Obgyn · Year 3 · from Obgyn

Case 1: IUD Counseling and Insertion in a Nulliparous Patient

Patient Demographics

• Age: 22 years
• Sex: Female
• Occupation: College senior

Chief Complaint

"I want to get an IUD. I'm tired of taking pills every day."

History of Present Illness

The patient is a 22-year-old nulliparous woman seeking long-acting reversible contraception. She has been on combined oral contraceptive pills for 3 years but frequently forgets doses, resulting in breakthrough bleeding and anxiety about contraceptive failure. She had a pregnancy scare 3 months ago after missing several pills (pregnancy test was negative). She has researched IUDs online and wants to discuss her options.

Gynecologic History

• Menarche: Age 13
• Cycles on OCPs: Regular withdrawal bleeds
• Cycles off OCPs: 28-30 days, moderate flow, mild dysmenorrhea
• LMP: 5 days ago
• Sexually active: Yes, with one male partner x 1 year
• Prior pregnancies: G0
• STI history: None
• Last Pap smear: 1 year ago, normal
• Last chlamydia/gonorrhea testing: 1 year ago, negative

Past Medical History

• No chronic conditions
• No known drug allergies
• Currently on combined OCP (ethinyl estradiol 30 mcg/levonorgestrel)

Contraceptive Counseling

Patient Goals:

• Highly effective method
• Low maintenance ("set it and forget it")
• Does not want daily pills
• Wants to preserve future fertility
• Concerned about hormonal side effects (mood changes, acne on pills)

Options Discussed:

Debunking IUD Myths:

• "IUDs are only for women who've had children" - FALSE. IUDs are safe and effective for nulliparous women and adolescents.
• "IUDs increase infection risk" - FALSE. Infection risk is limited to first 20 days post-insertion.
• "IUDs cause infertility" - FALSE. Fertility returns immediately after removal.

Patient's Decision: Hormonal IUD (Kyleena)

Rationale:

• Highly effective, long-acting
• May reduce dysmenorrhea (a concern for her)
• Lower hormone dose than 52mg devices
• Smaller device appropriate for nulliparous uterus
• Does not require daily adherence

Pre-Insertion Evaluation

Eligibility Screening:

• Pregnancy test: Negative (required before insertion)
• Current chlamydia/gonorrhea: Tested today (results pending, will treat if positive)
• No active cervicitis on exam
• No contraindications: No Wilson's disease, no uterine anomaly, no current PID

Timing:

• Day 5 of menstrual cycle
• Can insert any time in cycle with negative pregnancy test
• Backup method not needed if within 7 days of period start

IUD Insertion Procedure

Preparation:

• Informed consent obtained (risks: perforation 1/1000, expulsion 2-10%, infection first 20 days, cramping)
• NSAID (ibuprofen 800 mg) taken 1 hour prior
• Chaperone present

Procedure:

1. Bimanual exam: Anteverted uterus, normal size
2. Speculum placed, cervix visualized
3. Cervix cleansed with antiseptic
4. Tenaculum applied to anterior lip
5. Uterine sounding: 7.5 cm (normal)
6. IUD inserted through cervix, deployed at fundus
7. Strings cut to 3 cm from external os
8. String length documented

Patient Tolerance:

• Moderate cramping during insertion
• Mild vasovagal symptoms (sweating, nausea) - resolved with rest
• Observed for 15 minutes, feeling well at discharge

Post-Insertion Instructions

• Cramping and spotting normal for days to weeks
• Ibuprofen as needed for cramping
• Irregular bleeding common for first 3-6 months, then lightens
• Check strings monthly after first period
• No tampons or intercourse for 24 hours
• Return for: fever, severe pain, foul discharge, unable to feel strings, pregnancy symptoms

Follow-up Visit (6 weeks)

• Strings visible, appropriately positioned
• Minimal spotting, cramping resolved
• Satisfied with choice

Chlamydia Result

• Negative (if positive, would have treated with antibiotics; IUD does not need to be removed for uncomplicated infection)

Teaching Points

• LARC methods (IUDs and implant) are first-line recommendations for most women, including adolescents and nulliparous women
• Pregnancy must be excluded before IUD insertion
• Chlamydia/gonorrhea testing can be done same day; does not delay insertion
• Most common reason for IUD discontinuation is irregular bleeding
• Proper counseling about expected side effects improves continuation rates

Clinical Image

Image Description: Illustration demonstrating proper positioning of an intrauterine device within the uterine cavity. The IUD is shown deployed at the fundus with the strings extending through the cervix into the upper vagina. Correct placement ensures the device sits at the top of the uterine cavity.

Attribution: Educational illustration. Public domain medical education resource.

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