In the United States, approximately 10% of women use long-acting reversible contraception (LARC) (1). Intrauterine devices (IUDs) are the most commonly used LARC. IUDs are a popular choice because they are highly effective and have minimal side effects. Also, IUDs need to be removed or replaced only every 3, 5, 8, or 10 years, avoiding the need to use a daily, weekly, or monthly contraceptive method.
In the United States, available IUDs include levonorgestrel-releasing IUDs and an intrauterine copper contraceptive. In the United States, available IUDs include levonorgestrel-releasing IUDs and an intrauterine copper contraceptive.
Levonorgestrel-releasing IUDs include:Levonorgestrel-releasing IUDs include:
A 13.5-mg IUD (14 mcg a day) effective for 3 years with a 3-year cumulative pregnancy rate of 1.0% (2)
A 19.5-mg IUD (17.5 mcg a day) effective for 5 years with a cumulative 5-year pregnancy rate of 0.9 to 1.4%
Two 52 mg IUDs (20 mcg a day initially, declining to 10 mcg a day after 5 years) effective for 8 years with a cumulative 8-year pregnancy rate of 0.5 to 1.1% (3, 4)
The intrauterine copper contraceptive is effective for 10 years; it has a cumulative 12-year pregnancy rate of < 2% (5). See table Comparison of Intrauterine Devices.
Comparison of Intrauterine Devices
Levonorgestrel 3-year (13.5 mg) IUDLevonorgestrel 3-year (13.5 mg) IUD | Levonorgestrel 5-year (19.5 mg) IUDLevonorgestrel 5-year (19.5 mg) IUD | Levonorgestrel 8-year (52 mg) IUDLevonorgestrel 8-year (52 mg) IUD | Copper-T380ACopper-T380A | |
Pregnancy rate at 1 year of use | 0.4% | 0.2% | 0.2–0.6% | — |
Cumulative pregnancy rate for maximum duration of use | 1.0% | 0.9–1.4% | 0.5–1.1% | < 2% at 12 years |
Reversibility | Rapid | Rapid | Rapid | Rapid |
Standard duration | 3 years | 5 years | 8 years | 10 years* |
Changes in bleeding | Irregular bleeding Amenorrhea at 1 year: 6% | Irregular bleeding Amenorrhea at 1 year: 12% | Irregular bleeding Amenorrhea at 1 year: 20% | No change in cyclical nature of cycles |
Mean monthly blood loss | — | 5 mL (at 6 months of use) | 5 mL (at 6 months of use) | 50‒80 mL |
Additional benefits | — | — | May be used to treat heavy menstrual bleeding, chronic pelvic pain, or endometriosis | May be used as emergency contraception Nonhormonal |
Adverse effects | Minimal: Headache, spotting, breast tenderness, nausea (which usually resolves within 6 months) | Same as for the 3-year IUD | Same as for the 3-year IUD | More severe menstrual cramps (usually relieved by nonsteroidal anti-inflammatory drugs [NSAIDs]) and heavier flow |
Primary mechanism of action† | Thickens cervical mucus and prevents fertilization | Same as for the 3-year IUD | Same as for the 3-year IUD | Use of copper ions to produce a sterile inflammatory response that is toxic to sperm, thus preventing fertilization Use of copper ions to produce a sterile inflammatory response that is toxic to sperm, thus preventing fertilization |
* Evidence supports use for 12 years. †In rare circumstances, an IUD may prevent implantation of a blastocyst. | ||||
Insertion of the IUD
Clinicians do not need to do a Papanicolaou (Pap) test or human papillomavirus (HPV) test before they insert an IUD, unless the patient is due for cervical cancer screening. Testing for sexually transmitted infections (STIs)—gonorrhea and chlamydia—prior to IUD insertion should be based on "risk-based" screening (age ≤ 25 years, multiple sexual partners, inconsistent condom use, and/or history of a STI) (6). However, clinicians do not need to wait for results of STI testing before they insert an IUD. If results are positive, patients should be treated with appropriate antibiotics; the IUD is left in place. If purulent cervical discharge is observed just before planned IUD insertion, the IUD is not inserted and STI testing is performed; the infection, if present, is then treated, and the IUD is inserted after treatment of the infection is complete.
