Archives of Gynecology and Obstetrics (2018) 297:989–996

https://doi.org/10.1007/s00404-018-4711-y

GENERAL GYNECOLOGY

Relationship between copper IUD complications and ultrasonographic

findings
Seyma Fadiloglu1   · B. Dilbaz1 · E. Fadiloglu1 · S. Dilbaz1

Received: 31 March 2017 / Accepted: 7 November 2017 / Published online: 10 February 2018
© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Objective  Intrauterine device (IUD) is a widely used long-acting contraceptive method; however, the side-effects related to
IUD may lead to method discontinuation. The aim of this study is to evaluate the relation between the most common side-
effects of IUD use; mainly dysmenorrhea, menorrhaghia, pelvic cramping and the relation of these complications with the
position of the IUD device within the cavity and uterine dimensions evaluated by transvaginal ultrasonography.
Material and method  Two hundred and eighty-four patients who had Cu-T380A IUD insertion at the Family Planning Clinic
of a tertiary health center were evaluated at insertion and 6 and 12 weeks after the insertion. Demographic characteristics,
medical history, symptoms and findings of the gynecological examination were recorded. Transvaginal ultrasonographic
measurement of the uterine dimensions, the distance between the tip of the Cu-IUD and the fundus, myometrium and
endometrium were measured to evaluate the displacement of the IUD. The relationship between the symptoms and IUD
displacement diagnosed by ultrasonographic examination were investigated.
Results  Two hundred and sixty-seven patients were followed-up for 12 weeks as the remaining 16 had partial or complete
IUD expulsion. A statistically significantly shorter uterine length was measured in patients who complained of menorrhagia
in comparison to the ones without this complaint (54.27 ± 6.11 vs 60.25 ± 10.52 mm, p = 0.02) while uterine length was
similar in patients with or without dysmenorrhea at 12 weeks (59.60 ± 10.25 vs 60.33 ± 10.68 mm, p = 0.71). The distances
between the tip of the IUD and the endometrium, myometrium and the uterine fundus, were statistically and significantly
longer in patients who experienced pelvic cramping at 3rd month, showing a downward movement of the IUD. (Endometrium;
0.29 ± 0.72 vs 0.45 ± 0.35 mm, p = 0.02, Myometrium; 1.25 ± 1.39 vs 2.38 ± 2.26 mm p < 0.05, Fundus; 1.68 ± 2.39 vs
2.92 ± 1.78 mm, p < 0.05).
Conclusion  A shorter uterine cavity length seems to be a predictor of menorrhagia in patients with Cu-T 380A IUD. Patients
experiencing pelvic cramping with IUD are more susceptible for IUD expulsion as the downward movement of IUD is more
prominent in these patients.

Keywords  Copper IUD · Ultrasonography · Menorrhagia · Dysmenorrhea · Pelvic cramping

Introduction may cause method discontinuation. Heavy menstrual periods

Copper Intrauterine devices are the most widely used
method of long-acting reversible contraception (LARC) with
a very low failure of 0.2–1.0% [1, 2]. Cu-T 380A is preferred
due to its low failure rate and long life-span [3]. The side-
effects related to IUD use mainly pelvic cramping, dysmen-
orrhea, heavy menstrual periods, spotting and IUD expulsion
* Seyma Fadiloglu
seymasilturk@hotmail.com
1
Etlik Zubeyde Hanim Women’s Health Teaching
and Researching Hospital, Ankara, Turkey
are the most common reason for IUD removal [4]. Clini-
cal follow-up of patients with IUD usually consist of pelvic
examination and transvaginal ultrasonography (TVUSG).
Ultrasonography is a cost-effective radiation free method
that is commonly used in the evaluation of the IUD place-
ment as the arms and the stem of the copper IUD are echo-
genic. Ultrasonographic imaging has been accepted as the
initial step in evaluation and management of malpositioned
IUDs [5]. IUD malpositions are categorized as expulsion,
embedding, displacement and perforation.
The etiology of some of the side-effects like menorrhagia,
dysmenorrhoea and pelvic cramping related to IUD use are

