Intrauterine Devices: An Update



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Three intrauterine devices (IUDs) are available in the United States: the copper T 380A and two levonorgestrel-releasing IUDs, one that releases 20 mcg of levonorgestrel per 24 hours, and one that releases 14 mcg per 24 hours. All are safe and effective methods of contraception that work predominantly by prefertilization mechanisms. The copper T 380A IUD may be placed in nonpregnant women at any time in the menstrual cycle. The prescribing information for the 20- and 14-mcg levonorgestrel-releasing IUDs advises that insertion occur during the first seven days of menses. Insertion immediately after vaginal or cesarean delivery may be considered with the copper T 380A and the 20-mcg levonorgestrel-releasing IUDs; however, expulsion rates are higher than with delayed postpartum insertion. The prescribing information for both levonorgestrel-releasing IUDs advises a waiting period of six weeks postpartum or following second-trimester pregnancy loss. Current guidelines indicate that IUDs are acceptable for use in nulliparous women, in adolescents, and in women who are breastfeeding. They may also be used in women who have a history of sexually transmitted infection, although screening is recommended. IUDs should not be inserted for at least three months after resolution of a sexually transmitted infection. Neither antibiotic prophylaxis nor misoprostol use before IUD insertion is beneficial. If pregnancy occurs, the IUD should be removed if feasible. Possible side effects of levonorgestrel-releasing IUDs include headaches, nausea, hair loss, breast tenderness, depression, decreased libido, ovarian cysts, oligomenorrhea, and amenorrhea. The main side effect of the copper T 380A IUD is increased menstrual bleeding, which may continue even with long-term use.

The intrauterine device (IUD) is a safe and highly effective means of contraception. Three intrauterine devices are available in the United States, the copper T 380A (Paragard) and two levonorgestrel-releasing IUDs (LNG-IUDs), one that releases 20 mcg of levonorgestrel per 24 hours (Mirena) and a new low-dose device that releases 14 mcg per 24 hours (Skyla).14 Failure rates within the first year after insertion are 0.6% to 0.8% for the copper T 380A IUD, 0.2% for the 20-mcg LNG-IUD, and 0.9% for the 14-mcg LNG-IUD.4,5 In contrast to that of many forms of contraception, the effectiveness of IUDs is not heavily dependent on user compliance.5

There is a normal return to fertility after discontinuation of the copper T 380A IUD or the 20-mcg LNG-IUD, with a pregnancy rate of 82% one year after device removal and 89% two years after device removal.6 Clinical trials for the 14-mcg LNG-IUD have found that 77% of women attempting to become pregnant within the first year after IUD removal are successful.4 Even with increasing costs of IUDs, they are one of the most cost-effective forms of long-term contraception.7,8 When discussing the mechanism of IUDs as part of the informed consent process, patients may be told that although prefertilization and postfertilization mechanisms may both contribute to the contraceptive effectiveness of IUDs, research suggests that the majority of effects occur prefertilization.1,9,10

This article focuses on updated considerations and guidelines for recommending and prescribing IUDs. A previous article in American Family Physician provides an overview of insertion and removal techniques.11

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Nulliparous women and adolescents can be offered an IUD, although the 20-mcg per 24 hours levonorgestrel-releasing IUD (Mirena) is not approved by the U.S. Food and Drug Administration for use in nulliparous women.

C

1, 3, 4, 26

Women who are at high risk of STIs but have no active signs or symptoms of genital tract STI should be tested for STIs at the time of IUD insertion. Insertion of the IUD may occur on the same day as STI testing, without waiting for test results. If results are subsequently found to be positive, treatment can be administered at that time and the IUD left in place.

C

1, 2225

For women with a known STI that causes cervical infection, it is recommended that IUD insertion be delayed for at least three months after resolution of the infection.

C

1

Prophylactic antibiotics should not routinely be administered before IUD insertion. Antibiotic prophylaxis does not have a major effect on reducing the risk of pelvic infection, and does not alter the need for IUD removal in the months after insertion.

B

1, 30, 31

Misoprostol (Cytotec) should not be administered before IUD insertion. Although an earlier study showed easier insertion with misoprostol, subsequent studies showed no benefit and increased side effects.

B

3235

If a woman with an IUD becomes pregnant, the IUD should be removed.

C

1, 3, 4


IUD = intrauterine device; STI = sexually transmitted infection.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality

The Authors

JULIA HARDEMAN, MD, is an assistant professor in the Department of Family and Community Medicine at the University of Arizona in Tucson.

BARRY D. WEISS, MD, is a professor in the Department of Family and Community Medicine at the University of Arizona.

Address correspondence to Julia Hardeman, MD, University of Arizona, 1450 N. Cherry, Tucson, AZ 85719 (e-mail: julia.hardeman@uahealth.com). Reprints are not available from the authors.

EDITOR'S NOTE: Barry Weiss, MD, is medical editor of FP Essentials and is an associate medical editor for American Family Physician.

 

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