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How will I know if my Mirena IUD has perforated my uterus? #621/9

I had my Mirena inserted in February 2009.  Some spotting, but no cramping or associated period-like issues. Haven’t even had to use a tampon, perhaps just a panty liner.


Since Thursday, I have had heavier bleeding and cramping.  I have read that some times the Mirena can perforate the uterus.  Is this what is going on?

Thanks so much for your patience.  I was on my back with open heart surgery for a mitral valve repair 16 days ago.  Now I have reopened my computer.  I am feeling more energetic each day.  Each morning I go out and pick raspberries and blueberries for cereal before breakfast.


Where do you stand now?  Was your insertion extremely painful?


Mirena can perforate the uterus in about 1 in 1,000 to 1 in 2,000 insertions.



Her reply on 6-25: “Glad to hear that you are on the mend!  Picking raspberries and blueberries will absolutely raise your spirits.”


“The heavy bleeding stopped after about a week.  So far nothing, but as fate will have it, I just started spotting about 5 minutes ago.  I also have developed an occasional fishy odor that my doctor has attributed to altered ph levels from the old blood.  How would I know if my Mirena was perforated?”

I may be missing the point, but I am not sure I understand why you are concerned that your IUD may have perforated your uterus at the time of insertion.


Some women do stop bleeding almost completely immediately after Mirena insertion.  Can you feel the strings of your IUD?

Her reply on 7-4: “Yes, I can still feel my strings.  I guess the neurotic portion of my brain assumed that there may be a problem.  I had not experienced any cramping at all immediately following the insertion, so to suddenly have cramping and bleeding alarmed me.  Is cramping and light bleeding 5 months later common?


Perforation of the uterus can occur at the time of IUD insertion; no evidence supports that notion that IUDs “migrate” outside the uterus thereafter. The most important determinant of the risk of perforation is the skill of the person doing the insertion (“the magic is in the magician and not in the wand”). In experienced hands, this risk is 1 per 1,000 insertions or less.


Copper-bearing IUDs found to be outside the endometrial cavity should be removed promptly. Copper in the peritoneal cavity induces adhesion formation, which may involve the adnexa, omentum, and bowel. Laparoscopy is the preferred approach for removal. In contrast, non-medicated and progestin-bearing devices do not evoke similar intraperitoneal adhesions. No clear medical indication exists for removal of T-shaped IUDs not containing copper, although this is commonly done. 

String Problems

Missing strings may signal an unsuspected perforation or spontaneous expulsion; alternatively, some strings ascend into the endometrial cavity and descend without known explanation. Ultrasound examination can quickly confirm the presence of an IUD within the endometrial cavity. Should the device be present but no strings visible and should the woman request its removal, a cotton swab or endometrial biopsy instrument can sometimes tease the strings from the endometrium to the endocervix.


Removal of a T-shaped device without visible strings has two prerequisites: the patient’s comfort and cervical dilation. A paracervical block or intrauterine instillation of anesthetic administered before manipulation, supplemented by an oral analgesic, can decrease the pain associated with the procedure. Second, osmotic dilators left in the os overnight, or misoprostol 400 mcg (vaginally or orally), will dilate the cervix. Gentle exploration with an alligator forceps usually yields the device quickly; if not, ultrasound guidance may be helpful. Rarely are the expense and inconvenience of hysteroscopy required for IUD removal.


Several mechanical problems relate to string length. If the male partner complains of penile discomfort from the string being cut too short, one option is to cut the strings off even shorter within the endocervical canal. This may eliminate the barb-like sensation and obviate the need to replace the IUD. If the strings initially are too long, simply trim them. If the strings become longer at a later time, check for partial expulsion of the IUD.


This answer came in part from the 19th edition of Contraceptive Technology, a book that describes how all the contraceptives work, the advantages and disadvantages of each and much more!  The chapters are by nationally recognized experts.


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Key Words:  Mirena IUD, inserted, cramping, spotting, bleeding, tampons, liners, period, perforated, uterus, painful, fishy odor, ph bleed levels, migrate, risk, endometrial cavity, laparoscopy, progestin-bearing devices, adhesions, string problems, Contraceptive Technology

Posted 6-30-2009, Updated 7-4-2009

Robert A. Hatcher MD, MPH
Emeritus Professor of Gynecology and Obstetrics
Emory University School of Medicine
Atlanta, GA

The directors and owners of this website and any publications and information concerning health matters offered here advise a person with a particular problem to consult a primary-care clinician or a specialist in obstetrics, gynecology, or urology (depending on the problem or the contraceptive) as well as the product package insert and other references before diagnosing, managing, or treating the problem.
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