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990
investigated by various researchers by ultrasonographic eval-
uation of the location of the IUD and its relationship with
the uterine dimensions although some of these side-effects
occurred even when the IUD was in a normal position [6–8].
The aim of this study is to evaluate the relationship
between the most common side-effects of IUD such as dys-
menorrhea, menorrhagia, pelvic cramping and the position
of the IUD device within the cavity and uterine dimensions
evaluated by transvaginal ultrasonography.
Materials and methods
Two hundred and eighty-four patients who applied to the
Family Planning Clinic of a tertiary health center for an
IUD insertion were recruited to the study after receiving
information about the study aim and study protocol and a
signed informed consent was obtained from the volunteers.
The insertions were carried out by the residents during the
menstrual period, or immediately after voluntary termina-
tion of pregnancy (< 10 weeks is the legal limit for vol-
untary termination of pregnancies in Turkey) via manual
vacuum aspiration or postpartum 6th week under the super-
vision of obstetrics and gynecology specialists. The study
was approved by the Institutional Review Board on 6.03.14
with the approval number of 191.
The medical eligibility of the patients was based on WHO
Criteria [4]. Query of pregnancy, history of unexplained
abnormal uterine bleeding and presence of uterine anomaly,
uterine fibroid or polyp causing distortion of the endometrial
cavity, pelvic inflammatory disease or septic abortion were
exclusion criteria. Demographic characteristics, medical his-
tory, symptoms and findings of the gynecological examina-
tion were recorded. After pelvic examination, a speculum
was inserted into the vagina for visualization of the cervix.
After cleansing the vagina and the cervix with povidone-
iodine solution, a tenaculum was placed to the upper lip of
the cervix. After correction of the uterine axis by traction of
the tenaculum, the length of the uterine cavity was measured
with hysterometry and the results were recorded. Then the
IUD was inserted through the cervix using the cannula based
on the measured cavity length. After placement of the IUD
to the apex of the uterine cavity, the cannula was removed
gently leaving IUD inside the uterine cavity. Afterwards, the
threads of the IUD were shortened. Postabortion IUD inser-
tion was performed using the same technique after complete
evacuation of the cavity using the manual vacuum aspira-
tor (MVA) in patients who had a voluntary termination of
pregnancy with a gestational age < 10 weeks. All patients
had Cu-T 380A IUD inserted.
The patients were asked to come for follow-up visits 6 and
12 weeks after insertion. All the patients were questioned for
13
Archives of Gynecology and Obstetrics (2018) 297:989–996
the presence of symptoms related to IUD use; dysmenorrhea,
pelvic cramping, menorrhagia besides signs of infection.
The diagnosis of menorrhagia was not based on objective
measurement of the blood loss by the patients recording the
number of tampons and pads used and complaining of pass-
ing increased volume of blood and clots and using increased
number of tampons and pads with an increased frequency
after IUD insertion as defined by Warner et al. [9]. Presence
of dysmenorrhea was defined as having significant pain and
cramping during menstrual periods which was not present
before the IUD insertion.
As a part of the study protocol transvaginal ultrasonog-
raphy was performed at insertion, 6th week and 12th week
after insertion by the same ultrasonographist who was
blinded to the complaints and previous measurements of the
same patient. Transvaginal ultrasonographic measurement of
the uterine dimensions was recorded. The distance between
the tip of the Cu-IUD (TCu380A) and the fundus, myome-
trium and endometrium were measured at sagittal section
by transvaginal ultrasonography (Mindray M5, China) as
described by Faundes et al. [10]. The plane of the measure-
ment of the parameters is demonstrated in Figs. 1, 2. All the
findings were recorded.
Statistical analyses were carried out due to the proper-
ties of the input data (parametric or non-parametric, num-
ber of groups, etc.) using IBM SPSS Statistics 21.0 soft-
ware. Cochrane Q test, Friedman test, Wilcoxon test and
Mann–Whitney U test were used. Cochrane Q test is used for
non-parametric statistical test used to test whether a number
of dependent factors, Friedman test is used to detect differ-
ences in treatments across non-parametric values, Wilcoxon
test is used when comparing two related non-parametric
samples and Mann–Whitney U test is a test used for non-
parametric values coming from the same population against
an alternative hypothesis.
Findings
Overall 283 patients were followed-up and 16 (6%) patients
who had spontaneous complete or partial expulsion before
examination at 6 weeks were not included in the analysis.
The demographic characteristics of the 267 patients are
given in Table 1; only one woman was nulliparous, while
82.4% of the patients had more than one previous delivery.
Most of the cases had IUD inserted during the men-
strual cycle (85.8%), while only 3 had post-abortive inser-
tion and the remaining patients (13.1%) were 6  weeks
postpartum at the time of IUD insertion. The incidence of
previous history of IUD expulsion was 9.4% (Table 1). No
pregnancy occured during the follow-up and one patient
had the IUD removed due to menorrhagia.
Archives of Gynecology and Obstetrics (2018) 297:989–996 991

Fig. 1  Transvaginal ultrasono-
graphic picture displaying the
distance between the top of the
intrauterine device (IUD) and
the end of the uterine cavity: the
IUD–endometrium distance and
IUD-fundus distance

The comparison of the incidence of dysmenorrhea, pel-

Fig. 2  A schematic drawing of the distances measured at sagittal sec-
tion. Distance between 1-2: IUD-endometrium, 1-3: IUD-myome-
trium, 1-4: IUD-fundus
vic cramping and menorrhage recorded during insertion
with the incidence of the same symptoms recorded during
the 6th week and 12th week visits is shown in Table 2. The
incidence of these three complaints increased at 6th week
with addition of 16 patients for dysmenorrhea, 42 patients
for pelvic cramping and 35 patients for menorrhagia to the
patients who had these complaints before IUD application.
However, the incidence declined at the 12th week for all of
these three complaints, but still the incidence was higher
then the initial evaluation. These differences showed sta-
tistically significant importance due to Cochrane Q test
(p < 0.05).
The measured distance between the tip of the IUD and
the endometrium, myometrium and fundus at insertion and

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992 Archives of Gynecology and Obstetrics (2018) 297:989–996

Table 1  Demographic characteristics and obstetric history of the cramping at the 6th and 12 week follow-ups, there was no
patients difference in the uterine dimensions (hysterometry and
Variable Patient group (N) 267 % transvaginal ultrasonographic measurement of the uterine
width and uterine length) according to the statistical analysis
Age (mean ± SD) 31.75 ± 7.26
using Mann–Whitney U test (Table 4). The patients who
Number of deliveries
complained of menorrhagia had shorter uterine length in
 Nulliparous 1 0.4
comparison to the patients who had not experienced men-
 Primiparous 46 17.2
orrhagia. Despite no statistical difference was detected at
 Multiparous 220 82.4
6th week, a significant statistical relation between uterine
Route of previous delivery
length and menorrhagia was shown at the 12th week using
 Vaginal 193 72.3
Mann–Whitney U test (Table 4).
 C/S 49 18.4
No statistically significant change was recorded in the
 Vaginal + C/S 24 9.0
IUD-endometrium, IUD-myometrium and IUD-fundus
History of IUD expulsion
distance measurements after 3  months in women who
 Absent 242 90.6
experienced dysmenorrhea or menorrhagia according to
 Present 25 9.4
Mann–Whitney U test (Table 5). Although the measure-
Timing of IUD insertion
ments taken at 6th week in women with pelvic cramping
 Menstruation 229 85.8
demonstrated a lower displacement of the IUD in patients
 Postpartum 35 13.1
with pelvic cramping, the difference was not statistically
 After D&C 3 1.1
significant. At 12th week, there was a significant difference
Total 267 100
between the IUD-endometrium, IUD-myometrium and IUD-
fundus measurements of the patients who experienced pel-
vic cramping in comparison to the women without pelvic
the 6- and 12-week follow-up are shown in Table 3. The cramping. (IUD-endometrium: 0.29 ± 0.72 vs 0.45 ± 0.35
mean change in the IUD-endometrium, IUD-myometrium p = 0.02, ∆IUD-myometrium: 1.25 ± 1.39 s 2.38 ± 2.26,
and IUD-fundus distance from insertion to 12th week were p < 0.05, IUD-fundus: 1.68 ± 2.39 vs 2.92 ± 1.78, p < 0.05).
0.94, 1.37 and 1.77 mm, respectively, showing statistical
significance within each group using Friedman test. The dif-
ferences of the distance between IUD-endometrium, IUD- Discussion
myometrium and IUD-fundus at the time of insertion, and
at 6th week and 12th week after insertion evaluated sepa- IUD is the most widely used reversible contraceptive method
rately with Wilcoxon statistical test showed a statistically worldwide. Method discontinuation related to side-effects
significant difference at all time intervals (Table 3). These experienced by patients is a problem both for the health ser-
changes demonstrated a statistically significant downwards vice providers and the IUD-users. Nearly 10% of IUD-users
movement of the IUD within the cavity (Table 3). need removal of IUD due to the side-effects [11]. Although
When the patients were divided into 2 groups with ultrasonography has become a routinely used procedure
regards to the presence or absence of dysmenorrhea or pelvic during gynecological examination, no relation has been

