Intrauterine Contraception

Timing

• The Cu-IUD can be inserted at any time if it is reasonably certain that the woman is not pregnant (Box 2).
• The Cu-IUD also can be inserted within 5 days of the first act of unprotected sexual intercourse as an emergency contraceptive. If the day of ovulation can be estimated, the Cu-IUD also can be inserted >5 days after sexual intercourse as long as insertion does not occur >5 days after ovulation.

Need for Back-Up Contraception

• No additional contraceptive protection is needed after Cu-IUD insertion.

Special Considerations

Amenorrhea (Not Postpartum)

• Timing: The Cu-IUD can be inserted at any time if it is reasonably certain that the woman is not pregnant (Box 2).
• Need for back-up contraception: No additional contraceptive protection is needed.

Postpartum (Including After Cesarean Delivery)

• Timing: The Cu-IUD can be inserted at any time postpartum, including immediately postpartum (U.S. MEC 1 or 2) (Box 1), if it is reasonably certain that the woman is not pregnant (Box 2). The Cu-IUD should not be inserted in a woman with postpartum sepsis (e.g., chorioamnionitis or endometritis) (U.S. MEC 4).
• Need for back-up contraception: No additional contraceptive protection is needed.

Postabortion (Spontaneous or Induced)

• Timing: The Cu-IUD can be inserted within the first 7 days, including immediately postabortion (U.S. MEC 1 for first trimester abortion and U.S. MEC 2 for second trimester abortion). The Cu-IUD should not be inserted immediately after septic abortion (U.S. MEC 4).
• Need for back-up contraception: No additional contraceptive protection is needed.

Switching from Another Contraceptive Method

• Timing: The Cu-IUD can be inserted immediately if it is reasonably certain that the woman is not pregnant (Box 2). Waiting for her next menstrual period is unnecessary.
• Need for back-up contraception: No additional contraceptive protection is needed.

Comments and Evidence Summary. In situations in which the health care provider is not reasonably certain that the woman is not pregnant, the woman should be provided with another contraceptive method to use until the health care provider can be reasonably certain that she is not pregnant and can insert the Cu-IUD.

A systematic review identified eight studies that suggested that timing of Cu-IUD insertion in relation to the menstrual cycle in non-postpartum women had little effect on long-term outcomes (rates of continuation, removal, expulsion, or pregnancy) or on short-term outcomes (pain at insertion, bleeding at insertion, or immediate expulsion) (43) (Level of evidence: II-2, fair, direct).

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Among healthy women, few examinations or tests are needed before initiation of an IUD (Table 1). Bimanual examination and cervical inspection are necessary before IUD insertion. A baseline weight and BMI measurement might be useful for monitoring IUD users over time. If a woman has not been screened for STDs according to STD screening guidelines, screening can be performed at the time of insertion. Women with known medical problems or other special conditions might need additional examinations or tests before being determined to be appropriate candidates for a particular method of contraception. U.S. MEC might be useful in such circumstances (5).

Comments and Evidence Summary. Weight (body mass index [BMI]): Obese women can use IUDs (U.S. MEC 1) (5); therefore, screening for obesity is not necessary for the safe initiation of IUDs. However, measuring weight and calculating BMI (weight [kg] / height [m]²) at baseline might be helpful for monitoring any changes and counseling women who might be concerned about weight change perceived to be associated with their contraceptive method.

Bimanual examination and cervical inspection: Bimanual examination and cervical inspection are necessary before IUD insertion to assess uterine size and position and to detect any cervical or uterine abnormalities that might indicate infection or otherwise prevent IUD insertion (44,45).

STDs: Women should be routinely screened for chlamydial infection and gonorrhea according to national screening guidelines. The CDC Sexually Transmitted Diseases Treatment Guidelines provide information on screening eligibility, timing, and frequency of screening and on screening for persons with risk factors (15) (https://www.cdc.gov/std/treatment). If STD screening guidelines have been followed, most women do not need additional STD screening at the time of IUD insertion. If a woman has not been screened according to guidelines, screening can be performed at the time of IUD insertion and insertion should not be delayed. If a woman with risk factors for STDs has not been screened for gonorrhea and chlamydia according to CDC STD treatment guidelines, screening can be performed at the time of IUD insertion, and insertion should not be delayed. Women with current purulent cervicitis or chlamydial infection or gonorrhea should not undergo IUD insertion (U.S. MEC 4). A systematic review identified two studies that demonstrated no differences in PID rates among women who screened positive for gonorrhea or chlamydia and underwent concurrent IUD insertion compared with women who screened positive and initiated other contraceptive methods (46). Indirect evidence demonstrates women who undergo same-day STD screening and IUD insertion have similar PID rates compared with women who have delayed IUD insertion. Women who undergo same-day STD screening and IUD insertion have low incidence rates of PID. Algorithms for predicting PID among women with risk factors for STDs have poor predictive value. Risk for PID among women with risk factors for STDs is low (15,47–57). Although women with STDs at the time of IUD insertion have a higher risk for PID, the overall rate of PID among all IUD users is low (51,54).

