A 35-year-old multiparous woman with a copper IUCD (inserted 3 years ago) presents with complaint of heavy menstrual bleeding and severe dysmenorrhoea for the past 6 months. She denies fever, abnormal discharge, or pelvic pain between periods. Pelvic examination is normal; no masses or tenderness. Urine pregnancy test is negative. What is the most appropriate next step in management?

Explanation

## Management of Heavy Menstrual Bleeding with Copper IUCD ### Clinical Context: Copper IUCD Side Effects **Key Point:** Heavy menstrual bleeding (HMB) and dysmenorrhoea are the most common reasons for copper IUCD discontinuation, affecting 10–15% of users. These are expected side effects, not complications, but must be investigated to exclude pathology. **High-Yield:** When a copper IUCD user presents with HMB or dysmenorrhoea, the first step is **imaging to exclude malposition, perforation, or concurrent pelvic pathology** (fibroids, polyps, adenomyosis). Transvaginal ultrasound is the gold standard. ### Diagnostic Algorithm ```mermaid flowchart TD A[Copper IUCD user with HMB/dysmenorrhoea]:::outcome --> B[Exclude pregnancy]:::action B --> C{Pelvic exam normal?}:::decision C -->|Yes| D[Transvaginal ultrasound]:::action D --> E{IUCD position, perforation, or other pathology?}:::decision E -->|Normal| F[Medical management: NSAIDs, counselling]:::action E -->|Malpositioned/perforated| G[Remove and replace or manage perforation]:::urgent E -->|Fibroids/polyps/adenomyosis| H[Treat underlying pathology or consider LNG-IUD]:::action ``` ### Investigation: Transvaginal Ultrasound | Finding | Implication | Action | |---------|---|---| | **Normal IUCD position** | Expected side effect of copper IUCD | Proceed to medical management | | **Partial perforation** | IUCD partially embedded in myometrium | Remove and replace; may reduce bleeding | | **Complete perforation** | IUCD in peritoneal cavity | Surgical removal; counsel on alternative contraception | | **Malposition** (low, tilted) | IUCD not optimally placed | Remove and reinsert or switch method | | **Fibroids/polyps/adenomyosis** | Concurrent pathology worsening bleeding | Treat underlying condition; consider LNG-IUD | ### Medical Management (if imaging normal) **Clinical Pearl:** NSAIDs (mefenamic acid 500 mg TDS during menses, or naproxen 500 mg BD) reduce menstrual blood loss by 20–50% in copper IUCD users. This is first-line for side effect management. **Counselling:** Reassure the woman that HMB and dysmenorrhoea typically improve after 3–6 months as the endometrium adapts. If symptoms persist despite NSAIDs and imaging is normal, options include: - Continued expectant management - Switch to levonorgestrel-releasing IUCD (reduces bleeding by 90%) - Alternative contraceptive method ### Why Imaging First? **Warning:** Do not assume HMB is a simple side effect without imaging. Perforation, malposition, or concurrent fibroids/adenomyosis must be excluded. Imaging is non-invasive, cost-effective, and guides further management.