What are the benefits, risks, and alternatives of a non-hormonal Intrauterine Device (IUD)?

Non-Hormonal IUD: Benefits, Risks, and Alternatives

The copper IUD is a highly effective, hormone-free contraceptive option with a failure rate of less than 1%, effective for at least 10 years, and provides immediate return to fertility upon removal. 1

Benefits of the Copper (Non-Hormonal) IUD

Contraceptive Efficacy

• Highly effective contraception with typical failure rates of less than 1% per year, comparable to sterilization 1
• Effective for at least 10 years (approved for 10 years, with data supporting use up to 12 years) 1
• Does not require daily adherence or user action after insertion, making it more effective than methods requiring consistent user compliance 1

Non-Contraceptive Benefits

• No hormonal side effects - completely hormone-free option 1
• No increased risk of venous thromboembolism (VTE), making it ideal for patients with thrombotic risk factors 1
• Immediate return to fertility upon removal with no waiting period required 2
• Can be used as emergency contraception with the highest efficacy (<1% failure rate) when inserted within 5 days of unprotected intercourse 1

Special Population Benefits

• Safe for immunocompromised patients, including those with HIV, on immunosuppressive therapy, or solid organ transplant recipients 1
• Safe for breastfeeding women and can be inserted immediately postpartum 3
• First-line option for patients with contraindications to estrogen, including history of deep venous thrombosis, pulmonary embolism, or coronary events 3
• Appropriate for nulliparous adolescents - does not cause tubal infertility 1

Risks and Side Effects of the Copper IUD

Common Side Effects

• Increased menstrual bleeding and cramping, particularly during the first several months after insertion 1
• Heavier menstrual flow compared to baseline 3
• These symptoms typically improve over time but may persist in some users 1

Insertion-Related Complications

• Expulsion occurs in 5-10% of cases within 5 years, with recurrence in approximately 30% of those who experience expulsion 3
• Uterine perforation is rare (0.6 to 16 per 1000 insertions), with higher risk when inserted less than 4-6 weeks postpartum or post-abortion 3
• Pain, bleeding, and syncope during insertion reported in less than 1.5% of cases 3

Infection Risk

• Small increased risk of pelvic infection during the first 20 days after insertion, but not beyond this period 1, 3
• Approximately 6 pelvic infections per 1000 woman-years of use 3
• No increased infection risk in immunocompromised patients, including those with HIV or on immunosuppressive therapy 1
• Pre-existing asymptomatic Chlamydia trachomatis infection increases early infection risk 3

Pregnancy-Related Risks

• Ectopic pregnancy: While ectopic pregnancies are rarer in IUD users than in women using no contraception, approximately 1 in 20 pregnancies that occur with an IUD in place is ectopic 3
• Intrauterine pregnancies with IUD in place generally end in miscarriage; about 25% result in live birth if device left in place versus 90% if removed 3

Contraindications

• Current or recent (past 3 months) pelvic inflammatory disease 1
• Current gonorrhea, chlamydia, or purulent cervicitis 1
• Pregnancy 1, 4
• Uterine anomalies that distort the cavity incompatible with insertion 1
• Unexplained vaginal bleeding (postpone insertion until evaluated) 3

Important caveat: High risk of STIs is considered by CDC as level 2-3 (benefits may or may not outweigh risks), though screening can be performed at insertion with subsequent treatment without IUD removal 1

Alternatives to the Copper IUD

Hormonal IUD (Levonorgestrel-Releasing)

• Similar contraceptive efficacy (failure rate <1%) but effective for 3-7 years depending on formulation 1
• Reduces menstrual bleeding - may cause amenorrhea in 35% of users after 2 years, making it preferable for those with heavy menses or on anticoagulation 1, 3
• No increased VTE risk (RR 0.61,95% CI 0.24-1.53) 1
• May cause irregular bleeding/spotting initially, plus hormonal side effects (headache, acne, breast tension, functional ovarian cysts) 3

Progestin-Only Pills

• Less effective than IUDs (typical failure rate ~9%) and require strict daily adherence 1
• No increased VTE risk (RR 0.90,95% CI 0.57-1.45) 1
• Appropriate alternative for patients unable or unwilling to use an IUD 1

Progestin Implant (Etonogestrel)

• Highest contraceptive efficacy (failure rate 0.05%) among all methods 1
• Effective for 3 years with minimal to no bone loss 1
• No estrogen-associated risks 1

Depot Medroxyprogesterone Acetate (DMPA)

• Typical failure rate ~6%, administered every 12 weeks 1
• Black box warning for decreased bone density (normalizes after cessation) 1
• Not recommended for patients with positive antiphospholipid antibodies due to increased VTE risk (RR 2.67,95% CI 1.29-5.53) 1
• Delays return to fertility up to 18 months 1

Combined Hormonal Contraceptives (Pills, Patch, Ring)

• Contraindicated in multiple conditions: decompensated cirrhosis, graft failure, hepatic adenomas, history of VTE, positive antiphospholipid antibodies, multiple cardiovascular risk factors 1
• VTE risk 36 times higher than baseline in healthy women 1
• Acceptable in compensated cirrhosis and most other chronic liver diseases 1

Barrier Methods and Natural Family Planning

• Significantly less effective than IUDs but no systemic effects
• Appropriate for those declining long-acting methods or with contraindications to all other options