The package insert for the IUD should be read before insertion to review the insertion technique. When IUDs are inserted, sterile technique is used as much as possible. Bimanual examination should be performed to determine the position of the uterus and a tenaculum should be placed on the anterior lip of the cervix to stabilize the uterus, straighten the uterine axis, and help ensure correct placement of the IUD. A uterine sound device may be used to measure the length of the uterine cavity before IUD insertion. Before insertion, options for pain management should be discussed with the patient. A paracervical block may be used to decrease pain during insertion (7).
An IUD may be inserted at any time during the menstrual cycle if a woman has not had unprotected intercourse during the past month.
A routine follow-up visit after IUD insertion is not necessary. Patients should be counseled to return for evaluation if they experience symptoms or complications (eg, pain, heavy bleeding, abnormal vaginal discharge, fever, expulsion) or are dissatisfied with the method (8).
An IUD may be inserted immediately after an induced or a spontaneous abortion during the first or second trimester and immediately after delivery of the placenta in a cesarean or vaginal delivery.
Contraindications
Most women can use an IUD. Contraindications include the following:
Anatomic abnormalities that distort the uterine cavity
Current pelvic infection, usually pelvic inflammatory disease (PID), mucopurulent cervicitis with a suspected STI, pelvic tuberculosis, septic abortion, or puerperal endometritis or sepsis within the past 3 months
Unexplained vaginal bleeding
Pregnancy
Gestational trophoblastic disease with persistently elevated serum beta–human chorionic gonadotropin (beta-hCG) levels (a relative contraindication because supporting data are lacking)with persistently elevated serum beta–human chorionic gonadotropin (beta-hCG) levels (a relative contraindication because supporting data are lacking)
Known cervical cancer or endometrial cancer
For levonorgestrel-releasing IUDs, For levonorgestrel-releasing IUDs,breast cancer or allergy to levonorgestrel
For copper T380 IUDs, Wilson disease or allergy to copper
Conditions that do not contraindicate IUDs include the following:
Contraindications to contraceptives that contain estrogen (eg, history of venous thromboembolism, smoking > 15 cigarettes a day in women > 35, migraine with aura, migraine of any type in women > 35)
A history of PID, STIs, or ectopic pregnancy
Breastfeeding
Adolescence
Adverse effects
Vaginal bleeding is often irregular in the first several months after insertion of a levonorgestrel-releasing IUD. Bleeding then stops completely within 1 year in up to 20% of women; some patients consider this effect a benefit of the IUD.Vaginal bleeding is often irregular in the first several months after insertion of a levonorgestrel-releasing IUD. Bleeding then stops completely within 1 year in up to 20% of women; some patients consider this effect a benefit of the IUD.
An intrauterine copper contraceptive may cause heavier menstrual bleeding and more severe cramping, which can be relieved by nonsteroidal anti-inflammatory drugs (NSAIDs; eg, ibuprofen).An intrauterine copper contraceptive may cause heavier menstrual bleeding and more severe cramping, which can be relieved by nonsteroidal anti-inflammatory drugs (NSAIDs; eg, ibuprofen).
Women should be told about these effects before the IUD is inserted because this information may help them decide which type of IUD to choose.
Similar to other hormonal contraceptives, there are conflicting data regarding whether IUDs slightly increase the risk of breast cancer. Even in studies that have found a risk, the absolute risk of breast cancer with the LNG-IUS was low (9).
Potential benefits
Levonorgestrel-releasing IUDs are associated with a decreased risk of endometrial cancer and ovarian cancer (Levonorgestrel-releasing IUDs are associated with a decreased risk of endometrial cancer and ovarian cancer (10, 11).
