What are the recommended insertion tips for the Skyla (levonorgestrel‑releasing intrauterine system) in a patient without contraindications such as pregnancy, untreated pelvic infection, uterine anomalies, or cervical/uterine cancer?

Skyla IUD Insertion Tips

The Skyla levonorgestrel-releasing IUD can be inserted at any time during the menstrual cycle if pregnancy is reasonably excluded, with bimanual examination and cervical inspection being the only mandatory pre-insertion requirements. 1

Pre-Insertion Assessment

Essential Examinations (Class A - Mandatory)

• Perform bimanual examination and cervical inspection to assess uterine size, position, and detect cervical or uterine abnormalities that might prevent insertion or indicate infection 1, 2
• Confirm the patient is not pregnant using standard criteria (Box 1 in guidelines) 1, 2

Optional Assessments (Class C - Not Required)

• Blood pressure, weight/BMI, clinical breast examination, cervical cytology, glucose, lipids, liver enzymes, hemoglobin, and thrombogenic mutation testing are not necessary before IUD insertion 1
• STI screening can be performed on the same day as insertion, with treatment provided afterward without device removal if needed 3, 2

Timing of Insertion

Any Time During Cycle

• Insert at any point in the menstrual cycle if reasonably certain the patient is not pregnant—waiting for menses is unnecessary 1
• If >5 days since menstrual bleeding started, advise abstinence or backup contraception for 7 days post-insertion 1

Special Timing Scenarios

• Postpartum (breastfeeding or not): Can insert immediately postpartum or at any time if pregnancy is excluded 1, 3
• Postabortion: Insert within first 7 days, including immediately after abortion 1
• Switching from another method: Insert immediately if pregnancy excluded; if >5 days since menses and switching from copper IUD, consider providing emergency contraception at insertion 1

Key Insertion Pitfalls to Avoid

Common Misconceptions (NOT Contraindications)

• Past pelvic inflammatory disease, HIV infection, immunosuppression, and nulliparity are NOT contraindications to Skyla insertion 3, 2
• Obesity does not preclude IUD use (Category 1) 1
• The risk of pelvic infection is confined to the first 20-21 days after insertion; beyond this period, IUDs do not increase STI or PID rates 3, 2

Absolute Contraindications (Category 4)

• Confirmed or suspected pregnancy 3, 2
• Current pelvic inflammatory disease (treat with antibiotics first; device can stay if already inserted) 1, 2
• Current purulent cervicitis, active chlamydia or gonorrhea (treat first; if device already in place, can continue with treatment) 1, 2
• Distorted uterine cavity from congenital or acquired abnormalities incompatible with insertion 1, 2
• Current breast cancer 2
• Persistently elevated β-hCG or malignant gestational trophoblastic disease 2
• Current cervical or endometrial cancer awaiting treatment 2

Relative Contraindications (Category 2-3)

• Uterine fibroids may increase expulsion rates (11% vs 0-3% without fibroids), though not an absolute contraindication 1, 2
• Unexplained vaginal bleeding should be evaluated before insertion (Category 4 for initiation, Category 2 for continuation) 2

Patient Counseling Before Insertion

Bleeding Pattern Changes

• Counsel extensively about expected bleeding changes before insertion—all women will notice alterations in bleeding patterns 4
• Initial spotting for many days is common in the first 3-6 months 2, 4
• Prescribe NSAIDs for 5-7 days during bleeding episodes as first-line treatment for breakthrough bleeding 2
• Most women experience reduced menstrual blood loss (71-95% reduction), with many developing amenorrhea or oligomenorrhea over time 2, 5, 4

Efficacy and Follow-Up

• No backup contraception needed if inserted within 7 days of menses onset 1
• Pearl index of 0.09-0.18 per 100 woman-years makes this one of the most effective reversible contraceptives 5, 4
• Expulsion rates are 5-10% within 5 years, higher in younger nulliparous women 3

STI Protection Warning

• The Skyla IUD does not protect against STIs or HIV—recommend correct and consistent condom use if at risk 3