Intrauterine Device

Aka: Intrauterine Device, IUD, Paragard, Copper T-380A IUD, Levonorgestrel IUD, Progestasert, Mirena, Skyla, Liletta, Kyleena, Quick Start Algorithm for Intrauterine Device

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II. Contraindications: Absolute

  1. Undiagnosed Abnormal Uterine Bleeding
  2. Uterine abnormality that distorts endometrial cavity
  3. Current intrauterine infection
  4. Unresolved abnormal Pap Smear
  5. Current endometrial or Cervical Cancer
  6. Findings suggestive of trophoblastic disease
  7. Wilson's Disease or Copper allergy (Copper-T IUD)
  8. Uterine or pelvic infection within last 3 months
    1. Sexually Transmitted Infection
    2. Chorioamnionitis
    3. Endometritis

III. Contraindications: Historical that are no longer contraindications (restrictions loosened by FDA in 2010)

  1. Nulliparity
    1. More difficult to place if no prior pregnancy
    2. Must be able to sound Uterus to 6 cm or greater
    3. Expulsion rates and longterm device tolerance and continuation rates are similar to women previously pregnant
      1. Paterson (2009) Contraception 79(6): 433-8 [PubMed]
      2. Veldhuis (2004) Eur J Gen Pract 10(3): 82-7 [PubMed]
  2. Adolescents
    1. USMEC recommends IUD for Contraception in this cohort due to high efficacy that outweighs potential risks
    2. Risk of PID or future Infertility does not appear to be increased
  3. Sexually Transmitted Disease history or multiple sexual partners
    1. PID may now be lower risk with modern IUDs
      1. Campbell (2007) Am J Obstet Gynecol 197(2): 193 [PubMed]
    2. Screen women for STIs per CDC guidelines
    3. Delay IUD Placement for 3 months following Sexually Transmitted Infection treatment
  4. Ectopic Pregnancy
    1. Ectopic risk is not increased with IUD use
    2. However, if breakthrough pregnancy occurs, it is much more likely to occur as an Ectopic Pregnancy

IV. Adverse Effects

  1. First 3 months after IUD insertion
    1. Perception of vaginal infection
    2. Changes in menstrual flow (30%)
      1. Dysmenorrhea or prolonged flow
      2. Levonorgestrel IUDs (e.g. Mirena, Liletta, Kyleena, Skyla) are associated with prolonged bleeding in first 3 months
        1. Bleeding decreases in the first 12 months in 90% of patients
        2. Up to 20% will have Amenorrhea within 12 months
      3. Results in 10-15% discontinuation in first year
      4. Reduced with NSAIDs taken 2-3 days with flow onset
  2. Pelvic Inflammatory Disease
    1. Risk increases in first 20 days after insertion
    2. Risk is <1 per 1000 insertions
    3. Use of prophylactic Antibiotics not warranted (not effective, do not alter course)
  3. Expulsion in first 2 months
    1. Increased expulsion rates if placed immediately after delivery, Cesarean Section or pregnancy loss
    2. Days 1-5: 5% expulsion rate
    3. Days 6-12: 3% expulsion rate
    4. Days >12: 2% expulsion rate
  4. Progestin IUD (e.g. Mirena, Skyla) related adverse effects
    1. Headache
    2. Hair Loss
    3. Acne Vulgaris
    4. Major Depression
    5. Breast tenderness
    6. Vaginitis
    7. Pelvic Pain
  5. Tubal Infertility
    1. Cohort study (n=4185)
      1. Primary (Nulliparous) Tubal Infertility Risk
        1. Dalkon Shield Relative Risk: 3.3
        2. Lippes Loop or Saf-T-Coil Relative Risk: 2.9
        3. Copper-T IUD Relative Risk: 1.6
        4. Having only one sexual partner: No increased risk
      2. Secondary (Multiparous) Tubal Infertility Risk
        1. Copper-T IUD Relative Risk: 1.5 (not significant)
        2. Non-Copper IUD Relative Risk: 2.8
    2. References
      1. Cramer (1985) N Engl J Med, 312(15): 941-7 [PubMed]

V. Safety

  1. IUDs are compatible with Lactation
  2. IUD insertion is safe immediately after placental delivery (and recommended as excellent postpartum Contraception)
    1. Lopez (2015) Cochrane Database Syst Rev (6): CD003036 +PMID:26115018 [PubMed]

