Intrauterine Contraception

Overview

This Guidelines summary of Faculty of Sexual & Reproductive Healthcare (FSRH) guidance provides information and recommendations on intrauterine contraception (IUC). It considers the two categories of IUC available in the UK at the time of publication: copper intrauterine devices (Cu-IUDs) and levonorgestrel intrauterine devices (LNG-IUDs).

The guideline is designed to enable clinicians to support individuals to make informed decisions about choosing and using IUC. It includes guidance on assessing suitability of IUC use for contraception, the risks and benefits of IUC, IUC procedures, complications, and follow-up.

For further information on IUDs and the grading of recommendations, as well as recommendations on cost-effectiveness of IUC, future research, and implementation of the guideline, refer to the full guideline. Also refer to Appendix 2 of the full guideline for an example pathway for postpartum IUC (PPIUC) follow-up.

View the related Guidelines in Practice article: Key Learning Points: Intrauterine Contraception.

What Is Intrauterine Contraception?

• Any 52-mg LNG-IUD inserted at age <45 years can be used for contraception for 6 years
• Any 52-mg LNG-IUD inserted at age ≥45 years can be used for contraception until age 55 years
• Any Cu-IUD with copper surface area ≥300 mm² inserted at age ≥40 years can be used for contraception until menopause. It can be removed 1 year after the final menstrual period if this occurs after age 50 years
• Any 52-mg LNG-IUD can be used for 5 years as endometrial protection as part of hormone-replacement therapy (HRT).

Details of the types of Cu-IUD and LNG-IUD listed in the British National Formulary can be found in Tables 1 and 2 of the full guideline.

Assessing Suitability 

Few medical conditions contraindicate insertion or use of IUC. UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) provides evidence-based recommendations on the use of contraceptive methods in the presence of different medical and social factors, and health professionals should ensure they are familiar with or refer to the most up-to-date version of this publication when assessing an individual’s eligibility to use intrauterine methods (refer to UKMEC [2016] and the full guideline).

Young People, Individuals Who Have Never Been Pregnant and Individuals Who Have Never Been Sexually Active

• IUC can be used by young people, individuals who have never been pregnant and individuals who have never been sexually active.

Transgender and Gender-diverse Individuals Assigned Female at Birth

• The medical indications and contraindications for IUC are the same for transgender and gender-diverse individuals assigned female at birth and cisgender women
• Further information can be found in the FSRH Clinical Effectiveness Unit (CEU) statement on contraceptive choices and sexual health for transgender and non-binary people.

After Pregnancy

• Immediate postpartum IUC (within 48 hours of childbirth) is safe, effective, convenient, and associated with high continuation rates
• When inserted within 48 hours of childbirth, the insertion technique is different to that of standard IUC insertion and clinicians need to be appropriately trained in this technique
• After medical abortion, or medical or expectant management of miscarriage, IUC can be inserted any time after expulsion of the pregnancy, providing there is no clinical suspicion of sepsis and no new risk of pregnancy
• IUC can be inserted immediately after surgical abortion or surgical management of miscarriage or ectopic pregnancy, providing there is no clinical suspicion of sepsis
• If >48 hours have passed since childbirth, insertion should be delayed until 28 days after childbirth (interval insertion). The risks of insertion from 48 hours until 28 days after childbirth generally outweigh the benefits (UKMEC3)
• More detailed information is available in the FSRH guideline on contraception after pregnancy.

For further information and recommendations on IUC after childbirth, abortion, ectopic pregnancy, miscarriage, and gestational trophoblastic disease, refer to the full guideline. 

Perimenopause

• Additional investigations may be indicated prior to or at the same time as IUC insertion in individuals with abnormal uterine bleeding, or if an individual has risk factors for gynaecological disease
• The FSRH supports the use of any 52-mg LNG-IUD for endometrial protection as part of HRT for 5 years
• Further information can be found in the FSRH guideline on contraception for women aged over 40 years.

After Breast Cancer

• There are no contraindications to use of a Cu-IUD for an individual with current or previous breast cancer (UKMEC1).

