A 32-year-old multiparous woman attends the family planning clinic requesting contraception. She has no contraindications to any method. On examination, her uterus is found to be retroverted with a depth of 6 cm on sounding. She is counselled about copper IUCD and hormonal IUCD options. After insertion of a copper IUCD 3 weeks ago, she presents with severe dysmenorrhoea and menorrhagia. What is the most appropriate next step in management?

Explanation

## Clinical Assessment of Post-IUCD Insertion Symptoms **Key Point:** While dysmenorrhoea and menorrhagia are common side effects of copper IUCDs, especially in the first 3–6 months, the presentation at 3 weeks warrants exclusion of mechanical complications before attributing symptoms solely to the device type. ### Why Ultrasound Is the Immediate Next Step **High-Yield:** The timing (3 weeks post-insertion) and severity of symptoms necessitate imaging to rule out: - Partial or complete uterine perforation - Malposition of the IUCD (fundal vs. lower segment) - Expulsion (partial or complete) - Associated endometrial inflammation or infection Once mechanical complications are excluded, medical management or device change can be considered. ### Management Algorithm for Post-IUCD Symptoms ```mermaid flowchart TD A["IUCD inserted; dysmenorrhoea + menorrhagia at 3 weeks"]:::outcome --> B{"Mechanical complication?"}:::decision B -->|"Perforation, malposition, expulsion"| C["Remove IUCD; manage complication"]:::action B -->|"Position normal, no perforation"| D{"Symptom severity?"}:::decision D -->|"Mild-moderate"| E["NSAIDs + antifibrinolytic; review 3 months"]:::action D -->|"Severe, unacceptable"| F["Consider device change to LNG-IUS"]:::action C --> G["Counselling; re-insertion if desired"]:::action ``` **Clinical Pearl:** Copper IUCDs increase menstrual blood loss by 20–30% in the first 3–6 months; however, severe symptoms or rapid onset may indicate malposition or perforation. **Warning:** Do NOT assume symptoms are purely device-related without excluding perforation — uterine perforation is a surgical emergency that can lead to bowel injury or peritonitis. ### Expected Natural History Symptoms of dysmenorrhoea and menorrhagia with copper IUCD typically: - Peak in the first 3–6 months - Gradually improve by 6–12 months in ~60% of users - Persist in ~30–40% (may warrant device change) **Tip:** Imaging before medical management avoids delaying diagnosis of a serious complication and reassures the patient that symptoms are not due to device malposition. [cite:Park 26e Ch 10]