IUDs (intrauterine devices) are becoming more popular than ever. IUDs like Mirena and ParaGard are amongst the most highly effective of all available contraception (with equal effectiveness to a vasectomy, and in some cases, even greater efficiency than a tubal ligation). These long-acting, reversible methods are good options for:
- Women who have yet to have children
- If you are looking for a long-term, cost effective method that requires very little maintenance (periodically checking to make sure the strings are in place).
When it comes to IUD use, I am often asked questions about the IUD strings. The "strings" are attached to the IUD, run down the uterus and out the cervix, finding their final resting place somewhere high up in the vaginal canal. The IUD strings are an important way that you can determine if your IUD is still in place.
Research seems to indicate that during your first year of ParaGard IUD use, expulsion (when the IUD could partially or completely slip out of the uterus) appears to happen in 3-10% of women; there also seems to be a 6% expulsion rate for women who use Mirena.
According to UptoDate, there are certain risk factors that may lead to IUD expulsion, including:
- Nulliparity (if you have never given birth)
- Severe dysmenorrhea
- Prior IUD expulsion
- Under 20 years of age
- IUD insertion happens immediately after a second trimester abortion or if you are postpartum
Since many women may show no symptoms of IUD expulsion, it is super important that you learn how to check your IUD strings because this may be the only way to tell for sure if your IUD has dislodged or has moved out of place. When you first have your IUD inserted, you should be checking for the IUD strings every few days for the first few weeks as well as between periods to make sure that the IUD is still in place. The general overriding guideline appears to be that if the IUD or the IUD strings are not visible (or can’t be felt), full expulsion may have taken place. If this happens, you are no longer being protected against pregnancy.
This leads into the very common question I often get...
"How Come I Can’t Feel My IUD Strings? Should I Be Worried?"Well, to answer your questions about missing IUD strings, what to do if you can’t see or find your IUD strings, etc., I investigated this topic in an article on UpToDate -- a trusted electronic reference used by many doctors and patients. If you cannot locate your strings, the next step is to call your doctor and have him/her perform an exam to locate your IUD strings.
According this excerpt from UpToDate,
"If the IUD strings are not visible on speculum examination, possible explanations from most to least common are:
- The IUD is in situ, but the strings are curled and retracted into the endocervical canal or uterine cavity, or they are broken. Uterine enlargement secondary to fibroids or pregnancy, or rotation of the IUD can also cause retraction of strings.
- The IUD has been expelled.
- The IUD has perforated the uterus and is in the myometrium or abdomen."
Yikes! What does all this mean? Let’s just take a deep breath and don’t panic -- I will explain each of these scenarios to you. Basically, UpToDate is suggesting a couple of specific things may have occurred that could explain why both you AND your doctor can’t locate your IUD strings. Two of the most straightforward reasons for missing IUD strings: 1) that the IUD has come out of the uterus, or 2) a similar (but rare) issue that the IUD has become perforated during insertion. This means that the IUD has been pushed through the uterus wall. Generally, this is quickly discovered and can be corrected right away. If either of these situations happens to you, make sure to use a back-up method to protect against pregnancy because the IUD will not be of much help.
Another scenario that can cause the IUD strings to be pulled back up into the uterine cavity is if you are experiencing some type of enlargement/swelling in your uterus. This may be due to fibroids or a pregnancy. If this has occurred, the IUD is still in the uterus, but further investigation would be needed. So, most doctors would try to locate the IUD and/or rule out pregnancy by using an ultrasound. As per UptoDate,
"If the woman is pregnant, an ultrasound should be performed to determine the location of the IUD and the pregnancy. Management depends upon the location of the IUD, the trimester of pregnancy, and the patient's desire to continue or terminate the pregnancy."
The good news... if the ultrasound reveals that the IUD is in its proper position (within the uterus), you can continue to use it for contraception even though you cannot locate the IUD strings. If you are in this situation, doctors recommend that you have an ultrasound once a year for the first few years (when you are more at risk for expulsion), just to make sure your IUD is still there.
Another scenario that can also cause an IUD string problem occurs when the IUD is still located in the correct position, yet for whatever reason, the IUD strings have coiled and bent back into the passageway between your cervix and your uterus (known as the endocervical canal). The strings could have also broken off. Finally, the IUD may have actually rotated either during or after insertion. This turning around could cause the IUD strings to retract up higher in your body. If any of these are the culprits, the good news is that the IUD is still working and is in place; the issue is just with the IUD strings.
So What Happens Now? Do I Get My IUD Strings Back?
As long as it is determined that you are not pregnant, doctors have several ways to try to recover your IUD strings. As per UptoDate,
"We twist a cytobrush in the endocervical canal to try to draw the string out of the canal. If the string becomes visible with this maneuver, no additional action is required. If this maneuver is unsuccessful, we examine the endocervical canal with a uterine sound or an endocervical speculum to determine if the IUD is in the process of being expelled. Usually the strings become more visible in this situation, but they can also become twisted and remain hidden from view. If the IUD is in the cervix, we remove it using a grasping forceps, IUD hook, IUD thread retriever, or Kelly clamp, and, if the woman desires, we replace it with a new IUD."
OK, this, too, sounds a bit more daunting that it may actually be. In a nutshell, the doctors are going to use a special brush (that looks like a long mascara brush) to try to maneuver out the IUD strings. This usually works, but if attempts are unsuccessful, doctors may use various tools to dilate (open) the cervix, measure your uterus and obtain a precise view of the endocervical canal. Doctors can then determine if the IUD may be in the process of expulsion. If this is the case, the IUD strings tend to become more visible. But, to complicate matters, the strings can also become twisted and out of view. If it has been determined that the IUD has been partially expelled into the cervix, the doctors will typically remove the IUD and can replace it with a new one on the spot, if you’d like.
At last, if all of these attempts fail to locate the IUD, (from untwisting the IUD strings to ultrasound), doctors may conduct X-rays of your abdomen and pelvis. Since both the Mirena and ParaGard have radiopaque, they can be seen in an x-ray. If your IUD does not show up on the x-ray film, expulsion can be confirmed. At this time, you can also get a new IUD inserted if you wish. If your x-ray reveals that the IUD is located outside the uterus, perforation has happened. This would need to be corrected as soon as possible before possible damage occurs to adjoining areas.
The only other way to definitively detect IUD expulsion is if you actually experienced your IUD coming out... this will typically happen during the first few months of IUD use. Your IUD is most likely to slip out of place during your period. So check your pads and tampons to confirm that your IUD has not been expelled.
Want to learn more? See UpToDate's topic, "Management of problems related to intrauterine contraception," for additional in-depth medical information on missing IUD strings and other problems related to intrauterine contraception.
Dean, Gillian & Goldberg, Alisa. "Management of problems related to intrauterine contraception." UpToDate. Accessed: January 2012.