Individuals With a Raised Body Mass Index

• IUC is a safe, feasible and highly effective contraceptive option for individuals who are overweight or obese
• More detailed information can be found in the FSRH clinical guideline on overweight, obesity, and contraception.

Individuals With Uterine Cavity Distortion

• For individuals with known distortion of the uterine cavity, risks associated with IUC insertion generally outweigh the benefits (UKMEC3)
• The decision to insert an IUC in an individual with uterine cavity distortion should be made on an individualised basis, considering the degree of distortion, uterine cavity size, the accuracy of imaging available, the indication for use and other suitable alternatives, the type of device being inserted, and the potential consequence of complications for that particular individual
• IUC insertion for an individual with uterine cavity distortion due to fibroids or uterine malformation should be undertaken in a specialist setting with access to concurrent ultrasound or hysteroscopy
• The uncertainty around the safety and contraceptive effectiveness of IUC in individuals with uterine cavity distortion should be explained to the individual, with advice on how and when to seek review
• The decision to insert IUC at an interval following endometrial ablation should be made on an individualised basis, considering the indication for IUC insertion, the need for a reliable concurrent endometrial biopsy, and the ultrasound appearance of the endometrium
• If IUC insertion is considered for an individual who has previously undergone endometrial ablation, the procedure should be undertaken in a specialist setting, with ultrasound or hysteroscopic assessment of the cavity to determine suitability.

After Large Loop Excision of the Transformation Zone Procedure

• If an IUC is removed during large loop excision of the transformation zone and not immediately reinserted, alternative contraception should be provided and emergency contraception (EC) considered.

Individuals at Risk of Infection

• Current pelvic inflammatory disease (PID), postpartum or post-abortion sepsis, known gonorrhoea infection, symptomatic chlamydia infection, and purulent cervicitis are all contraindications to IUC insertion (UKMEC4)
• If IUC insertion has to be delayed due to infection, bridging contraception should be offered
• A sexual history should be taken prior to IUC insertion and screening offered to individuals at risk of sexually transmitted infections. Screening can be performed at the time of insertion.

For recommendations specific to Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium, as well as to other infections (and bacterial vaginosis), refer to the full guideline.

Individuals Who Are Immunosuppressed or Taking Immunosuppressants

• The contraceptive effectiveness of Cu-IUD does not appear to be reduced in individuals who are immunosuppressed/on immunosuppressants
• Where an immunosuppressed individual is having an IUC procedure, the use of prophylactic antibiotics should be discussed with the individual’s lead clinician in order to assess the suitability for that individual.

Adrenal Insufficiency

• Individuals with adrenal insufficiency are advised to increase their steroid dose at times when an adrenal crisis may be provoked
• Individuals at risk of an adrenal crisis should ideally have their IUC procedure scheduled for early morning
• Individuals at risk of an adrenal crisis will usually need to increase their steroid dose prior to, and for 24 hours after, IUC insertion.

Ehlers–Danlos Syndrome

• Some types of Ehlers–Danlos syndrome (EDS) are associated with an increased risk of uterine rupture in pregnancy and/or joint hyperlaxity, both of which may be relevant to IUC procedures
• Suitability of IUC and the most appropriate setting for IUC insertion should be discussed with the individual’s EDS specialist
• Clinicians should be guided by the individual with EDS as to their most appropriate/comfortable positioning during IUC insertion.

Individuals With Cardiac Disease

• Antibiotic prophylaxis is not routinely recommended when an individual at increased risk of developing infective endocarditis has an IUC procedure
• Contraception choice for individuals with cardiac disease will often require a multidisciplinary approach and discussion with the individual’s cardiologist is recommended
• For individuals with pre-existing arrhythmia, Eisenmenger physiology, single ventricle (or Fontan) circulation, long QT syndrome, or impaired ventricular function, a vasovagal reaction could pose a serious risk of a significant cardiac event and therefore IUC procedures should be undertaken in a hospital setting
• If an individual with postural orthostatic tachycardia syndrome has a history of postural syncope, advice should be sought from their cardiologist as it may be recommended that insertion should be undertaken in a hospital setting
• IUC insertion for an individual who is anticoagulated should be undertaken by an experienced clinician, with consideration given to the timing of the procedure, as well as ensuring availability of haemostatic agents/equipment
• See the FSRH clinical guideline on contraceptive choices for women with cardiac disease.

