In the US, 12% of women who use contraception use intrauterine devices (IUDs); IUDs are becoming more popular because of their advantages over oral contraceptives:
IUDs are highly effective.
IUDs have minimal systemic effects.
Only one contraceptive decision every 3, 5, or 10 years is required.
In the US, 5 IUDs are currently available. There are 4 types of levonorgestrel-releasing IUDs:
A 13.5-mg IUD is effective for 3 years and has a 3-year cumulative pregnancy rate of 0.9%.
A 19.5-mg IUD is effective for 5 years and has a cumulative 5- year pregnancy rate of 1.5%.
Two IUDs contain 52 mg, are effective for ≥ 5 years, and have a 5-year pregnancy rate of 0.7 to 0.9%.
The efficacy of the 52-mg IUD for 8 years of use is being evaluated.
The 5th IUD is a copper-bearing T380A IUD. It is effective for 10 years; it has a cumulative 12-year pregnancy rate of < 2% (see table Comparison of Intrauterine Devices Comparison of Intrauterine Devices In the US, 12% of women who use contraception use intrauterine devices (IUDs); IUDs are becoming more popular because of their advantages over oral contraceptives: IUDs are highly effective... read more ).
Insertion of the IUD
Clinicians do not need to do a Papanicolaou (Pap) test before they insert an IUD unless they suspect cervical lesions are present. Then, a Pap test or cervical biopsy should be done. Also, clinicians do not need to wait for results of sexually transmitted disease (STD) testing (for gonorrhea and chlamydial infection) before they insert an IUD. However, STD testing should be done just before the IUD is inserted, and if results are positive, patients should be treated with appropriate antibiotics; the IUD is left in place. If purulent discharge is observed at the time of IUD insertion, the IUD is not inserted, STD testing is done, and empiric treatment with antibiotics is started before test results are available.
When IUDs are inserted, sterile technique is used as much as possible. Bimanual examination should be done 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 or an endometrial aspirator (used for biopsy) is often used to measure the length of the uterine cavity before IUD insertion. The package insert for the IUD should be reviewed before insertion because the 5 types of IUDs are inserted differently.
Routine follow-up 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) or are dissatisfied with the method (1 Insertion reference In the US, 12% of women who use contraception use intrauterine devices (IUDs); IUDs are becoming more popular because of their advantages over oral contraceptives: IUDs are highly effective... read more ).
An IUD may be inserted at any time during the menstrual cycle if a woman has not had unprotected intercourse during the past month.
An IUD may be inserted immediately after an induced or a spontaneous abortion during the 1st or 2nd trimester and immediately after delivery of the placenta in a cesarean or vaginal delivery.
Insertion reference
1. 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.
Contraindications
Most women can use an IUD. Contraindications include the following:
Current pelvic infection, usually pelvic inflammatory disease Pelvic Inflammatory Disease (PID) Pelvic inflammatory disease (PID) is a polymicrobial infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscess may occur. PID may be sexually transmitted... read more (PID), mucopurulent cervicitis Cervicitis Cervicitis is infectious or noninfectious inflammation of the cervix. Findings may include vaginal discharge, vaginal bleeding, and cervical erythema and friability. Women are tested for infectious... read more
with a suspected STD, pelvic tuberculosis Genitourinary TB Tuberculosis outside the lung usually results from hematogenous dissemination. Sometimes infection directly extends from an adjacent organ. Symptoms vary by site but generally include fever... read more 
, septic abortion Septic Abortion Septic abortion is serious uterine infection during or shortly before or after an abortion. Septic abortions usually result from induced abortions done by untrained practitioners using nonsterile... read more , or puerperal endometritis Puerperal Endometritis Puerperal endometritis is uterine infection, typically caused by bacteria ascending from the lower genital or gastrointestinal tract. Symptoms are uterine tenderness, abdominal or pelvic pain... read more or sepsis Sepsis and Septic Shock Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. In septic shock, there is critical reduction in tissue perfusion; acute failure... read more within the past 3 monthsAnatomic abnormalities that distort the uterine cavity
