Intrauterine Devices: An Update
FREE PREVIEW Log in or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.
FREE PREVIEW Subscribe or buy this issue. AAFP members and paid subscribers get free access to all articles.
Am Fam Physician. 2014 Mar 15;89(6):445-450.
Patient information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/prevention-wellness/sex-birth-control/birth-control/intrauterine-device-iud.html.
Related editorial: Optimal Use of IUDs: Why Aren't We There Yet?
Author disclosure: No relevant financial affiliations.
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).1–4 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.
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.
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.
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.
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.
If a woman with an IUD becomes pregnant, the IUD should be removed.
IUD = intrauterine device; STI = sexually transmitted infection.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality
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: firstname.lastname@example.org). 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.
1. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 121: Long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol. 2011;118(1):184–196.
2. Paragard T 380 A. Intrauterine copper contraceptive [package insert]. Sellersville, Pa.; 2013. http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/018680s066lbl.pdf. Accessed June 10, 2013.
3. U.S. Food and Drug Administration. Mirena (levonorgestrel-releasing intrauterine system) July 2008. Safety labeling changes approved by FDA Center for Drug Evaluation and Research (CDER). http://www.fda.gov/safety/medwatch/safetyinformation/safety-relateddruglabelingchanges/ucm121936.htm. Accessed June 9, 2012.
4. Skyla (levonorgestrel-releasing intrauterine system) [package insert]. Wayne, N.J.: Bayer HealthCare Pharmaceuticals, Inc.; 2013. http://labeling.bayerhealthcare.com/html/products/pi/Skyla_PI.pdf. Accessed June 10, 2013.
5. Trussell J. Contraceptive failure in the United States. Contraception. 2011;83(5):397–404.
6. Sivin I, Stern J, Diaz S, et al. Rates and outcomes of planned pregnancy after use of Norplant capsules, Norplant II rods, or levonorgestrel-releasing or copper TCu 380Ag intrauterine contraceptive devices. Am J Obstet Gynecol. 1992;166(4):1208–1213.
7. Trussell J, Lalla AM, Doan QV, Reyes E, Pinto L, Gricar J. Cost effectiveness of contraceptives in the United States [published correction appears in Contraception. 2009;80(2):229–230]. Contraception. 2009;79(1):5–14.
8. Trussell J. Update on and correction to the cost effectiveness of contraceptives in the United States. Contraception. 2012;85(2):218.
9. Stanford JB, Mikolajczyk RT. Mechanisms of action of intrauterine devices: update and estimation of postfertilization effects. Am J Obstet Gynecol. 2002;187(6):1699–1708.
10. Alvarez F, Brache V, Fernandez E, et al. New insights on the mode of action of intrauterine contraceptive devices in women. Fertil Steril. 1988;49(5):768–773.
11. Johnson BA. Insertion and removal of intrauterine devices. Am Fam Physician. 2005;71(1):95–102.
12. Grimes DA, Lopez LM, Schulz KF, Van Vliet HA, Stanwood NL. Immediate post-partum insertion of intrauterine devices. Cochrane Database Sys Rev. 2010;(5)CD003036.
13. Chen BA, Reeves MF, Hayes JL, Hohmann HL, Perriera LK, Creinin MD. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2010;116(5):1079–1087.
14. Celen S, Möröy P, Sucak A, Aktulay A, Danişman N. Clinical outcomes of early postplacental insertion of intrauterine contraceptive devices. Contraception. 2004;69(4):279–282.
15. Çelen S, Şucak A, Yıldız Y, Danişman N. Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section. Contraception. 2011;84(3):240–243.
16. International Medical Advisory Panel. IMAP statement on intrauterine devices. IPPF Med Bull. 2003;37(2):1–4.
17. Tyler CP, Whiteman MK, Zapata LB, Curtis KM, Hillis SD, Marchbanks PA. Health care provider attitudes and practices related to intrauterine devices for nulliparous women. Obstet Gynecol. 2012;119(4):762–771.
18. Hubacher D. Copper intrauterine device use by nulliparous women: review of side effects. Contraception. 2007;75(6 suppl):S8–S11.
19. Paterson H, Ashton J, Harrison-Woolrych M. A nationwide cohort study of the use of the levonorgestrel intrauterine device in New Zealand adolescents. Contraception. 2009;79(6):433–438.
20. Veldhuis HM, Vos AG, Lagro-Janssen AL. Complications of the intrauterine device in nulliparous and parous women. Eur J Gen Pract. 2004;10(3):82–87.
21. Suhonen S, Haukkamaa M, Jakobsson T, Rauramo I. Clinical performance of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: a comparative study. Contraception. 2004;69(5):407–412.
22. Centers for Disease Control and Prevention. U.S. Medical eligibility criteria for contraceptive use, 2010. MMWR Recomm Rep. 2010;59(RR-4):1–86.