Table 2  The incidence of Insertion 6th week 12th week p (0–6 weeks) p (6–12 weeks)

dysmenorrhea, pelvic cramping
and menorrhage at insertion and Dysmenorrhea 70/267 (26.1%) 86/267 (32.2%) 82/267 (30.7%) 0.01 0.34
6- and 12-week follow-up visits
Pelvic cramping 7/267 (0.26%) 49/267 (18.3%) 21/267 (7.86%) 0.00 0.00
Menorrhagia 3/267 (7.86%) 38/267 (14.3%) 16/267 (5.99%) 0.00 0.00

Table 3  The change of Insertion 6th week 12th week p (0–6 weeks) p (6–12 weeks)

the distance measured by
transvaginal ultrasonography IUD-endometrium (mm) 1.25 ± 0.58 1.90 ± 0.74 2.19 ± 0.92 0.00 0.00
between IUD-endometrium, R = 0.1–3.05 R = 0.8–5.7 R = 1–11
IUD-myometrium, IUD-
IUD-myometrium (mm) 3.92 ± 1.12 4.84 ± 1.75 5.29 ± 1.59 0.00 0.00
fundus from insertion to 6- and
R = 0.8–8.2 R = 1.2–20 R = 1.4–19
12-week follow-up
IUD-fundus (mm) 18.20 ± 3.65 19,28 ± 3,41 19.97 ± 3.48 0.00 0.00
R = 2–35 R = 4.1–36.2 R = 4.2–37.1

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Archives of Gynecology and Obstetrics (2018) 297:989–996 993

Table 4  The uterine dimensions of the patients with or without dysmenorrhea, pelvic cramping and menorrhage at the 6th and 12th week
Dysmenorrhea
6 Weeks Absent (n = 181/ %67.8) Ave. ± SD Present (n = 86/ % 32.2) Ave. ± SD p

Hysterometry (cm) 7.60 ± 0.79 7.73 ± 1.51 0.86

Uterine width (mm) 43.31 ± 7.33 43.74 ± 8.81 0.16
Uterine length(mm) 59.60 ± 10.25 60.33 ± 10.68 0.71
Cervical length (mm) 23.45 ± 4.43 24.00 ± 4.47 0.96
12 Weeks Absent (n = 185/ % 69.3) med ± SD Present (n = 82/ % 30.7) med ± SD p

Hysterometry (cm) 7.58 ± 0.78 7.75 ± 1.54 0.88

Uterine width (mm) 43.34 ± 7.34 43.70 ± 8.85 0.18
Uterine length (mm) 59.60 ± 10.24 60.36 ± 10.71 0.70
Cervical length (mm) 23.51 ± 4.44 23.79 ± 4.47 0.70
Pelvic cramping
6 Weeks Absent (n = 218/ % 81.6) Ave. ± SD Present (n = 49/ % 18.4) Ave. ± SD p

Hysterometry 7.62 ± 1.11 7.57 ± 0.86 0.40

Uterine width 43.27 ± 7.81 44.27 ± 7.92 0.37
Uterine length 60.05 ± 10.61 59.01 ± 9.36 0.99
Cervical length 23.57 ± 4.56 23.67 ± 3.92 0.91
12 Weeks Absent (n = 246/ % 92.1) Ave. ± SD Present (n = 21/ % 7.9) Ave. ± SD p

Hysterometry 7.64 ± 1.08 7.68 ± 0.90 0.99

Uterine width 43.47 ± 7.85 43.08 ± 7.60 0.56
Uterine length 60.00 ± 10.49 58.14 ± 9.06 0.32
Cervical length 23.70 ± 4.47 23.40 ± 4.12 0.44
Menorrhagia
6 Weeks Absent (n = 229/ % 85.7) Ave. ± SD Present (n = 38/ % 14.3) Ave. ± SD p

Hysterometry 7.67 ± 1.11 7.45 ± 0.75 0.07

Uterine width 43.74 ± 8.03 41.61 ± 6.10 0.25
Uterine length 60.43 ± 10.60 56.31 ± 8.27 0.07
Cervical length 23.56 ± 4.50 23.77 ± 4.13 0.68
12 Weeks Absent (n = 251/ % 94) Ave. ± SD Present (n = 16/ % 6) Ave. ± SD p

Hysterometry 7.66 ± 1.09 7.33 ± 0.75 0.27

Uterine width 43.49 ± 7.99 42.83 ± 4.75 0.58
Uterine length 60.25 ± 10.52 54.27 ± 6.11 0.02
Cervical length 23.53 ± 4.48 24.49 ± 3.95 0.44

Significant p value < 0.05 is shown in bold

determined between the complications and the position of
IUD [10]. Displacement described as a downward move-
ment of the IUD is related with decreased efficacy and an
increased risk of expulsion [12]. While recent studies define
ultrasonography crucial for follow-up of IUDs and associ-
ated complications [5], some studies have linked the cavity
dimensions with the risk of IUD expulsion [13, 14]. The
relationship between menorrhagia and the uterine blood flow
was investigated by doppler studies of the uterine artery and
a relation between lower PI values and increased incidence
of menorrhagia has been described [15, 16]. Additionally,
subendometrial blood flow was evaluated by three-dimen-
sional doppler ultrasound and an increased vascularization
was observed in the patients with menorrhagia, but this was
not accepted as a predictor of menorrhagia [16]. There are
also reports showing no difference at doppler indices of uter-
ine and ovarian arteries [17, 18]. Similar to menorrhagia,
doppler findings were investigated for dysmenorrhea and a
relation with increased resistance has been described [19].
This phenomenon was explained by the relation between
hypoxia occurring via uterine contractions leading to
increased vascular resistance and dysmenorrhea.

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994 Archives of Gynecology and Obstetrics (2018) 297:989–996

Table 5  The changes in the IUD-endometrium, IUD-myometrium, IUD-fundus distances (∆) in patients with or without dysmenorrhea, pelvic
cramping and menorrhage at the 6th and 12th week
Dysmenorrhea
6 Weeks Absent (n = 181/ %67.8) Present (n = 86/ % 32.2) p

Endometrium-IUD 0.68 ± 0.75 0.57 ± 0.65 0.27

Myometrium-IUD 0.93 ± 1.35 0.93 ± 2.01 0.92
Fundus-IUD 1.07 ± 2.28 1.10 ± 2.18 0.75
12 Weeks Absent (n = 185/ %69.3) Present (n = 82/ %30.7) p

Endometrium-IUD 0.30 ± 0.81 0.28 ± 0.36 0.90

Myometrium-IUD 1.32 ± 1.20 1.36 ± 1.99 0.46
Fundus-IUD 1.74 ± 2.30 1.84 ± 2.52 0.52
Menorrhagia
6 Weeks Absent (n = 229/ %85.7) Present (n = 38/ % 14.3) p

Endometrium-IUD 0.63 ± 0.72 0.68 ± 0.70 0.44

Myometrium-IUD 0.95 ± 1.64 0.82 ± 1.36 0.23
Fundus-IUD 1.08 ± 2.34 1.11 ± 1.67 0.76
12 Weeks Absent (n = 251/ %94) Present (n = 16/ %6) p

Endometrium-IUD 0.30 ± 0.71 0.29 ± 0.50 0.91

Myometrium-IUD 1.36 ± 1.50 1.04 ± 1.55 0.59
Fundus-IUD 1.73 ± 2.30 2.54 ± 3.22 0.34
Pelvic cramping
6 Weeks Absent (n = 218/ %81.6) Present (n = 49/ % 18.4) p

