Contraindications to IUD Placement
IUDs have very few absolute contraindications, with the most critical being pregnancy, current pelvic infection (PID, purulent cervicitis, gonorrhea, or chlamydia), and anatomical distortion of the uterine cavity that prevents proper placement. 1, 2
Absolute Contraindications (US MEC Category 4 - Unacceptable Risk)
For ALL IUDs (Both Copper and Levonorgestrel):
- Pregnancy - Risk of serious pelvic infection and septic spontaneous abortion 2
- Current pelvic inflammatory disease (PID) 2
- Current purulent cervicitis, gonorrhea, or chlamydia infection 2
- Post-septic abortion 1
- Puerperal sepsis 1
- Pelvic tuberculosis 1, 2
- Distorted uterine cavity (any congenital or acquired abnormality incompatible with IUD insertion) 2
- Cervical cancer awaiting treatment 2
- Endometrial cancer 1, 2, 1
- Malignant gestational trophoblastic disease (persistently elevated β-hCG) 1, 2, 1
- Unexplained vaginal bleeding 1
Device-Specific Contraindications:
Additional Immediate Postpartum Contraindications:
For immediate postpartum insertion specifically, delay placement if:
- Active chorioamnionitis or prenatal STI without test of cure
- Known uterine cavity anomaly
- Ongoing postpartum hemorrhage
- Retained placenta requiring manual removal or surgical evacuation 1
Important Clinical Nuances
Conditions That Are NOT Contraindications:
The evidence strongly supports that the following are safe for IUD use despite historical concerns:
- HIV/AIDS - Category 2 for initiation, Category 2 for continuation 2, 3
- Past PID (with subsequent pregnancy) - Category 1 2
- Past PID (without subsequent pregnancy) - Category 2 2
- Nulliparity - Category 2 (may have higher expulsion rates and insertion discomfort, but not contraindicated) 2, 4
- Adolescence - Safe and appropriate 4
- History of ectopic pregnancy - Category 1 2, 3
- Uterine fibroids (if not distorting cavity) - Category 2 2
- Breastfeeding - Category 1 or 2 depending on timing 2
- Most medical conditions including diabetes, hypertension, thromboembolism - Category 1 or 2 1
Critical Management Points:
For STI screening: Most patients do not require additional STI screening at time of placement. If risk factors exist and screening hasn't been done per CDC guidelines, screen at the time of placement and do not delay insertion 5. Treatment can occur with IUD in place if the patient is improving 2.
For current PID or STI: This is Category 4 for initiation but Category 2 for continuation - meaning if infection develops after IUD is placed, treat with antibiotics and the IUD usually does not need removal 2.
For breast cancer history: Past breast cancer with no evidence of disease for 5 years is Category 3 for levonorgestrel IUD but Category 1 for copper IUD - offer copper IUD as alternative 2.
Common Pitfalls to Avoid:
Do not deny IUDs to nulliparous women or adolescents - outdated concern about infertility has been disproven 2, 4, 3
Do not delay insertion for STI screening in asymptomatic patients - screen and insert same day 5
Do not remove IUD automatically if STI or PID develops - treat infection first, removal only if patient not improving 2
Do not confuse "distorted uterine cavity" with all anatomical variants - only cavities incompatible with insertion are contraindicated; other abnormalities like cervical stenosis are Category 2 2
Remember device-specific contraindications - current breast cancer patients can still use copper IUD; Wilson disease patients can still use levonorgestrel IUD 1