial expulsion of the device, or an intracavitary fibroid. Two ultrasonographic studies comparing women with these symptoms after 6 months to women with no bleeding complaints show downward displacement of the IUDs into the cervical canal in many of the symptomatic women and in some cases, intracavitary fibroids (104,105). When the patient wishes to continue with an IUD, removal of the displaced device and insertion of a new one is advisable. In situations where IUDs are inexpensive and ultrasound is expensive or not available, the best course is to offer immediate removal and replacement of the IUD without ultrasound proof of displacement.
Hormonal contraceptives are female sex steroids, synthetic estrogen and synthetic progesterone (progestin), or progestin-only without estrogen. They can be administered in the form of OCs, patches, implants, and injectables. The most widely used hormonal contraceptive is the combination OC containing both estrogen and progestin. Combination OCs can be monophasic, with the same dose of estrogen and progestin administered each day, or multiphasic, in which varying doses of steroids are given through a 21-day or 24-day cycle. Combination OCs are packaged with 21 active tablets and 7 placebos, or 24 active tablets and 4 placebo tablets. The inclusion of placebos allows the user to take one pill every day without having to count. The medication-free interval while the user takes the placebo tablets allows withdrawal bleeding that mimics a 28-day menstrual cycle. To begin OC use, the user takes the first pill any time from the first day of menses through the Sunday after menstruation begins and thereafter starts a new pack as soon as the first pack is completed. The 7-day medication-free interval was standard for years, but studies showed that a shorter medication-free interval is adequate to trigger cyclic withdrawal bleeding and maintains better suppression of ovulation. Ovarian follicles mature more during the 7-day medication-free interval than during the 4-day interval. Hence the new 24/4 combination theoretically could be more effective in preventing pregnancy than the 21/7 combination, but this has not been demonstrated. Other variations of OC administration are the extended cycle and the continuous cycle methods. Users take active pills containing an estrogen–progestin combination for 3 months at a time (extended cycle) or indefinitely for a year or more (continuous cycle). Users on these regimens have more unscheduled days of spotting or bleeding than those on 28-day cycles in the beginning, but become amenorrheic. As a result they experience fewer cycle triggered symptoms such as headache and menstrual pain. Continuous-combined regimens are preferred for women with chronic pelvic pain or when dysmenorrhea is not relieved by OCs taken in 28-day cycles (106).
Progestin-only OCs are taken every day without interruption. Other forms of hormonal contraception include transdermal administration with the patch, injectable progestins, injectable estrogen–progestin combinations, subdermal implants that release progestin, and vaginal rings that release either estrogen–progestin or progestin alone (107).