(Published September 2011)

Intrauterine Contraception

Description

Intrauterine contraception (IUC), also referred to as an intrauterine device (IUD) or intrauterine system (IUS), is a long-acting reversible contraceptive method that involves the placement of a small T-shaped device inside the uterus. Two IUC methods are available: the Copper T 380A (brand name ParaGard^®) and the levonorgestrel intrauterine system (LNG IUS; brand name Mirena^®). Because IUCs use either non-hormonal ingredients or progestin to prevent fertilization, they are a good contraceptive choice for women who cannot use estrogen. IUDs have one of the highest satisfaction and continuation rates among patients.³²

Copper T IUD

The Copper T IUD contains polyethylene with copper along the vertical stem and horizontal arms.
A polyethylene string is secured to the device, allowing for easy removal.
The Copper T IUD is approved for 10 years of use, although studies have shown it to be effective for as long as 20 years.⁶⁹
The device causes an immune response that creates a hostile environment for sperm, thereby preventing fertilization of an ovum.
In addition, it appears that the device also disrupts the normal division of oocytes and the formation of fertilizable ova.⁷⁰

LNG IUS

Once placed in the uterus, the LNG IUS initially releases 20 mcg LNG/day; the rate decreases progressively to 10 mcg/day after 5 years.
The LNG IUS thickens the cervical mucus and inhibits sperm motility and function.⁷¹
The endometrial atrophy caused by the high LNG levels leads to a substantial decrease in menstrual flow and absence of bleeding in some women.

Use

Copper T IUD

The Copper T IUD can be used off-label as emergency contraception. It can be inserted up to 5 days after unprotected intercourse and reduces the risk of pregnancy by more than 99%.⁷²

LNG IUS

The LNG IUS is approved for 5 years of use, although data demonstrate that it is effective for up to 7 years.⁷³

Effectiveness

IUC is extremely effective.
The Copper T IUD is effective immediately after insertion and has a failure rate of 0.8 percent with typical use.¹⁸
The LNG IUS is effective 7 days after insertion and has a failure rate of 0.2 percent with typical use.¹⁸

Risks

Complications associated with IUC include uterine perforation during the insertion procedure.
Expulsion of the device occurs in 2 to 10 percent of users within the first year.⁵⁸
Expulsion may be more common in nulliparous women.⁵⁸
Because bacteria may be introduced into the uterus during IUC insertion, there is a slight increased risk of infection during the first month of use.
IUC poses no increased risk of infections (i.e or PID-associated infertility) beyond the first month of use.⁷⁴
Providers can consider obtaining gonorrhea and chlamydia cultures for women at risk of STIs at the time of IUC insertion. If results are positive, antibiotic treatment should be started, but there is usually no need to remove the device.⁴¹

Dispelling Myths About Intrauterine Contraception

IUC can be safely used in:

Women with multiple partners
Teens
Women who are immediately postpartum/postabortion
Women with a history of STI or PID
Nulliparous women
Women with a history of ectopic pregnancy

Side Effects

The copper-containing IUD increases the duration and amount of menstrual bleeding, resulting in approximately 50 percent greater blood loss.^75-77

For LNG IUS users, bleeding patterns are unpredictable, with frequent light bleeding for the first 3 months after insertion.78 By 3–6 months, most women experience dramatically reduced bleeding. About one-third of women will have amenorrhea after 12 months.⁷⁹