VI. Mechanism: Levonorgestrel IUDs (e.g. Mirena, Liletta, Kyleena, Skyla)

  1. Primarily spermicidal activity
    1. Thins endometrium and thickens Cervical Mucus
    2. Inhibits sperm movement and function
    3. May also suppress Ovulation
  2. Reduces Menstrual Bleeding
    1. Consider for Dysfunctional Uterine Bleeding
    2. Irregular bleeding may occur in first 6 months
    3. Amenorrhea at one year of use if common (20%)

VII. Medications: Available in U.S.

  1. Copper T-380A IUD (Paragard): 10 year Copper device (studies support 12 years of Contraception)
    1. First year failure rate: 0.7%
    2. Cumulative ten year failure rate: 2.1%
    3. Reduces Ectopic Pregnancy rate significantly
    4. Barium impregnated
  2. Mirena: 7 year Progesterone (Levonorgestrel) device (previously labelled for 5 years)
    1. First year failure rate: 0.2%
      1. Of pregnancies, 50% will be ectopic
      2. Better efficacy than Copper-T IUD
    2. Polyethylene-barium T-shape 52 mg Levonorgestrel
    3. Releases 20 mcg/day of Levonorgestrel
    4. Conception occurs for 80% within 12 months of removal
  3. Liletta: 6 year Progesterone (Levonorgestrel) device
    1. Releases 19 mcg/day of Levonorgestrel (similar to Mirena)
    2. Released in 2015 and originally approved for 3 years of protection (now 6 years)
  4. Kyleena: 5 year Progesterone (Levonorgestrel) IUD
    1. Releases 17.5 mcg Levonorgestrel per day
  5. Skyla: 3 year Progesterone (Levonorgestrel) device
    1. New in 2014 from Bayer (also makes Mirena)
    2. Releases 14 mcg/day of Levonorgestrel (lower dose than Mirena)
    3. Similar inserter as Mirena
    4. Marketed for Nulliparous patients (but other IUDs are also considered safe in this cohort)
    5. First year failure rate: 0.4 to 0.9%
      1. Less effective than either Mirena or Copper-T IUD
    6. Conception occurs for 77% within 12 months of removal

VIII. Medications: Discontinued

  1. Progestasert: 1 year Progesterone device (discontinued in U.S. in 2001)
    1. First year failure rate: 2%
    2. Ethylene/vinyl acetate T-shape 38 mg Progesterone
    3. Higher rate of ectopic compared with Copper IUD
    4. Less bleeding complications
    5. Progesterone adverse effects may occur

IX. Indications: Prophylactic Antibiotics on insertion

  1. Routine prophylaxis no longer indicated
    1. No difference in outcomes
  2. Prior indications for Antibiotic prophylaxis
    1. History of Bacterial Vaginosis
    2. Difficult insertion
    3. SBE Prophylaxis (not indicated in IUD insertion)

X. Procedure

  1. See IUD Insertion

XI. Management: Quick Start Algorithm for Progestin-Releasing Intrauterine Device

  1. See Quick Start Algorithm for Non-IUD Hormonal Contraception
  2. Step 1: First Day of Last Menstrual Period (LMP)
    1. LMP >7 days ago: Go to Step 2
    2. LMP <7 days ago
      1. Insert Intrauterine Device today (after negative Urine Pregnancy Test)
  3. Step 2: LMP >7 days ago
    1. No unprotected sex since LMP
      1. Insert Intrauterine Device today (after negative Urine Pregnancy Test)
      2. Use backup Contraception for 7 days
    2. Unprotected sex since LMP and Urine Pregnancy Test negative
      1. Go to Step 3
  4. Step 3: Offer Contraception with discussion of pregnancy risk
    1. Informed Consent
      1. Early pregnancy is possible despite negative Pregnancy Test
      2. Pregnancy is complicated by Intrauterine Device Insertion
    2. Patient opts to insert IUD
      1. Offer Emergency Contraception with Plan B (Levonorgestrel) if unprotected sex within last 5 days
      2. Insert Intrauterine Device today (after negative Urine Pregnancy Test)
      3. Use backup Contraception for first 7 days
      4. Repeat Pregnancy Test in 2 weeks (in home or office)
    3. Patient opts to delay start of new Contraception
      1. Go to Step 4
  5. Step 4: Delayed Intrauterine Device Insertion
    1. Offer Emergency Contraception (Levonorgestrel or Ulipristal) if unprotected sex within last 5 days
    2. Offer other Hormonal Contraception (OCP, ring, injection) to be used with Condoms until IUD placed
    3. Return in 2+ weeks for repeat Urine Pregnancy Test and IUD Placement at that time
  6. Resources
    1. Quick Start Algorithm (Reproductive Health Access Project)
      1. https://www.reproductiveaccess.org/wp-content/uploads/2014/12/QuickstartAlgorithm.pdf

