What to expect in the first 3 months

Once the IUD or IUS is placed, it is important to notify the woman of what to expect for the first few months following placement and before the follow-up visit. Written information can be helpful.

Menstrual Calendar

Normal Bleeding

• IUD: Women who have their Cu-IUD placed in the luteal phase of the cycle may experience more spotting up until their first menses. Spotting (bleeding not requiring sanitary protection) and cramping throughout the first few months is normal. Irregular bleeding is normal, and usually abates with time.
  • Menstrual bleeding tends to increase among Cu-IUD users. An extra half-day to one-day of bleeding per cycle is expected. Up to two extra days of menstrual flow is considered normal. Women with pre-existing dysmenorrhea may experience more cramping with their menses.
• IUS: Women using an IUS may experience spotting and unscheduled bleeding as the endometrial lining responds to progestin. Over time, menstrual blood loss lessens. At 1 year, 8-10% of women using an LNG-8, 12% of LNG-12 users, and 20-40% of women using a LNG-20 will experience amenorrhea.

Other Progestin Symptoms

Some IUS users will experience transient progestin side effects. These include breast tenderness, mild nausea, and occasional headaches. Acne may occur in some women. In an RCT comparing Cu-IUD and LNG-IUS users, acne occurred in 5% of IUS users and 3% of Cu-IUD users. Some women will experience a return of acne as a result of stopping their combined hormonal contraception.

Red Flags

• New onset amenorrhea in a Cu-IUD user
• Severe pelvic pain
• New onset bleeding after a period of amenorrhea
• Signs and symptoms of pregnancy
• Fever and chills
• Cervical/vaginal discharge

String Check

The exact timing and frequency of a string check following IUC insertion is unclear. Historically, it has been recommended for Cu-IUD users to perform a string check after each menses. According to the WHO Selected Practice Recommendations, a string check should be performed as needed.

Because most expulsions occur within the first three months, a string check at three months (or at the follow-up) may be helpful in ruling out expulsion. A string check can be performed by the woman herself, by physical examination (single digit or bimanual exam); or by speculum exam.

Recommendations following placement of IUD or IUS

Costescu et al. Levonorgestrel-Releasing Intrauterine Systems for Long-Acting Contraception: Current Perspectives, Safety, and Patient Counseling.Int J Womens Health 2016.
WHO:Selected Practice Recommendations for contraceptive use. 3rd Edition 2016.