Contraindications and Precautions

Copper T IUD

Medical Eligibility Criteria for Copper T IUD
Category 4 (unacceptable health risk if the contraceptive method is used)	Pregnancy Puerperal sepsis Unexplained vaginal bleeding—for initiating method (designated category 2 for continuing method) Gestational trophoblastic disease (designated category 3 if ß-hCG levels are decreasting or undetectable) Cervical cancer awaiting treatment (designated category 2 for continuing method) Current endometrial cancer (designated category 2 for continuing method) Anatomical abnormality of uterus (designated category 2 if no distortion of uterine cavity or interference with IUD insertion) Current PID—for initiating method (designated category 2 for continuing method) Current purulent cervicitis, chlamydial infection, or gonorrhea—for initiating method (designated category 2 for continuing method); also designated category 2 if other STI or vaginitis is present) Pelvic tuberculosis—for initiating method (designated category 3 for continuing method)
Category 3 (theoretical or proven risks usually outweigh the advantages of using the method)	SLE with severe thrombocytopenia—for initiating method (designated category 2 for continuing method) Increased risk for STIs (designated category 2 if low personal risk for gonorrhea or chlamydial infection) Solid organ transplantation with complications—for initiating method (designated category 2 for continuing method) or if uncomplicated) AIDS—for initiating method (designated category 2 for continuing method or if clinically well on antiretroviral therapy) Antiretroviral therapy—for initiating method (designated category 2 if clinically well on therapy or for continuing method)
Source: Reference 5

Medical Eligibility Criteria for LNG IUS
Category 4 (unacceptable health risk if the contraceptive method is used)	Pregnancy Puerperal sepsis Immediate postseptic abortion Unexplained vaginal bleeding—for initiating method (designated category 2 for continuing method) Gestational trophoblastic disease (designated category 3 if β-hCG levels are decreasing or undetectable) Cervical cancer awaiting treatment—for initiating method (designated category 2 for continuing method) Current breast cancer (designated category 3 if no evidence of disease for 5 years) Current endometrial cancer (designated category 2 for continuing method) Anatomical abnormality of uterus (designated category 2 if no distortion of uterine cavity or interference with IUD insertion) Current PID—for initiating method (designated category 2 for continuing method) Current purulent cervicitis, chlamydial infection, or gonorrhea—for initiating method (designated category 2 for continuing method; also designated category 2 if other STI or vaginitis is present) AIDS—for initiating method (designated category 2 if clinically well on antiretroviral therapy or for continuing method) Pelvic tuberculosis—for initiating method (designated category 3 for continuing method)
Category 3 (theoretical or proven risks usually outweigh the advantages of using the method)	Ischemic heart disease (current or previous)—for continuing method (designated as category 2 for initiating method) SLE (positive for antiphospholipid antibodies or status unknown; designated category 2 if antiphospholipid antibodies are known to be negative) Migraine with aura—for continuing method (designated category 2 for initiating method) Increased risk for STIs (designated category 2 if low personal risk for gonorrhea or chlamydial infection) Severe cirrhosis Liver tumors Malignant Hepatocellular adenoma (designated category 2 if focal nodular hyperplasia is present) Solid organ transplantation with complications—for initiating method (designated category 2 forcontinuing method or for no complications) Antiretroviral therapy—for initiating method (designated category 2 if clinically well on therapy or for continuing method)
Source: Reference 5

Advantages of IUC

Long-term method (10 to 20 years for Copper T IUD; 5 to 7 years for LNG IUS)
Discreet
Extremely effective
After up-front cost, cost-effective for term of use
Rapid return to fertility after removal
Can be inserted any time during menstrual cycle when pregnancy can be excluded
Can be inserted immediately after abortion or delivery (i.e., after placenta is delivered) or as long as 4 weeks afterward
Lack of estrogen makes IUC appropriate for smokers older than age 35, postpartum women who are breastfeeding, and others with contraindications to estrogen.
LNG IUS may reduce menstrual symptoms in women who have uterine fibroids or adenomyosis^80,81 and may reduce menstrual blood loss in women at risk for anemia.
Copper T IUD provides a hormone-free option for women.

Disadvantages

Requires visit to trained clinician for insertion and removal
Some risk of expulsion within first year
No protection against STIs

Counseling Messages

IUC is an excellent contraceptive choice for women who desire a highly effective and long-term but reversible method of contraception.
Women who want reassurance about the placement of the IUD can check for presence of the string, although checking on a regular basis is not necessary.
It is important for women to be aware of the warning signs of expulsion and infection.
Follow-up visits after IUC insertion are important.
Women should use back-up contraception for 7 days after insertion of IUC.
This method does not protect against STIs.