If a woman has had unprotected intercourse within the past 7 days, an intrauterine copper contraceptive or a 52-mg levonorgestrel-releasing IUD may be inserted as If a woman has had unprotected intercourse within the past 7 days, an intrauterine copper contraceptive or a 52-mg levonorgestrel-releasing IUD may be inserted asemergency contraception.
Complications
Average IUD expulsion rates are usually < 5% within the first year after insertion; however, expulsion rates are higher if the IUD is inserted immediately (< 10 minutes) after a delivery. After insertion, a clinician confirms correct placement at 6 weeks by looking for the strings attached to the IUD, which are typically trimmed to 3 cm from the external cervical os.
The uterus is perforated in about 1/1000 IUD insertions (12). Perforation typically occurs at the time of IUD insertion. Sometimes only the distal part of the IUD penetrates; then over the next few months, uterine contractions force the IUD into the peritoneal cavity. If the strings are not visible during pelvic examination, clinicians may do one or more of the following:
Use a cytobrush to attempt to sweep the strings out of the cervical canal
Perform ultrasound to identify the IUD location (the copper IUD is reflective through the length of the device; the levonorgestrel IUD is reflective only at the tips of the long and short arms)Perform ultrasound to identify the IUD location (the copper IUD is reflective through the length of the device; the levonorgestrel IUD is reflective only at the tips of the long and short arms)
Gently probe the uterine cavity with an IUD hook, sound, or biopsy instrument (unless pregnancy is suspected), being careful not to push the IUD further into the uterine cavity or myometrium; alligator forceps may be used under sonographic guidance (13)
If the IUD is not visualized on ultrasound, an abdominal radiograph is recommended to exclude an intraperitoneal location. It is recommended to remove an intraperitoneal IUD ideally laparoscopically, because IUDs may cause intestinal adhesions if left in place (14).
If expulsion or perforation is suspected, a backup contraceptive method should be used.
Rarely, salpingitis (pelvic inflammatory disease [PID]) develops during the first month after insertion because bacteria are displaced into the uterine cavity during insertion; however, this risk is low and routine antibiotic prophylaxis is not indicated. If PID develops, antibiotics should be given. The IUD need not be removed unless the infection persists despite antibiotics. IUD strings do not provide access for bacteria. Except during the first month after insertion, IUDs do not increase the risk of pelvic inflammatory disease.
If Actinomyces-like organisms on a Pap test in women with no symptoms of infection does not require antibiotics nor IUD removal (15).
The incidence of ectopic pregnancy is much lower in IUD users than in women using no contraceptive method because IUDs effectively prevent pregnancy. However, if a women becomes pregnant while an IUD is in place, she should be told that risk of ectopic pregnancy is increased, and she should be evaluated promptly.
References
1. Daniels K, Abma JC. Current Contraceptive Status Among Women Aged 15-49: United States, 2017-2019. NCHS Data Brief. 2020;(388):1-8.
2. Nelson A, Apter D, Hauck B, et al. Two low-dose levonorgestrel intrauterine contraceptive systems: a randomized controlled trial [published correction appears in Obstet Gynecol 123(5):1109, 2014]. Obstet Gynecol 122(6):1205-1213, 2013. doi:10.1097/AOG.0000000000000019
3. Jensen JT, Lukkari-Lax E, Schulze A, et al. Contraceptive efficacy and safety of the 52-mg levonorgestrel intrauterine system for up to 8 years: findings from the Mirena Extension Trial. Am J Obstet Gynecol 227(6):873.e1-873.e12, 2022. doi:10.1016/j.ajog.2022.09.007
4. Creinin MD, Schreiber CA, Turok DK, et al. Levonorgestrel 52 mg intrauterine system efficacy and safety through 8 years of use. Am J Obstet Gynecol 227(6):871.e1-871.e7, 2022. doi:10.1016/j.ajog.2022.05.022
5. Long-term reversible contraception. Twelve years of experience with the TCu380A and TCu220C. Contraception 56(6):341-352, 1997.
