What is the best Intrauterine Device (IUD) for a nulliparous female?

From the Guidelines

For nulliparous females, the best IUD option is typically the smaller hormonal IUD such as Skyla, due to its smaller size and lower dose of levonorgestrel, making it a more suitable choice for women with a smaller uterus and narrower cervical canal 1.

Key Considerations

• The Skyla IUD is approved for 3 years and releases a low dose of levonorgestrel, which can help reduce bleeding and cramping, making it a more comfortable option for nulliparous women 1.
• The smaller size of the Skyla IUD (28mm x 30mm) can make insertion less uncomfortable for women with a smaller uterus, and its lower dose of levonorgestrel can reduce the risk of side effects such as irregular bleeding and weight gain 1.
• While copper IUDs (ParaGard) are also an option, they may cause heavier periods and more cramping, which can be particularly challenging for nulliparous women, and are therefore not the preferred choice for this population 1.

Benefits and Risks

• The Skyla IUD has a failure rate of less than 1%, making it a highly effective method of contraception 1.
• The primary mechanism of action of the Skyla IUD is preventing fertilization by inhibiting sperm motility and thickening cervical mucus, which occurs before implantation and does not affect fertility 1.
• There is a small increase in infection risk around the time of IUD insertion, but beyond the first 20 days after insertion, IUDs do not increase rates of pelvic inflammatory disease (PID) above baseline 1.

Recommendations

• For nulliparous females, the Skyla IUD is the recommended option due to its smaller size, lower dose of levonorgestrel, and high efficacy 1.
• Before insertion, taking ibuprofen 800mg one hour prior can help reduce discomfort, and scheduling the insertion during menstruation when the cervix is naturally slightly more dilated may ease the procedure 1.
• It is essential to discuss the benefits and risks of the Skyla IUD with the patient and address any concerns or questions they may have before insertion 1.

From the Research

Types of IUDs

• There are five intrauterine devices (IUDs) available in the United States: four levonorgestrel-releasing intrauterine systems and one copper-bearing device (Copper T 380A) 2.
• The levonorgestrel-releasing intrauterine systems have different levonorgestrel contents, including 52 mg, 19.5 mg, and 13.5 mg 2.

Safety and Efficacy of IUDs in Nulliparous Women

• IUDs are safe and effective for the majority of women, including those who are nulliparous, and should be routinely included in the contraception options offered to them 2.
• The levonorgestrel intrauterine system (LNG-IUS) has been used internationally for over 15 years by 7 million women, and its safety and efficacy in nulliparous women have been established 3.
• Expulsion rates do not vary by parity, and perforation rates are low in all women, including nulliparous women 3.
• The efficacy of the LNG-IUS is excellent regardless of parity, with less than 1 pregnancy per 100 woman-years of use 3.

Benefits of LNG-IUS

• The LNG-IUS releases 20 microg/24 h of levonorgestrel, which reduces menstrual blood flow and provides high contraceptive efficacy 4.
• The LNG-IUS has additional health benefits, including increased hemoglobin, decreased dysmenorrhea, and a possible decrease in pelvic inflammatory disease 4.
• The LNG-IUS may also decrease the growth of fibroids and provide endometrial protection during postmenopausal estrogen replacement therapy 5.

Acceptability and Satisfaction

• Acceptability of the LNG-IUS is high in nulliparous women, with typical annual continuation rates above 80% in clinical studies 4.
• Nulliparous women seem to experience fewer expulsions than parous ones, and bleeding pattern is acceptable for the majority of patients 6.
• The LNG-IUS achieves high levels of satisfaction among patients, and its use should not be delayed in nulliparous women due to the number of advantages it offers 6.