What progestin‑only contraceptive regimen and dosing should be started immediately after intrauterine device removal in a woman?

Progestin-Only Contraception After IUD Removal

Start progestin-only contraception immediately at the time of IUD removal, with specific dosing and backup contraception requirements depending on the method chosen and timing within the menstrual cycle.

Immediate Initiation Algorithm

When removing an IUD and transitioning to progestin-only contraception, you can start the new method immediately without waiting for the next menstrual period 1, 2. The CDC explicitly states that waiting is unnecessary when discontinuing contraceptive methods including IUDs 2.

Specific Progestin-Only Method Dosing and Backup Requirements

Progestin-Only Pills

• Standard dosing: Daily oral pill (e.g., norethindrone 0.35 mg daily) 3
• Backup contraception needed: 2 days if starting >5 days after menses began 1
• If starting ≤5 days after menses: No backup needed 1

Depot Medroxyprogesterone Acetate (DMPA) Injectable

• Standard dosing: 150 mg intramuscularly every 12-13 weeks 3
• Backup contraception needed: 7 days if starting >7 days after menses began 1
• If starting ≤7 days after menses: No backup needed 1

Etonogestrel Implant

• Standard dosing: Single 68 mg subdermal implant (releases ~60 mcg/day initially, declining over 3 years) 3
• Backup contraception needed: 7 days if starting >5 days after menses began 1
• If starting ≤5 days after menses: No backup needed 1

Critical Consideration: Residual Sperm Risk

If the patient had unprotected intercourse within 7 days before IUD removal, you must address residual sperm that may still be viable in the reproductive tract 1, 4. The CDC references a 5-7 day window for sperm survival 4.

Three Options to Manage Residual Sperm Risk:

1. Delay IUD removal for >7 days after starting the new progestin method 1
2. Require abstinence or barrier methods for 7 days before IUD removal 1
3. Offer emergency contraceptive pills at the time of IUD removal 1

Common Pitfalls to Avoid

• Don't assume backup contraception is always needed: If starting within the specified days after menses (5 days for pills/implant, 7 days for injectable), no backup is required 1
• Don't forget about residual sperm: This is the most commonly overlooked risk when switching from IUDs 1, 4
• Don't delay unnecessarily: There is no medical reason to wait for the next menstrual period before starting progestin contraception after IUD removal 2

Counseling on Expected Side Effects

Progestin-only methods commonly cause menstrual irregularities 3, 5:

• Implant: Changes in bleeding patterns are the most common adverse effect 3
• DMPA: Expect bleeding pattern changes and potential reversible bone mineral density loss 3
• Pills: Generally well-tolerated but require daily adherence 3

Special Populations

Postpartum and breastfeeding women: All progestin-only methods are safe to start immediately postpartum and during breastfeeding 1, 3, 5. This is a major advantage over estrogen-containing methods, which should be deferred until at least 3-6 weeks postpartum due to venous thromboembolism risk 1.