Individuals With Inherited Bleeding Disorders

• When an individual with an inherited bleeding disorder requests IUC insertion, clinicians should take advice from the individual’s haematologist as to the appropriateness of the method, where the procedure should be undertaken, and whether any additional precautions are required.

Allergy and Sensitivity

• Use of IUC is contraindicated if there is a known or suspected allergy or hypersensitivity to any of the components of the device.

Wilson’s Disease and Copper Toxicity

• Cu-IUD use is not recommended for individuals with Wilson’s disease.

Health Risks Associated With IUC Use

Breast Cancer

• The available evidence suggests a possible association between current or recent use of hormonal contraception (including LNG-IUDs) and a small increase in risk of breast cancer; absolute risk remains very small.

Ovarian Cysts

• Although incidence of ovarian cysts may be elevated during LNG-IUD use, this does not appear to be clinically significant
• Presence of (or history of) ovarian cysts or polycystic ovary syndrome is not a contraindication to IUC use.

Bone Mineral Density

• The limited evidence available suggests that IUC use has no significant effect on serum oestradiol levels or bone mineral density.

Side Effects Associated With IUC Use

Bleeding Patterns

• Individuals should be informed about the expected changes in bleeding pattern with an IUC.

For information on hormonal side effects, libido, and the effect of IUC use on weight, and further information on the effect of IUC use on bleeding patterns, refer to the full guideline.

IUC Insertion

Discussion

• IUC discussion and assessment is essential to ensure the method and procedure will be safe for the individual and that they have sufficient information to make an informed choice about their contraception options and be able to give informed consent
• The discussion may be done at the time of the procedure, or at a prior appointment, depending on local service pathways and the urgency of the IUC insertion
• The mode of discussion and assessment varies and may be undertaken face-to-face, via telephone or virtual appointment, or by self-assessment and signposting to patient resources.

When Can IUC Be Inserted?

• IUC can be inserted at any time during the menstrual cycle providing that pregnancy can be reasonably excluded (see Box 1 in the full guideline)
• Recommendations for starting IUC can be found in Table 1 (at the end of this section), and recommendations on switching to IUC can be found in Table 16 of the full guideline
• The Cu-IUD can be used for EC if inserted within 5 days of the first episode of UPSI that cycle, or within 5 days of the earliest expected date of ovulation. Further information regarding the use of the Cu-IUD as EC can be found in the FSRH clinical guideline on EC.

Insertion Checklist

• Prior to insertion of their chosen IUC, individuals should be advised about contraceptive effectiveness, duration of use, potential bleeding patterns and side effects, any noncontraceptive benefits, the procedure (including associated risks), analgesia options, checking threads, and when to seek review. The clinician should answer any questions the user has about the method
• The clinician should confirm the type of device with the individual and assistant prior to IUC insertion
• The expiry date on the IUC ± anaesthetic/analgesia should be checked prior to use
• Recommendations for pre-insertion information and preparation are outlined in Box 2 of the full guideline.

How Can Safe Insertion of IUC Be Facilitated?

• Clinicians offering IUC insertion should hold the appropriate FSRH Letter of Competence in Intrauterine Techniques or have achieved equivalent recognised competencies and show evidence of recertification/reaccreditation
• The insertion procedure for immediate PPIUC is different to that for standard IUC insertion and should only be performed by those who have been trained in this technique
• An appropriately trained assistant should be present during all uterine instrumentation procedures.

Informed Consent

• Informed consent for undertaking an IUC procedure should be obtained in line with local policy. The FSRH service standard on obtaining valid consent in sexual and reproductive health services provides further information.

