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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