PAINS
IUD Warning Signs
Call the office for any of these IUD red flags.
Clinicians lean on this acronym when counseling a patient leaving the office with a new IUD and three minutes for safety teaching. PAINS — Period late or abnormal bleeding, Abdominal pain or pain with sex, Infection (abnormal discharge), Not feeling well (fever, chills), Strings missing, shorter, or longer — covers the symptoms that warrant a same-day call. Period changes are common and not always concerning, but combine with pain and they point to expulsion, perforation, or PID. AANP exam vignettes test the warning signs and the immediate next step: bring her in, confirm placement with ultrasound or speculum exam, and rule out pregnancy if a period is late.
- PPeriod late or absentPossible pregnancy — higher fraction are ectopic with IUD in place.
- AAbdominal painSevere or persistent — could signal perforation or PID.
- IInfectionAbnormal discharge, unusual odor, fever.
- NNot feeling wellFever, chills, malaise — PID symptoms.
- SString missingCheck placement — possible expulsion or migration.
Clinical Context
Contraceptive counseling mnemonic for IUD (copper or hormonal) users. Cramping and irregular bleeding are common in the first 3-6 months — usually settle. PID risk is elevated only in the first 3 weeks post-insertion; after that, IUDs don't increase STI risk.
Ectopic pregnancy: absolute numbers are low with IUD, but any pregnancy that does occur has a higher ectopic fraction. Urgent ultrasound for any positive pregnancy test. AANP tests the "missing strings" scenario — next step is ultrasound to confirm placement.
Related Mnemonics
Sources
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