Chaperones

• A chaperone should be offered for all intimate examinations. The chaperone’s role is to support the patient. The chaperone should usually be a healthcare professional and therefore the assistant will usually also fill the role of a chaperone.

Practical Aspects of IUC Insertion

• A bimanual pelvic examination should be performed prior to inserting IUC
• To reduce the risk of perforation and facilitate fundal placement of the device, tissue forceps should usually be used to stabilise the cervix and straighten the uterine cavity during IUC insertion, and a uterine sound should be used to assess the cavity length prior to insertion.

For further details on examination, measurement of pulse rate and blood pressure, cervical cleansing, sterile gloves, and use of forceps/tenaculum and assessment of the uterine cavity, refer to the full guideline.

Pain Associated With IUC Insertion

• Experiences vary for individuals having IUC inserted, and clinicians may underestimate the pain and anxiety users experience
• Individuals should be advised that most IUC insertions are associated with mild-to-moderate pain or discomfort, but that pain can range from none to severe
• Clinicians should support and encourage users to tell them if they are experiencing pain or discomfort and reassure them that the procedure can be paused or stopped at any time
• An assistant should be present to support the individual during the IUC procedure and monitor the patient for any signs of pain or distress
• Analgesia options should be discussed and offered to all individuals having IUC inserted
• Referral processes should be in place for circumstances where an individual requests an analgesia option that the clinician is unable to provide.

Post-procedure Analgesia

• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can reduce pain after IUC insertion and can be offered to individuals who experience pain after insertion of an intrauterine method.

Table 1: Starting IUC (No Recent Hormonal Contraception)

Emergency Management for Problems at IUC Insertion

• All staff involved with IUC insertion should undergo training and regular updates in resuscitation.

For further information and guidance on resuscitation, refer to the full guideline.

Documentation

• Clinicians inserting or removing IUC should document the procedure and consultation in line with local policy and protocol and notify (where applicable and with consent) other relevant healthcare providers (for example, primary care) of the type of device, date of insertion and recommended duration of use
• Recommendations for record-keeping are available within the FSRH service standards for record keeping.

Aftercare Advice and Follow-up

• After IUC insertion, individuals should be given information on the device inserted, including the name of the device, its mode of action, duration of use, and time to become effective
• When IUC has been inserted outside of product licence or as EC, information about how and when to perform a pregnancy test should be given
• With the exception of PPIUC, routine post-insertion check-ups with a clinician are not required
• When IUC has been inserted within 48 hours of a vaginal or caesarean birth (PPIUC), an IUC check-up with a clinician 4–6 weeks after insertion is recommended
• IUC users should be advised to feel for their threads within the first 4–6 weeks after insertion and then at regular intervals (for example, monthly or after menses).

For details on device information, follow-up, checking threads, when to seek review, advice about use of menstrual cups, discs, and tampons, and advice for individuals requiring magnetic resonance imaging, refer to the full guideline.

Managing Problems Associated With IUC

Unscheduled Bleeding

• Tranexamic acid or NSAIDs can be offered for management of heavy menstrual bleeding during use of IUC
• A 3-month trial of COC can be offered to medically eligible individuals with problematic bleeding during use of IUC
• Although unscheduled bleeding may be caused by the IUC itself, other causes (such as pregnancy, infection, pathology) should be considered and investigated in line with the FSRH clinical guideline on problematic bleeding with hormonal contraception.

New-onset Pelvic Pain

• New-onset pelvic pain in an IUC user should be assessed, and pregnancy should be excluded.

For further information on possible causes for new-onset pelvic pain in IUC users, including recommendations on clinical history and physical examination, refer to the full guideline.

Pregnancy

• If an individual with an IUC in situ has a positive pregnancy test, local early pregnancy assessment pathways should be followed to determine the location of the pregnancy
• When an intrauterine pregnancy is less than 12 weeks’ gestation, the IUC should usually be removed, if the threads are visible, as this could improve later pregnancy outcomes.

