What pre‑insertion questions should be asked to assess a patient’s age, parity, fertility desires, pregnancy status, menstrual pattern, history of pelvic inflammatory disease or uterine surgery, uterine anatomy, allergies to copper or hormonal IUDs, medical contraindications, current medications, sexual history, pain tolerance, and preference for copper versus hormonal intrauterine device (IUD) placement?

Pre-Insertion Assessment Questions for IUD Placement

Before inserting an IUD, you must systematically assess for absolute contraindications—specifically current purulent cervicitis, active gonorrhea/chlamydia infection, current pelvic inflammatory disease, pregnancy, and anatomical abnormalities that distort the uterine cavity—while also evaluating STI risk, menstrual patterns, medical conditions, and patient preferences to ensure safe placement. 1, 2, 3

Absolute Contraindications to Rule Out

Current Infections (Category 4 - Do Not Insert)

• Active purulent cervicitis: Ask about and examine for abnormal vaginal discharge, cervical inflammation 1
• Current gonorrhea or chlamydia infection: Screen can be performed same-day; insertion should not be delayed unless patient has very high individual likelihood of exposure (e.g., partner with known infection) 3, 2
• Current pelvic inflammatory disease: Ask about pelvic pain, fever, abnormal discharge 1
• Other current pelvic infections: Including postpartum endometritis, septic abortion 1

Pregnancy Status

• Is pregnancy reasonably certain to be excluded? Use appropriate pregnancy checklist; IUD can be placed at any point in menstrual cycle if pregnancy excluded 3, 4

Anatomical Abnormalities

• Any uterine abnormality distorting the cavity (Category 4): Ask about known fibroids, congenital anomalies, prior uterine surgery that may have altered cavity 1
• Cervical stenosis or lacerations not distorting cavity are Category 2 (generally can use) 1

Critical History Questions

STI Risk Assessment

• Sexual history: Number of partners, partner's STI status, new partner in last 60 days 1
• Very high individual likelihood of STI exposure makes insertion Category 3 (generally should not insert until tested/treated) 1
• Past PID without subsequent pregnancy is only Category 2; past PID is NOT a contraindication 1, 2
• Note: Most women don't require additional STI screening if already screened per CDC guidelines; can screen same-day and proceed with insertion 3

Medical History

• Current breast cancer (Category 4 for LNG-IUD, Category 1 for copper) 1
• Past breast cancer within 5 years (Category 3 for LNG-IUD, Category 1 for copper) 1
• Endometrial or cervical cancer: Concern for infection/perforation at insertion 1
• Diabetes with vascular complications: Category 2 for LNG-IUD, Category 1 for copper 1
• Severe decompensated cirrhosis: Category 3 for LNG-IUD, Category 1 for copper 1
• HIV/AIDS: NOT a contraindication; both copper and LNG-IUDs are Category 2-3 depending on disease status 1, 2, 1
• Immunosuppression: NOT a contraindication 2

Menstrual and Reproductive History

• Current menstrual pattern: Heavy/prolonged bleeding suggests need for evaluation before insertion 1
• Parity: Nulliparity is NOT a contraindication; IUDs are safe for nulliparous adolescents 2
• Age: No age restrictions; adolescents can safely use IUDs 2
• Future fertility desires: Rapid return to fertility after removal; does not cause infertility 2

Medication History

• Anticoagulants: Relative consideration for bleeding risk 5
• Antiretroviral therapy: Does not change IUD eligibility 1

Device Selection Questions

Copper vs. Hormonal IUD

• Copper allergy: Contraindication to copper IUD 5
• Desire for emergency contraception: Copper IUD effective up to 5 days post-intercourse (or >5 days if within 5 days of ovulation); LNG 52mg IUD up to 7 days but remains debated 2, 4
• Heavy menstrual bleeding: LNG-IUD may improve bleeding; copper may worsen 1
• Preference for hormone-free method: Copper IUD appropriate choice
• Duration desired: Copper 10 years, LNG 52mg 5 years, LNG 13.5mg 3 years 2

Pain Management Discussion

Counsel that more than half of young nulliparous women report moderate-to-severe insertion pain 2. Assess risk factors for painful procedure:

• Nulliparity
• Young age
• No prior vaginal delivery
• Cervical stenosis 4

Offer NSAIDs (naproxen 500-550mg or ketorolac 20mg) 1 hour before procedure 4, 6. Discuss patient preferences for additional analgesia options.

Common Pitfalls to Avoid

1. Do NOT delay insertion for STI screening in low-risk patients; screen same-day and proceed 3
2. Do NOT exclude nulliparous women or adolescents; these are appropriate candidates 2
3. Do NOT require pelvic exam before deciding on IUD unless symptomatic; exam is for insertion, not eligibility 7, 8
4. Do NOT exclude patients with past PID if no current STI risk factors 1, 2, 1
5. Do NOT exclude HIV-positive or immunosuppressed patients 1, 2, 1

Timing Considerations

• Can insert at any point in menstrual cycle if pregnancy reasonably excluded 4
• Immediate postpartum insertion is safe and effective option 2
• No "best time" in cycle for insertion 4