XII. Management: Quick Start Algorithm for Copper-T Intrauterine Device

  1. See Quick Start Algorithm for Non-IUD Hormonal Contraception
  2. Background
    1. Protocol is specific for Copper-T Intrauterine Device since it is also used for Emergency Contraception
  3. Step 1: First Day of Last Menstrual Period (LMP)
    1. LMP >7 days ago: Go to Step 2
    2. LMP <7 days ago
      1. Insert Intrauterine Device today (after negative Urine Pregnancy Test)
  4. Step 2: LMP >7 days ago
    1. No unprotected sex since LMP or
      1. Insert Intrauterine Device today (after negative Urine Pregnancy Test)
    2. Unprotected sex within last 5 days and Urine Pregnancy Test negative
      1. Insert Intrauterine Device today (after negative Urine Pregnancy Test)
    3. Unprotected sex more than 5 days ago and Urine Pregnancy Test negative
      1. Go to Step 3
  5. Step 3: Offer Contraception with discussion of pregnancy risk
    1. Informed Consent
      1. Early pregnancy is possible despite negative Pregnancy Test
      2. Pregnancy is complicated by Intrauterine Device Insertion
    2. Patient opts to insert IUD
      1. Insert Intrauterine Device today (after negative Urine Pregnancy Test)
      2. Repeat Pregnancy Test in 2 weeks (in home or office)
    3. Patient opts to delay start of new Contraception
      1. Go to Step 4
  6. Step 4: Delayed Intrauterine Device Insertion
    1. Offer other Hormonal Contraception (OCP, ring, injection) to be used with Condoms until IUD placed
    2. Return in 2+ weeks for repeat Urine Pregnancy Test and IUD Placement at that time
  7. Resources
    1. Quick Start Algorithm (Reproductive Health Access Project)
      1. https://www.reproductiveaccess.org/wp-content/uploads/2014/12/QuickstartAlgorithm.pdf

XIII. Protocol: Switching between contraceptives

  1. Switch to Mirena IUD from pill, patch, ring
    1. Use pill, patch, ring, or barrier protection for the first 7 days after Mirena insertion
    2. Switch may be made before the scheduled end of use of the prior contraceptive
  2. Switch to Mirena IUD from Copper-T IUD
    1. Use barrier protection for first 7 days
  3. Switch to Depo Provera from Copper-T IUD
    1. Give first injection 7 days prior to Copper-T-IUD removal (or use barrier contraceptive for 1 week)
  4. Switch to Nexplanon (Progestin implant) from Copper-T-IUD
    1. Nexplanon should be inserted 4 days prior to Copper-T IUD removal (or use barrier contraceptive for 4 days)
  5. Switch to contraceptive pill, patch or ring from the IUD
    1. Start the new contraceptive 7 days before IUD removal
  6. Switch to Copper IUD from other methods
    1. Insert Copper-T IUD no more than 5 days after stopping other contraceptive
    2. Insert Copper-T IUD no more than 16 weeks after last Depo Provera injection