Infection

• Individuals with PID and IUC in situ should be given antibiotic treatment, managed in accordance with British Association for Sexual Health and HIV guidance, and reviewed after 48–72 hours
• Individuals with mild-to-moderate PID and IUC in situ, whose clinical condition is improving over the first 48–72 hours, can retain their IUC
• Individuals whose clinical condition does not improve after 48–72 hours of antibiotics should usually have their IUC removed, but this decision should be considered alongside any potential risk of pregnancy if there has been unprotected vaginal sex within the preceding 7 days. EC and follow-up pregnancy testing should be considered if indicated
• IUC users with symptomatic, recurrent vulvovaginal candidiasis or bacterial vaginosis (BV) not controlled by standard treatment may wish to switch to an alternative method of contraception
• Asymptomatic individuals with positive Actinomyces-like organisms on cervical cytology are more likely to be colonised than infected, and there is no need to remove the IUC or to commence antibiotic treatment
• If Actinomycosis is suspected, further investigation and management should be discussed on an individual basis with local radiology, microbiology, and/or gynaecology teams.

For further details on PID, candida, BV, actinomycosis, and presence of actinomyces-like organisms, refer to the full guideline.

Malpositioned IUC

• There is insufficient evidence to definitively guide whether a malpositioned IUC should be left in situ or removed and replaced, and clinicians should consider each case on an individual basis
• The Guideline Development Group (GDG) suggests that, as a general guide, any of the following findings would usually be an indication to suggest that the IUC is removed and replaced:
  • IUC >2 cm from the fundus
  • IUC within the cervical canal (fully or partially), or
  • IUC user experiencing symptoms that may be related to malpositioned IUC (such as pain or bleeding)
• Clinicians should consider the need for EC and follow-up pregnancy testing when an IUC is found to be malpositioned.

For further considerations in the management of malpositioned IUC, refer to the full guideline.

Expulsion

• If there have been ≥2 IUC expulsions, a pelvic ultrasound to assess the uterine cavity may be helpful prior to insertion of a further IUC
• Post-insertion ultrasound scanning is not predictive of the likelihood of further expulsion but can provide immediate confirmation of correct positioning.

Perforation

• Lower abdominal pain, nonvisible threads, or changes in bleeding may indicate uterine perforation
• If perforation is suspected, an ultrasound scan ± plain abdominal and pelvic X-ray should be arranged as soon as possible in order to locate the device. EC and pregnancy testing should be considered, and ongoing contraception provided
• Following confirmed or suspected uterine perforation, the GDG suggests waiting at least 6 weeks before inserting a subsequent IUC. Referral to a specialist service, where ultrasound is available, is suggested for the subsequent insertion.

Thread Problems

• If no threads are visible on speculum examination, pregnancy should be excluded, EC considered, alternative contraception provided, and an ultrasound scan (± abdominal and pelvic X-ray) undertaken to locate the device
• If the IUC is confirmed to be correctly sited within the uterine cavity, the user can be reassured and the device left in situ
• The uterus should only be instrumented by a clinician with appropriate training to do so, and it is not advisable to instrument the uterine cavity without first confirming the intrauterine location of the device and excluding pregnancy
• As threads may descend into the vagina after PPIUC insertion, they may need to be trimmed at a subsequent IUC check.

For further recommendations on nonvisible threads, thread problems after immediate PPIUC insertion, long threads relating to PPIUC, and PPIUC devices visible at cervix, refer to the full guideline.

IUC Removal

For recommendations on facilitating safe removal, including on training and discussions about ongoing contraception needs, and unexpected findings at IUC removal, refer to the full guideline.

Timing of Removal/Replacement

• Individuals who do not wish to become pregnant should be advised to avoid UPSI for 7 days prior to IUC removal
• Individuals should be advised to avoid UPSI for 7 days prior to IUC removal and replacement in case it is not possible to insert the new device
• Recommendations regarding the timing of IUC removal and replacement can be found in Table 2.

Table 2: Recommendations for Timing of IUC Removal/Replacement