23. Campbell SJ, Cropsey KL, Matthews CA. Intrauterine device use in a high-risk population: experience from an urban university clinic. Am J Obstet Gynecol. 2007;197(2):193.e1–193.e6.
24. Centers for Disease Control and Prevention. 2010 STD treatment guidelines. http://www.cdc.gov/std/treatment. Accessed June 6, 2012.
25. Mohllajee AP, Curtis KM, Peterson HB. Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review. Contraception. 2006;73(2):145–153.
26. American College of Obstetricians and Gynecologists. ACOG committee opinion No. 539, October 2012. Adolescents and long-acting reversible contraception: implants and intrauterine devices. http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Adolescent_Health_Care/Adolescents_and_Long-Acting_Reversible_Contraception. Accessed December 11, 2013.
27. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366(21):1998–2007.
28. Shaamash AH, Sayed GH, Hussien MM, Shaaban MM. A comparative study of the levonorgestrel-releasing intrauterine system Mirena versus the Copper T380A intrauterine device during lactation: breast-feeding performance, infant growth and infant development. Contraception. 2005;72(5):346–351.
29. American Academy of Family Physicians. Breastfeeding, family physicians supporting (position paper). http://www.aafp.org/about/policies/all/breastfeeding-support.html. Accessed June 6, 2012.
30. Grimes DA, Lopez LM, Schulz KF. Antibiotic prophylaxis for intrauterine contraceptive device insertion. Cochrane Database Syst Rev. March 28, 2012. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001327/full. Accessed October 18, 2013.
31. Walsh T, Grimes D, Frezieres R, et al.; IUD Study Group. Randomised controlled trial of prophylactic antibiotics before insertion of intrauterine devices. Lancet. 1998;351(9108):1005–1008.
32. Sääv I, Aronsson A, Marions L, Stephansson O, Gemzell-Danielsson K. Cervical priming with sublingual misoprostol prior to insertion of an intrauterine device in nulliparous women: a randomized controlled trial. Hum Reprod. 2007;22(10):2647–2652.
33. Dijkhuizen K, Dekkers OM, Holleboom CA, et al. Vaginal misoprostol prior to insertion of an intrauterine device: an RCT. Hum Reprod. 2011;26(2):323–329.
34. Edelman AB, Schaefer E, Olson A, et al. Effects of prophylactic misoprostol administration prior to intrauterine device insertion in nulliparous women. Contraception. 2011;84(3):234–239.
35. Espey E, Singh RH, Leeman L, Ogburn T, Fowler K, Greene H. Misoprostol for intrauterine device insertion in nulliparous women: a randomized controlled trial [published ahead of print November 8, 2013]. Am J Obstet Gynecol. http://www.sciencedirect.com/science/article/pii/S0002937813020176. Accessed December 4, 2013.
36. Xiong X, Buekens P, Wollast E. IUD use and the risk of ectopic pregnancy: meta-analysis of case-control studies. Contraception. 1995;52(1):23–34.
37. Inal MM, Ertopçu K, Ozelmas I. The evaluation of 318 intrauterine pregnancy cases with an intrauterine device. Eur J Contracept Reprod Health Care. 2005:10(4):266–271.
38. Paterson H, Clifton J, Miller D, Ashton J, Harrison-Woolrych M. Hair loss with use of the levonorgestrel intrauterine device. Contraception. 2007;76(4):306–309.
39. Sivin I, Stern J, Diaz J, et al. Two years of intrauterine contraception with levonorgestrel and with copper: a randomized comparison of the TCu 380Ag and levonorgestrel 20 mcg/day devices. Contraception. 1987;35(3):245–255.
40. Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception. 1994;49(1):56–72.
41. Sivin I, Stern J, Coutinho E, et al. Prolonged intrauterine contraception: a seven-year randomized study of the levonorgestrel 20 mcg/day (LNg 20) and the Copper T380 Ag IUDS. Contraception. 1991;44(5):473–480.
42. Varma R, Sinha D, Gupta JK. Non-contraceptive uses of levonorgestrel-releasing hormone system (LNG-IUS)—a systematic enquiry and overview. Eur J Obstet Gynecol Reprod Biol. 2006;125(1):9–28.
43. Kaunitz AM, Meredith S, Inki P, Kubba A, Sanchez-Ramos L. Levonorg-estrel-releasing intrauterine system and endometrial ablation in heavy menstrual bleeding: a systematic review and meta-analysis. Obstet Gynecol. 2009;113(5):1104–1116.
44. Rauramo I, Elo I, Istre O. Long-term treatment of menorrhagia with levonorgestrel intrauterine system versus endometrial resection. Obstet Gynecol. 2004;104(6):1314–1321.
45. Hubacher D, Chen PL, Park S. Side effects from the copper IUD: do they decrease over time? Contraception. 2009;79(5):356–362.
46. Luukkainen T. Levonorgestrel-releasing intrauterine device. Ann N Y Acad Sci. 1991;626:43–49.
Copyright © 2014 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact email@example.com for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions