Managing Side Effects for IUDs
Doing simple things well is an excellent approach to managing IUD side effects. This means informing women about what side effects to expect, reassuring that common non-harmful side effects are indeed not harmful, treating common side effects with simple drugs when needed, and encouraging women to return whenever they has questions or concerns. The woman's confidence that her IUD use is safe and effective, and that her provider is competent and responsive are keys to success. She should also be urged to return for side effects that could be harmful, particularly signs of pelvic inflammatory disease or pregnancy. Information should be clear, correct non-alarming, and presented in verbal and written form. Good management of side effects will lead to many women being satisfied with their method and this success will spread to neighbors and the community.
Common practices to use and those to avoid in managing IUD side effects
Brief, clear descriptions of the most common side effects-before the IUD is inserted-reduces complaints and makes management easier. The most critical messages before insertion include:
- Heavier and longer menstrual bleeding is expected with copper IUDs-this usually becomes less over time
- Cramping may occur in the first several days
- Bleeding between menses may occur in the first few months of use.
These and other messages should be provided in writing and verbally. When non-harmful side effects occur, written information will help reassure her and her family. Written information should also include uncommon harmful side effect, to urge prompt return when medical treatment is needed.
Deal directly with any local misperceptions about IUDs, such as "IUDs cause infertility", "IUDs will migrate in the body", "IUDs are abortifacients".
Show the IUD to the woman, including how it will fit into the uterus by using a model or simply the woman's closed hand (as a simple substitute for a uterine model).
Timing can reduce insertion pain, cramping and bleeding
Postpartum IUD insertion at 4-6 weeks after delivery is easy for the woman and her provider. First, there is little pain during insertion and less cramping after insertion, due to the more open cervical canal and enlarged uterine cavity. Second, complaints about bleeding are minimal, since breastfeeding women have little or no bleeding for several months.
Postabortion insertion, immediately after evacuating the uterine cavity, will also reduce discomfort with insertion.
Ibuprofen or other non-steroidal analgesics (NSAIDS) can be used to reduce cramping in the first few days. Some providers may give a small advance supply, to be used if the woman has pain. Ibuprofen can also be selectively used to reduce heavy menstrual (see below).
Common changes in menstrual bleeding
Most complaints about heavier or longer menses are best managed by reassurance. Heavier periods may be particularly noticeable for women changing from combined oral contraceptives and other hormonal methods that reduce menstrual bleeding. When reassurance is not sufficient, or the bleeding is especially heavy, a short course of ibuprofen during menses may reduce bleeding. A short course can be repeated in several months, but it is not desirable to use for an extended period. Iron tablets may be given to reduce chances of anemia. Both interventions help the provider be actively responsive to the woman's concerns. Many women adjust to having somewhat heavier menstruation, and the amount of bleeding usually becomes less over several months.
Checking that the IUD is still in place
Inform the woman that about 3% of IUDs will be expelled, usually in the first few months. She can detect this by checking the string and also being aware of an expulsion that may occur at the time of menses or during a bowel movement. Routine string checks are often not practical after the first few months, and some women avoid checking the string at all. The provider will also check the string at 3-6 weeks after insertion. The vast majority of IUD expulsions will be detected by the woman if she checks herself during menses and when at the toilet.
If an IUD has been expelled, a new one may be reinserted immediately if it is reasonably certain she is not pregnant. A second IUD will remain in place for about 70% of women.
Partner complaints about the IUD string
Partner complaints about irritation from the string during sex should not be dismissed. Partner discomfort is a common cause of IUD discontinuation in numerous settings. One good solution is to cut the string at the opening of the cervical canal (os) such that it does not protrude and yet can be grasped by a forceps for removal. The string can usually be grasped for removal without seeing it. Often the string can be visualized when the speculum is opened or the outer canal is slightly opened by gently spreading the blades of a forceps.
Inform the woman that she will no longer feel the string and make a record of the string's location for future providers. This is important for removal. A string that does not protrude also makes the IUD one of the most confidential methods, an important benefit for some.
Simply removing the IUD when common non-harmful side effects occur is a poor first option, unless the woman definitely wants to discontinue or other measures are not acceptable.
Simple measures permit time to help manage side effects. Over time, cramping subsides, bleeding patterns become more acceptable, and the amount of menstrual bleeding decreases. Good management of side effects helps many women become satisfied long-term users-the goal most IUD acceptors want to achieve.