Endometrium-IUD 0.59 ± 0.62 0.86 ± 1.02 0.33

Myometrium-IUD 0.90 ± 1.57 1.08 ± 1.71 0.45
Fundus-IUD 1.05 ± 2.34 1.26 ± 1.77 0.14
12 Weeks Absent (n = 246/ %92.1) Present (n = 41/ %7.9) p

Endometrium-IUD 0.29 ± 0.72 0.45 ± 0.35 0.02

Myometrium-IUD 1.25 ± 1.39 2.38 ± 2.26 0.00
Fundus-IUD 1.68 ± 2.39 2.92 ± 1.78 0.00

Significant p values < 0.05 are shown in bold

Proper insertion of IUD is related with fewer side-effects
and greater satisfaction which leads to lesser method dis-
continuation rates [20]. With the increasing availability of
3D USG, there are reports defining 3D USG important for
imaging the IUD [21] and determining the malpositioned
IUDs that might be the cause of bleeding abnormalities and
pelvic pain [22].
Depending on our literature search no research has been
carried out to question the relationship between the cav-
ity dimensions and common side-effects like menorrhagia,
abdominal cramp and dysmenorrhea. After 3-month fol-
low-up a possible relation between a shorter uterine cavity
and menorrhagia has been determined. The previous stud-
ies have shown that a well-fitting IUD will decrease the
reported side-effects and a shorter uterus is a risk factor
for a difficult insertion [23, 24]. Contrary to our data; Kai-
slasuo et al. reported that the levonorgestrel bearing intra-
uterine system (LNG-IUS) users with smaller cavities had
less spotting/bleeding days than throughout the two 90-day
reference periods and less pain during the second reference
period [25]. However, the Cu-IUD arm of this study was
too small for statistical analysis so a comparison between
the two intrauterine devices could not be performed.
In the presented study; no relationship between dysmen-
orrhea and ultrasonographic evaluation was been detected.
Jiménez et al reported a relation between subendometrial
blood flow and severe dysmenorrhea and/or bleeding
although PI and RI showed no difference in women with
these complaints [26]. In our study group, the women with
pelvic cramping demonstrated a downward movement of the

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Archives of Gynecology and Obstetrics (2018) 297:989–996 995
IUD inside the cavity. This downward movement is reported
to be related with the uterine contractions [27, 28]. However,
Morales-Rosello reported that regardless of the previous par-
ity of the patient vast majority of low lying IUDs moved
upwards spontaneously at the 2-month follow-up [29].
The majority of the patients recruited to the presented
study had IUD inserted during the interval period. Previous
studies on immediate postplacental IUD insertion demon-
strated a higher expulsion rate [30, 31]; however, none of the
patients in the postpartum group in our study had an imme-
diate postplacental insertion. Restricted number of patients
recruited to the study and the shorter follow-up period are
the weakness of the study. A longer follow-up of a larger
number of patients with Cu-IUD may lead to a better under-
standing of the relationship between the position of the IUD
and the side-effects.
Conclusion
Shorter uterine length measured via ultrasonography seems
to be a predictor for menorrhagia in patients with IUD
and may be evaluated before IUD insertion. Additionally,
patients experiencing pelvic cramping with IUD are more
susceptible for IUD expulsion as the downward movement
of IUD is more prominent in these patients and that seems to
be a result of the uterine contractions. Nevertheless, it may
be speculated that a shorter uterine cavity may be a possi-
ble risk factor for menorrhagia and for a custom-fit Copper
IUD insertion the cavity may be evaluated before insertion
for predicting menorrhagia. However, further studies with
larger number of recruited women are required for a defini-
tive conclusion.
Author contributions  SF: Corresponding author, data curation, data
collection; BD: lead supervisor, project development; EF: writing, data
analysis; SD: supporting supervisor
Compliance with ethical issues  dict IUD expulsion after medical abortion? Contraception
Funding  This study was not funded by any company.
Conflict of interest  Conflict of interest is declared by none of the au-
thors.
Human and animal rights statement  This article does not contain any
studies with human participants or animals performed by any of the
authors.
Ethical approval  Study is approved by Ankara Etlik Zübeyde Hanım
Education and Training Hospital Institutional Review Board.
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