XIV. Management: Complications

  1. IUD migration
    1. Evaluate for IUD strings on speculum exam (may be obscured by cervical mucous or adhered to Cervix)
    2. IUD can be localized on a single AP Pelvis or pelvic Ultrasound
  2. Sexually Transmitted Infection without signs of Pelvic Inflammatory Disease
    1. IUD may be left in place and STD treated
    2. Remove IUD for Pelvic Inflammatory Disease or other symptomatic Sexually Transmitted Infection
  3. Pregnancy with IUD in place
    1. Transvaginal Ultrasound to exclude Ectopic Pregnancy (critical)
    2. IUD Removal
      1. UltrasoundUterus to confirm IUD in place if strings can not be found
      2. Recommended to reduce pregnancy loss, Placental Abruption, preterm delivery, and low birth weight
      3. However, pregnancy loss occurs in at least 40% of women after IUD removal
      4. Saav (2007) Hum Reprod 22(10): 2647-52 [PubMed]
  4. Abnormal Uterine Bleeding (Levonorgestrel IUD)
    1. See Abnormal Uterine Bleeding Associated with Hormonal Contraception
    2. Bleeding is most common in first 3 to 6 months, and markedly improved by 12 months
    3. Pregnancy Test (bHCG)
    4. Evaluate for malpositioned device
      1. Check IUD string visibility in vagina
      2. Consider Transvaginal Ultrasound if strings cannot be visualized
    5. Lower risk with IUD fundal placement (than with reduced depth of insertion)
      1. Alves (2019) Int J Gynaecol Obstet 147(3): 326-31 [PubMed]
    6. Naproxen
      1. Naproxen 500 mg orally twice daily for 5 days every 4 weeks
      2. Madden (2012) Am J Obstet Gynecol 206(2): 129.e1-e8 [PubMed]
    7. Estradiol
      1. Estradiol 2 mg orally daily for 6 weeks
      2. Oderkerk (2019) Front Womens Health (4):1-3 [PubMed]
    8. References
      1. Schrager (2024) Am Fam Physician 109(2): 161-6 [PubMed]

XV. References

  1. (2001) Med Lett Drugs Ther 43(1096):7-8 [PubMed]
  2. Andersson (1994) Contraception 49:56 [PubMed]
  3. French (2000) Br J Obstet Gynaecol 107:1281 [PubMed]
  4. Hardeman (2014) Am Fam Physician 89(6): 445-50 [PubMed]
  5. Herndon (2004) Am Fam Physician 69(4):853-60 [PubMed]
  6. Lesnewski (2021) Am Fam Physician 103(5):291-300 [PubMed]
  7. Paradise (2022) Am Fam Physician 106(3):251-9 [PubMed]

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Related Studies

Ontology: Intrauterine Devices (C0021900)

