With chronic perforation, a device can penetrate the muscular uterine wall to varying degrees. A patient may be asymptomatic but abdominal pain, uterine bleeding, or missing strings can be clues (Kaislasuo, 2013). hose with a predominantly intrauterine location are usually managed by hysteroscopic IUD removal. In contrast, devices that have nearly or completely perforated through the uterine wall are more easily removed laparoscopically. Notably, an extrauterine Cu-IUD frequently induces an intense local inlammatory reaction and adhesions (Kho, 2014). Laparotomy may be necessary, and bowel preparation is considered. Sigmoid and bladder perforations and small-bowel obstruction have been reported remote from insertion (Sano, 2017; Xu, 2015; Zeino, 2011).
Dysmenorrhea and bleeding irregularities can complicate IUD use (Aoun, 2014; Grunloh, 2013). These can be treated with some degree of success by nonsteroidal antiinlammatory drugs (NSAIDs) or tranexamic acid, which is an antiibrinolytic (Godfrey, 2013; Madden, 2012; S0rdal, 2013). Of the two IUDs, heavy bleeding more often complicates Cu-IUD use and may cause iron-deiciency anemia, for which oral iron salts are given. With the LNG-IUS, irregular spotting for up to 6 months after placement often gives way to progressive amenorrhea, which is reported by 30 percent of women after 2 years and by 60 percent after 12 years (Ronnerdag, 1999). his is frequently associated with improved dysmenorrhea.
he risk of upper genital tract device-related infection is greatest during the irst months following IUD insertion (Farley, 1992; Turok, 2016). Pathogens include Neisseria gonorrhoeae, Chlamydia trachomatis, and vaginal lora. Women at risk for sexually transmitted diseases (STDs) should be screened either before or at the time of IUD insertion (Centers for Disease Control and Prevention, 2015; Sufrin, 2012). That said, device insertion need not be delayed while awaiting sexually transmitted disease or Pap test results in asymptomatic women (Birgisson, 2015). If these bacteria are subsequently found and the patient is without symptoms, then the IUD may remain and treatment prescribed as detailed in Chapter 65 (p. 1240). Importantly, routine antimicrobial prophylaxis before insertion is not recommended (Grimes, 2012; Walsh, 1998). And the American Heart Association does not recommend bacterial endocarditis prophylaxis with insertion (Nishimura, 2014).
Mter the irst month, infection risk is not increased in IUD users who would otherwise be at low risk of sexually transmitted infections. Correspondingly, IUDs appear to cause little, if any, increase in infertility rates in these low-risk patients (H ubacher, 2001). The American College of 0bstetricians and Gynecologists (20 15c, 2016a) recommends that women at low risk for STDs, including adolescents, be considered good candidates for IUDs. he IUD is also safe and efective in women infected with human immunodeiciency virus (HIV) and may be used in others who are immunosuppressed (Centers for Disease Control and Prevention, 2015; Tepper, 2016a).