What are the considerations and recommendations for using an Intrauterine Device (IUD) for contraception?

From the Guidelines

Intrauterine devices (IUDs) are highly effective, long-acting reversible contraceptives that are appropriate for most women seeking reliable birth control. There are two main types: hormonal IUDs (Mirena, Kyleena, Liletta, Skyla) which release levonorgestrel and last 3-8 years depending on the brand, and the non-hormonal copper IUD (ParaGard) which lasts up to 12 years. IUDs are over 99% effective at preventing pregnancy and can be inserted at any time during the menstrual cycle, provided pregnancy has been ruled out, as supported by 1. Insertion is performed by a healthcare provider in a brief office procedure that may cause cramping. Common side effects of hormonal IUDs include irregular bleeding initially, which typically improves over time, with many users experiencing lighter periods or no periods at all, as noted in 1. The copper IUD may cause heavier periods and cramping, especially in the first few months. IUDs do not protect against sexually transmitted infections, so condom use is recommended if STI protection is needed. Women with certain conditions such as active pelvic infection, unexplained vaginal bleeding, or certain uterine abnormalities should not use IUDs, as stated in 1. Follow-up is recommended 4-6 weeks after insertion to check placement, and users should check for IUD strings monthly. The IUD can be removed at any time by a healthcare provider, with fertility returning quickly after removal, as indicated in 1.

Some key considerations for IUD use include:

• IUDs are safe for nulliparous adolescents, with no increased risk of tubal infertility, as supported by 1.
• The risk of pelvic infection with IUDs is limited to the time of insertion, and screening for gonorrhea and chlamydia can be performed on the day of insertion, as noted in 1.
• IUDs can be used as emergency contraception within 5 days of unprotected intercourse, as stated in 1.
• HIV infection is not a contraindication to IUD use, but women with advanced HIV disease may need to use an alternative contraceptive method, as indicated in 1.

Overall, IUDs are a highly effective and safe contraceptive option for most women, with a low risk of complications and a quick return to fertility after removal, as supported by the most recent and highest quality study, 1.

From the Research

Considerations for Using an Intrauterine Device (IUD) for Contraception

• IUDs are a highly effective form of contraception, with studies showing similar efficacy to combined oral contraceptives when used correctly 2.
• There are two main types of IUDs: copper IUDs and levonorgestrel-releasing IUDs, both of which work predominantly by prefertilization mechanisms 3.
• The copper T 380A IUD and levonorgestrel-releasing IUDs have similar contraceptive efficacy, with pregnancy rates of around 0.3-0.8% per year 2, 4.
• IUDs are more effective than oral contraception used incorrectly, with a lower risk of pregnancy and ectopic pregnancy 2, 5.

Recommendations for IUD Use

• IUDs can be safely used in breastfeeding women, immediately after a pregnancy, in cases of diabetes or HIV infection, during nonsteroidal antiinflammatory drug therapy, and after an ectopic pregnancy 2.
• The copper IUD is a first-line contraceptive method for women with a history of deep venous thrombosis, pulmonary embolism, or coronary events 2.
• IUD insertion is an effective alternative to "morning-after" hormonal contraception, with studies showing noninferiority of the levonorgestrel IUD to the copper IUD for emergency contraception 4.
• Current guidelines indicate that IUDs are acceptable for use in nulliparous women, in adolescents, and in women who are breastfeeding, with no increased risk of adverse outcomes 3, 6.

Potential Side Effects and Risks

• Common side effects of IUDs include increased menstrual bleeding, menstrual pain, and expulsion of the device 2, 3.
• The levonorgestrel IUD is associated with a marked reduction in menstrual blood loss and irregular bleeding, but may also cause hormonal adverse effects such as headache, acne, and breast tension 2, 3.
• The risk of pelvic infection is slightly higher in the first 3 months after IUD insertion, especially in women with pre-existing asymptomatic Chlamydia trachomatis infection 2.
• Uterine perforation during insertion is rare, occurring in 0.6 to 16 cases per 1000 insertions, regardless of the type of IUD 2.

Comparison of Copper and Levonorgestrel IUDs

• Studies have shown that levonorgestrel IUDs are associated with a lower risk of pregnancy and adverse reactions compared to copper IUDs, but may carry a higher risk of amenorrhea 5.
• The choice between copper and levonorgestrel IUDs should be based on individual patient preferences and medical history, with healthcare providers fully informing patients of the potential risks and benefits 5.