In the United States, 12% of women who use contraception use intrauterine devices (IUDs). IUDs are popular because of their advantages as a contraceptive method, including being highly effective and having minimal side effects. Also, IUDs need to be changed 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.
Levonorgestrel-releasing IUDs include
A 13.5-mg IUD (14 mcg a day) is effective for 3 years and has a 3-year cumulative pregnancy rate of 1.0% (1 References In the United States, 12% of women who use contraception use intrauterine devices (IUDs). IUDs are popular because of their advantages as a contraceptive method, including being highly effective... read more ).
A 19.5-mg IUD (17.5 mcg a day) is effective for 5 years and has 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) are effective for 8 years with a cumulative 8-year pregnancy rate of 0.5 to 1.1% (2 References In the United States, 12% of women who use contraception use intrauterine devices (IUDs). IUDs are popular because of their advantages as a contraceptive method, including being highly effective... read more , 3 References In the United States, 12% of women who use contraception use intrauterine devices (IUDs). IUDs are popular because of their advantages as a contraceptive method, including being highly effective... read more ).
The intrauterine copper contraceptive is effective for 10 years; it has a cumulative 12-year pregnancy rate of < 2% (4 References In the United States, 12% of women who use contraception use intrauterine devices (IUDs). IUDs are popular because of their advantages as a contraceptive method, including being highly effective... read more ). See table .
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 Overview of Sexually Transmitted Infections Sexually transmitted infection (STI) refers to infection with a pathogen that is transmitted through blood, semen, vaginal fluids, or other body fluids during oral, anal, or genital sex with... read more (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) (5 References In the United States, 12% of women who use contraception use intrauterine devices (IUDs). IUDs are popular because of their advantages as a contraceptive method, including being highly effective... read more ). 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 done; 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 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 may be used to measure the length of the uterine cavity before IUD insertion. Before insertion, a paracervical block may be used to decrease pain during insertion (6 References In the United States, 12% of women who use contraception use intrauterine devices (IUDs). IUDs are popular because of their advantages as a contraceptive method, including being 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.
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 (7 References In the United States, 12% of women who use contraception use intrauterine devices (IUDs). IUDs are popular because of their advantages as a contraceptive method, including being highly effective... read more ).
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.
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 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 caused by sexually... read more (PID), mucopurulent cervicitis Cervicitis Cervicitis is infectious or noninfectious inflammation of the cervix. Findings may include cervical or vaginal discharge and cervical erythema and friability. Diagnosis is with tests for cervical... read more
with a suspected STI, pelvic tuberculosis Genitourinary tuberculosis 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 a spontaneous or an induced abortion. Septic abortion is a gynecologic emergency. Septic abortions usually result... read more , or puerperal endometritis Postpartum Endometritis Postpartum 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 monthsPregnancy
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 squamous cell carcinoma; adenocarcinoma is less common. The cause of most cervical cancers is human papillomavirus (HPV) infection. Cervical neoplasia is often asymptomatic... read more
or endometrial cancer Endometrial Cancer Endometrial cancer is usually endometrioid adenocarcinoma. Typically, it manifests as postmenopausal uterine bleeding. Diagnosis is by biopsy. Staging is surgical. Treatment requires hysterectomy... read more For levonorgestrel-releasing IUDs, breast cancer Breast Cancer Breast cancers are most often epithelial tumors involving 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:
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
The patient's personal beliefs about abortion because IUDs are not abortifacients (however, a copper or 52-mg levonorgestrel-releasing IUD used for emergency contraception may prevent implantation of the blastocyst, possibly terminating a viable pregnancy)
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.
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.
Potential benefits
Levonorgestrel-releasing IUDs are associated with a decreased risk of endometrial cancer and ovarian cancer. Data about whether they increase the risk of breast cancer are conflicting (8 References In the United States, 12% of women who use contraception use intrauterine devices (IUDs). IUDs are popular because of their advantages as a contraceptive method, including being highly effective... read more ).
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 emergency contraception Emergency Contraception Emergency contraception may be used to prevent pregnancy for a short period of time after unprotected sex. Commonly used emergency contraception methods include Insertion of an intrauterine... read more .
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 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
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
Do ultrasonography; alligator forceps may be used under sonographic guidance (9 References In the United States, 12% of women who use contraception use intrauterine devices (IUDs). IUDs are popular because of their advantages as a contraceptive method, including being highly effective... read more )
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.
If Actinomyces-like organisms on a Pap test in women with no symptoms of infection does not require antibiotics nor IUD removal.
The incidence of ectopic pregnancy Ectopic Pregnancy Ectopic pregnancy is the implantation of a pregnancy in a site other than the endometrial lining of the uterine cavity—ie, in the fallopian tube, uterine cornua, cervix, ovary, or abdominal... 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.
References
1. 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
2. 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
3. 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
4. Long-term reversible contraception. Twelve years of experience with the TCu380A and TCu220C. Contraception 56(6):341-352, 1997.
5. 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
6. 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
7. 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
8. Jareid M, Thalabard JC, Aarflot M, et al: Levonorgestrel-releasing intrauterine system use is associated with a decreased risk of ovarian and endometrial cancer, without increased risk of breast cancer: Results from the NOWAC Study. Gynecol Oncol 149 (1), 127–132, 2018, doi.org/10.1016/j.ygyno.2018.02.006
9. 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
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%).
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 copper 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 an IUD hook, uterine sound, or biopsy instrument (unless pregnancy is suspected), and if needed, do ultrasonography or take an abdominal x-ray to check for location.
Drugs Mentioned In This Article
| Drug Name | Select Trade |
|---|---|
levonorgestrel |
AfterPill, EContra EZ, EContra One-Step, Fallback Solo, Kyleena , LILETTA, Mirena, My Choice, My Way, Next Choice, Next Choice One Dose, Norplant, Opcicon One-Step, Plan B, Plan B One-Step , Preventeza, React, Skyla, Take Action |
intrauterine copper contraceptive |
ParaGard T380A |
human chorionic gonadotropin |
Novarel, Ovidrel, Pregnyl |
ibuprofen |
Advil, Advil Children's, Advil Children's Fever, Advil Infants', Advil Junior Strength, Advil Migraine, Caldolor, Children's Ibuprofen, ElixSure IB, Genpril , Ibren , IBU, Midol, Midol Cramps and Body Aches, Motrin, Motrin Children's, Motrin IB, Motrin Infants', Motrin Junior Strength, Motrin Migraine Pain, PediaCare Children's Pain Reliever/Fever Reducer IB, PediaCare Infants' Pain Reliever/Fever Reducer IB, Samson-8 |