Gestational trophoblastic disease Gestational Trophoblastic Disease Gestational trophoblastic disease is proliferation of trophoblastic tissue in pregnant or recently pregnant women. Manifestations may include excessive uterine enlargement, vomiting, vaginal... read more
with persistently elevated serum beta–human chorionic gonadotropin (beta-hCG) levels (a relative contraindication because supporting data are lacking)Known cervical cancer Cervical Cancer Cervical cancer is usually a squamous cell carcinoma caused by human papillomavirus infection; less often, it is an adenocarcinoma. Cervical neoplasia is asymptomatic; the first symptom of early... read more
or endometrial cancer Endometrial Cancer Endometrial cancer is usually endometrioid adenocarcinoma. Typically, postmenopausal vaginal bleeding occurs. Diagnosis is by biopsy. Staging is surgical. Treatment requires hysterectomy, bilateral... read more Pregnancy
For levonorgestrel-releasing IUDs, breast cancer Breast Cancer Breast cancer most often involves glandular breast cells in the ducts or lobules. Most patients present with an asymptomatic mass discovered during examination or screening mammography. Diagnosis... read more
or allergy to levonorgestrel
Conditions that do not contraindicate IUDs include the following:
Religious beliefs that prohibit abortion because IUDs are not abortifacients (however, a copper IUD used for emergency contraception may prevent implantation of the blastocyst)
A history of PID, STDs, or ectopic pregnancy
Contraindications to contraceptives that contain estrogen (eg, history of venous thromboembolism, smoking > 15 cigarettes/day in women > 35, migraine with aura, migraine of any type in women > 35)
Breastfeeding
Adolescence
Adverse effects
Vaginal bleeding stops completely within 1 year in 6% of women using the 3-year IUD and in 20% of women using a 5-year IUD. A copper-bearing T380A IUD 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.
Potential benefits
If a woman has had unprotected intercourse within the past 7 days, a copper-bearing T380 IUD may be inserted as emergency contraception. The copper-bearing IUD may be left in place for long-term contraception if the woman desires. The resumption of menses plus a negative pregnancy test reliably excludes pregnancy; a pregnancy test should be done 2 to 3 weeks after insertion to be sure that an unintended pregnancy has not occurred before insertion.
IUDs do not increase and may decrease the risk of uterine cancer.
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. Perforation 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 ≥ 1 of the following:
Use a cytobrush to attempt to sweep the strings out of the uterus
Gently probe the uterine cavity with a sound or biopsy instrument (unless pregnancy is suspected)
Do ultrasonography
If the IUD is not seen, an abdominal x-ray is taken to exclude an intraperitoneal location. Intraperitoneal IUDs may cause intestinal adhesions. IUDs that have perforated the uterus are removed via laparoscopy.
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.
The incidence of ectopic pregnancy Ectopic Pregnancy In ectopic pregnancy, implantation occurs in a site other than the endometrial lining of the uterine cavity—ie, in the fallopian tube, uterine cornua, cervix, ovary, or abdominal or pelvic cavity... read more 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.
Key Points
IUDs are highly effective, have minimal systemic effects, and involve only one contraceptive decision every 3, 5, or 10 years depending on the IUD chosen.
Types include levonorgestrel-releasing IUDs (effective for 3 years or 5 years, depending on the type) and a copper-bearing IUD (effective for 10 years, with a 12-year pregnancy rate of < 2%).
A Pap test is not required before IUD insertion unless clinicians suspect cervical lesions are present.
Inform women that both types of IUDs can affect menstrual bleeding (amenorrhea within 1 year in 6% of women using the 3-year IUD and in 20% of those using a 5-year IUD and possibly heavier menstrual bleeding and more severe cramping in women using the copper-bearing T380 IUD).
Counsel patients to return for evaluation after IUD placement if they have complications (eg, pain, heavy bleeding, abnormal vaginal discharge or fever).
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 a uterine sound or biopsy instrument (unless pregnancy is suspected), and if needed, do ultrasonography or take an abdominal x-ray to check for an intraperitoneal location.
