Trichomoniasis is NOT a Contraindication for IUD Insertion
Trichomoniasis alone does not appear in the CDC Medical Eligibility Criteria as a contraindication for IUD placement, and you should treat the infection with metronidazole before or at the time of insertion rather than withholding this highly effective contraceptive method. 1, 2
Key Clinical Framework
The CDC guidelines specifically address which lower genital tract infections warrant delaying IUD insertion, and the critical distinction is between:
- Category 4 conditions (absolute contraindications): Current purulent cervicitis, current chlamydial infection, or current gonorrhea 2, 3
- Conditions NOT listed as contraindications: Trichomoniasis is notably absent from these restrictions 1
Pathophysiologic Rationale
The concern with IUD insertion during active infection relates to mechanical disruption of the cervical barrier, which facilitates upward spread of bacteria from the lower to upper genital tract 2, 3. However, the organisms of primary concern are:
- Chlamydia trachomatis and Neisseria gonorrhoeae (the sexually transmitted pathogens most strongly associated with PID) 2, 3
- Anaerobes and facultative bacteria that cause polymicrobial PID 2, 3
Trichomonas vaginalis is a protozoan that causes lower genital tract infection (vaginitis and cervicitis) but is not among the primary pathogens that cause post-insertion PID 4.
Practical Management Algorithm
If trichomoniasis is diagnosed before planned IUD insertion:
- Treat with single-dose metronidazole (highly effective in majority of cases) 4
- Proceed with IUD insertion after treatment initiation or completion
- No specific waiting period is mandated by CDC guidelines 1
If patient has purulent cervicitis of any etiology:
- Test for gonorrhea and chlamydia specifically 2, 3
- Delay IUD insertion until these infections are excluded or treated 2, 3
- Trichomoniasis can cause cervicitis but does not carry the same insertion restriction 4
Important Clinical Caveats
The observational association between IUD use and trichomoniasis detection does not establish causation. One study found higher rates of T. vaginalis in IUD users (14.7% vs 2.17% in non-users) 5, but this likely reflects:
- Selection bias (women with multiple partners may choose IUDs and have higher STI exposure)
- Detection bias (IUD users have more frequent gynecologic visits)
- Not a biological mechanism by which IUDs cause trichomoniasis
The absolute risk of PID following IUD insertion is low when pre-existing STIs are absent or treated. Multiple studies confirm that modern IUD insertion under appropriate conditions carries minimal infection risk 6, 7, 8. The key is addressing cervical infections—particularly gonorrhea and chlamydia—before insertion 2, 3.
Common Pitfall to Avoid
Do not conflate "any vaginal infection" with "contraindication to IUD insertion." The CDC Medical Eligibility Criteria are specific and evidence-based 1. Unnecessarily withholding IUDs from women with trichomoniasis denies them access to one of the most effective reversible contraceptive methods and increases their risk of unintended pregnancy—a far greater health risk than appropriately managed trichomoniasis 1.