• If a woman using the copper intrauterine device (IUD) is diagnosed with pelvic inflammatory disease:
• Test for the causative organism and institute appropriate antibiotic treatment — for information on testing and antibiotics, see the CKS topic on Pelvic inflammatory disease.
• Consider removing any contraceptive intrauterine device (IUD) in women presenting with pelvic inflammatory disease (PID), after discussion with the woman.
• Experts agree that the device should be removed if the woman wishes removal or if symptoms have not resolved within 72 hours.
• Evidence is limited and expert opinion is divided over whether it is necessary to remove the IUD at the initial presentation.
• If a decision is made to remove the IUD, ask if the woman has had sexual intercourse within the last 7 days and consider offering emergency hormonal contraception. For more information see the CKS topic on Contraception - emergency.
• If the woman develops pelvic pain and has had actinomyces-like organisms (ALOs) identified on a smear in the past:
• Take endocervical swabs, and
• Urgently seek specialist advice regarding treatment.
• Consider removal of the IUD.
• All women with confirmed or suspected pelvic inflammatory disease should be followed up to ensure:
• Resolution of symptoms and signs.
• Completion of the course of antibiotics.
• Risk assessment for sexually transmitted infections.
• Counselling regarding safer sex.
• Partner notification and treatment.

Removal of an intrauterine device

• Recommendations about removing the copper intrauterine device (IUD) when a woman has pelvic inflammatory disease are based on expert opinion and are not entirely consistent among authorities:
• Expert advice in the Faculty of Sexual and Reproductive Healthcare clinical guideline on intrauterine contraception does not routinely recommend the removal of an IUD. The Faculty's Clinical Effectiveness Unit supports the continued use of intrauterine contraception and appropriate antibiotic treatment if PID is suspected; there is no need to remove the IUD unless symptoms fail to resolve within 72 hours or the woman wants it removed [FFPRHC, 2006a; FSRH, 2007].
• Expert opinion in guidelines on the management of acute PID from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009] advises that consideration be given to removing the IUD, especially if symptoms have not resolved within 72 hours.
• The British Association for Sexual Health and HIV recommend considering removing the IUD if the woman develops PID. They advise balancing the decision to remove the IUD against the risk of pregnancy if the woman has had sexual intercourse in the preceding 7 days [BASHH, 2005].
• Selected practice recommendations for contraceptive use from the World Health Organization state that [WHO, 2004a]:
• There is no need for removal of the IUD if the woman wishes to continue its use.
• If the woman wishes removal, remove it after antibiotic treatment has been started.
• If the infection does not improve then generally the course would be to remove the IUD and continue antibiotics. If the IUD is not removed then the antibiotic should be continued and the woman should be monitored closely.

Presence of actinomyces-like organisms (ALOs)

• Expert opinion in guidelines from the Faculty of Sexual and Reproductive Healthcare is that [FSRH, 2007]:
• The role of ALOs in infection in women using intrauterine contraception is unclear. Actinomyces israelii is a commensal organism in the female genital tract and although these organisms may be found on cervical smears or swabs, their presence is not diagnostic or predictive of disease. Therefore, there is no need to remove an IUD if the woman does not have symptoms.
• If PID is suspected in a woman who has a history of ALOs on a cervical smear, it is important to consider that the infection may be due to other organisms.
• It may be appropriate to remove the IUD.