Definition (UMD) Contraceptive devices placed high in the uterine fundus with a string extending from the device through the cervical os into the vagina.
Definition (MSH) Contraceptive devices placed high in the uterine fundus.
Definition (NCI_NCI-GLOSS) A small, plastic T-shaped device that is placed inside the uterus (the small, hollow, pear-shaped organ in a woman's pelvis in which a fetus develops) to prevent pregnancy. Intrauterine devices prevent sperm from fertilizing an egg, and prevent fertilized eggs from implanting in the uterus. The use of intrauterine devices is also being studied in the prevention and treatment of endometrial cancer and other conditions.
Definition (NCI_NICHD) An Intra Uterine Contraceptive Device is a form of birth control that involves an object placed in the uterus to prevent fertilization of the egg by sperm. An IUCD can be a coil, loop, triangle, or T in shape; its material can be impregnated with a pharmaceutical agent.
Definition (NCI) A device usually made of plastic or metal, inserted into the uterus to prevent conception. IUCD can be a coil, loop, triangle, or T in shape; its material can be impregnated with a pharmaceutical agent. The primary action of all IUCDs is the induction of a foreign-body reaction within the endometrium. This sterile inflammatory process is toxic to gametes, primarily spermatozoa, and effectively prevents viable sperm from passing into the fallopian tubes. The copper-bearing device has an independent toxic effect on spermatozoa. The progestin-releasing devices produce changes in endometrial architecture and function that reduce the potential for implantation of a fertilized egg. The progestin effect on the cervical mucus also reduces the penetrability of sperm.
Concepts Medical Device (T074)
MSH D007434
SnomedCT 385253002, 78765007, 268460000, 135622008
LNC LA6527-1
English Contraceptive Device, Intrauterine, Contraceptive Devices, Intrauterine, Device, Intrauterine, Device, Intrauterine Contraceptive, Devices, Intrauterine, Devices, Intrauterine Contraceptive, Intrauterine Contraceptive Devices, IUCD - I/uter contracep device, IUCD - Intrauterine contraceptive device, Intra-uterine contraceptive device, IUCD, Intra-Uterine Device (IUD), Intrauterine Contraceptive Device, Intrauterine Device, IUDs, Intrauterine contracep device, Intrauterine device (product), Intra-uterine device, intrauterine devices (IUD) (medication), intrauterine devices (IUD), Intrauterine contraceptive device (physical object), Intrauterine contraceptive device, Contraceptive IUD, IUD, Contraceptive, IUDs, Contraceptive, Contraceptive IUDs, devices intrauterine, intrauterine devices, device intrauterine, intra uterine device, devices intra uterine, iucd, intra-uterine device, iuds, Intrauterine device (physical object), IUD - Intrauterine device, Intrauterine device (qualifier value), Intra Uterine Device, intrauterine device, IUD, Intrauterine device, INTRAUTERINE DEVICE, Intrauterine Devices
Italian Dispositivo contraccettivo intrauterino, Dispositivo intrauterino, Dispositivo anticoncezionale intrauterino, Dispositivi contraccettivi intrauterini, IUD, IUDs, Dispositivi intrauterini
Dutch IUCD, intra-uterien contraceptief hulpmiddel, Contraceptiva, intrauterine, Contraceptivum, intrauterien, IUD, Intra-uterine devices, Intrauterien contraceptivum
French DIU, DCIU, Appareils contraceptifs intra-utérins, Appareils intra-utérins, Dispositifs intra-utérins, Dispositifs contraceptifs intra-utérins, Stérilets, DIU (Dispositif Intra-Utérin), Dispositif intra-utérin
German IUD, IUCD, Intrauterinpessar, Intrauterinpessare, Kontrazeptive intrauterine Vorrichtungen
Portuguese DIU, Dispositivos Intrauterinos, Anticoncepcionais Intrauterinos, Diu, Dispositivo contraceptivo intra-uterino
Swedish Spiraler
Japanese ｼｷｭｳﾅｲﾋﾆﾝｸﾞ, 避妊具-子宮内, 子宮内避妊具, 子宮内ペッサリー, ペッサリー-子宮内, 避妊リング, ペッサリー-子宮頸管内, 子宮内器具, 子宮頸管内ペッサリー
Czech nitroděložní tělíska, nitroděložní antikoncepční prostředky, IUD, Nitroděložní tělísko
Spanish dispositivo intrauterino (producto), Anticonceptivos Intrauterinos, dispositivo anticonceptivo intrauterino (objeto físico), dispositivo anticonceptivo intrauterino, Intrauterine contraceptive device, dispositivo intrauterino (calificador), DIU, dispositivo intrauterino, dispositivo intrauterino anticonceptivo, dispositivo intrauterino (objeto físico), Contraceptivos Intrauterinos, Dispositivo anticonceptivo intrauterino, Dispositivos Intrauterinos
Finnish Kohdunsisäiset ehkäisimet
Russian VNUTRIMATOCHNYE USTROISTVA, KONTRATSEPTIVNYE SREDSTVA VNUTRIMATOCHNYE, PESSARII VNUTRIMATOCHNYE, PESSARII VNUTRISHEECHNYE, ВНУТРИМАТОЧНЫЕ УСТРОЙСТВА, КОНТРАЦЕПТИВНЫЕ СРЕДСТВА ВНУТРИМАТОЧНЫЕ, ПЕССАРИИ ВНУТРИМАТОЧНЫЕ, ПЕССАРИИ ВНУТРИШЕЕЧНЫЕ
Croatian KONTRACEPCIJSKA POMAGALA, INTRAUTERINA
Polish Środki antykoncepcyjne wewnątrzmaciczne
Hungarian Intrauterin fogamzásgátló eszköz, Méhen belüli fogamzásgátló eszköz
Norwegian Intrauterine innlegg, Livmorinnlegg, Spiraler, Intrauterine prevensjonsmidler, Intrauterine antikonseptiva
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Mirena (C0591811)

Concepts Pharmacologic Substance (T121) , Steroid (T110)
MSH D016912
Italian Levonorgestrel, Berlex, Levonorgestrel, Schering, Mirena
English mirena, Berlex Brand of Levonorgestrel, Levonorgestrel Berlex Brand, Schering Brand 1 of Levonorgestrel, Mirena
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Progestasert (C1515395)

Concepts Steroid (T110) , Pharmacologic Substance (T121) , Hormone (T125)
English Progestasert
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Skyla (C3531219)

Concepts Pharmacologic Substance (T121) , Hormone (T125)
English Skyla
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Contraception Management

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