6. Grentzer JM, Peipert JF, Zhao Q, et al. Risk-based screening for Chlamydia trachomatis and Neisseria gonorrhoeae prior to intrauterine device insertion. Contraception 92(4):313-318, 2015. doi:10.1016/j.contraception.2015.06.012
7. Mody SK, Farala JP, Jimenez B, et al. Paracervical block for intrauterine device placement among nulliparous women: A randomized controlled trial, Obstet Gynecol 132 (3): 575–582, 2018. doi: 10.1097/AOG.0000000000002790
8. Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 65 (4):1–66, 2016. doi: 10.15585/mmwr.rr6504a1
9. American College of Obstetricians and Gynecologists (ACOG). ACOG Practice Advisory January 2018, Hormonal Contraception and Risk of Breast Cancer. Reaffirmed October 2024.
10.Yi H, Zhang N, Huang J, et al. Association of levonorgestrel-releasing intrauterine device with gynecologic and breast cancers: a national cohort study in Sweden. . Association of levonorgestrel-releasing intrauterine device with gynecologic and breast cancers: a national cohort study in Sweden.Am J Obstet Gynecol. 2024;231(4):450.e1-450.e12. doi:10.1016/j.ajog.2024.05.011
11. Wheeler LJ, Desanto K, Teal SB, Sheeder J, Guntupalli SR. Intrauterine Device Use and Ovarian Cancer Risk: A Systematic Review and Meta-analysis. Obstet Gynecol. 2019;134(4):791-800. doi:10.1097/AOG.0000000000003463
12. Gatz JL, Armstrong MA, Postlethwaite D, et al. Association between intrauterine device type and risk of perforation and device expulsion: results from the Association of Perforation and Expulsion of Intrauterine Device study. Am J Obstet Gynecol. 2022;227(1):57.e1-57.e13. doi:10.1016/j.ajog.2022.03.062
13. Prabhakaran S, Chuang A. In-office retrieval of intrauterine contraceptive devices with missing strings. Contraception 83(2):102-106, 2011. doi:10.1016/j.contraception.2010.07.004
14. Kho KA, Chamsy DJ. Perforated intraperitoneal intrauterine contraceptive devices: diagnosis, management, and clinical outcomes. J Minim Invasive Gynecol. 2014;21(4):596-601. doi:10.1016/j.jmig.2013.12.123
15. Committee on Practice Bulletins-Gynecology, Long-Acting Reversible Contraception Work Group. Practice Bulletin No. 186: Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Obstet Gynecol. 2017;130(5):e251-e269. doi:10.1097/AOG.0000000000002400
Key Points
IUDs are highly effective contraceptives and have minimal systemic effects, and IUDs need to be changed only every 3, 5, 8, or 10 years depending on the IUD chosen.
Types include levonorgestrel-releasing IUDs (effective for 3 to 8 years, depending on the type) and an intrauterine copper contraceptive (effective for 10 years, with a 12-year pregnancy rate of < 2%).Types include levonorgestrel-releasing IUDs (effective for 3 to 8 years, depending on the type) and an intrauterine copper contraceptive (effective for 10 years, with a 12-year pregnancy rate of < 2%).
A Pap or HPV test is not required before IUD insertion unless the patient is due for cervical cancer screening.
Inform women that both types of IUDs can affect menstrual bleeding (amenorrhea with levonorgestrel-releasing IUDs and possibly heavier menstrual bleeding and more severe cramping with the Inform women that both types of IUDs can affect menstrual bleeding (amenorrhea with levonorgestrel-releasing IUDs and possibly heavier menstrual bleeding and more severe cramping with thecopper T380 IUD).
Counsel patients to return for evaluation after IUD placement if they have complications (eg, pain, heavy bleeding, abnormal vaginal discharge, fever, expulsion).
If the strings are not visible during the pelvic examination, attempt to sweep the strings out with a cytobrush or gently probe the uterine cavity using alligator forceps, IUD hook, uterine sound, or biopsy instrument (unless pregnancy is suspected), and if needed, perform ultrasound and/or abdominal radiograph to check for location.
Drugs Mentioned In This Article