Hemoglobin: Women with iron-deficiency anemia can use the LNG-IUD (U.S. MEC 1) (5); therefore, screening for anemia is not necessary for safe initiation of the LNG-IUD. Women with iron-deficiency anemia generally can use Cu-IUDs (U.S. MEC 2) (5). Measurement of hemoglobin before initiation of Cu-IUDs is not necessary because of the minimal change in hemoglobin among women with and without anemia using Cu-IUDs. A systematic review identified four studies that provided direct evidence for changes in hemoglobin among women with anemia who received Cu-IUDs (58). Evidence from one randomized trial (59) and one prospective cohort study (60) showed no significant changes in hemoglobin among Cu-IUD users with anemia, whereas two prospective cohort studies (61,62) showed a statistically significant decrease in hemoglobin levels during 12 months of follow-up; however, the magnitude of the decrease was small and most likely not clinically significant. The systematic review also identified 21 studies that provided indirect evidence by examining changes in hemoglobin among healthy women receiving Cu-IUDs (63–83), which generally showed no clinically significant changes in hemoglobin levels with up to 5 years of follow-up (Level of evidence: I to II-2, fair, direct).

Lipids: Screening for dyslipidemias is not necessary for the safe initiation of Cu-IUD or LNG-IUD because of the low prevalence of undiagnosed disease in women of reproductive age and the low likelihood of clinically significant changes with use of hormonal contraceptives. A systematic review did not identify any evidence regarding outcomes among women who were screened versus not screened with lipid measurement before initiation of hormonal contraceptives (57). During 2009–2012 among women aged 20–44 years in the United States, 7.6% had high cholesterol, defined as total serum cholesterol ≥240 mg/dL (84). During 1999–2008, the prevalence of undiagnosed hypercholesterolemia among women aged 20–44 years was approximately 2% (85). Studies have shown mixed results about the effects of hormonal methods on lipid levels among both healthy women and women with baseline lipid abnormalities, and the clinical significance of these changes is unclear (86–89).

Liver enzymes: Women with liver disease can use the Cu-IUD (U.S. MEC 1) (5); therefore, screening for liver disease is not necessary for the safe initiation of the Cu-IUD. Although women with certain liver diseases generally should not use the LNG-IUD (U.S. MEC 3) (5), screening for liver disease before initiation of the LNG-IUD is not necessary because of the low prevalence of these conditions and the high likelihood that women with liver disease already would have had the condition diagnosed. A systematic review did not identify any evidence regarding outcomes among women who were screened versus not screened with liver enzyme tests before initiation of hormonal contraceptive use (57). In 2012, among U.S. women, the percentage with liver disease (not further specified) was 1.3% (90). In 2013, the incidence of acute hepatitis A, B, or C was ≤1 per 100,000 U.S. population (91). During 2002–2011, the incidence of liver carcinoma among U.S. women was approximately 3.7 per 100,000 population (92). Because estrogen and progestins are metabolized in the liver, the use of hormonal contraceptives among women with liver disease might, theoretically, be a concern. The use of hormonal contraceptives, specifically COCs and POPs, does not affect disease progression or severity in women with hepatitis, cirrhosis, or benign focal nodular hyperplasia (93,94), although evidence is limited, and no evidence exists for the LNG-IUD.

Clinical breast examination: Women with breast disease can use the Cu-IUD (U.S. MEC 1) (5); therefore, screening for breast disease is not necessary for the safe initiation of the Cu-IUD. Although women with current breast cancer should not use the LNG-IUD (U.S. MEC 4) (5), screening asymptomatic women with a clinical breast examination before inserting an IUD is not necessary because of the low prevalence of breast cancer among women of reproductive age. A systematic review did not identify any evidence regarding outcomes among women who were screened versus not screened with a breast examination before initiation of hormonal contraceptives (95). The incidence of breast cancer among women of reproductive age in the United States is low. In 2012, the incidence of breast cancer among women aged 20–49 years was approximately 70.7 per 100,000 women (96).

Cervical cytology: Although women with cervical cancer should not undergo IUD insertion (U.S. MEC 4) (5), screening asymptomatic women with cervical cytology before IUD insertion is not necessary because of the high rates of cervical screening, low incidence of cervical cancer in the United States, and high likelihood that a woman with cervical cancer already would have had the condition diagnosed. A systematic review did not identify any evidence regarding outcomes among women who were screened versus not screened with cervical cytology before initiation of IUDs (57). Cervical cancer is rare in the United States, with an incidence rate of 9.8 per 100,000 women during 2012 (96). The incidence and mortality rates from cervical cancer have declined dramatically in the United States, largely because of cervical cytology screening (97). Overall screening rates for cervical cancer in the United States are high; in 2013 among women aged 18–44 years, approximately 77% reported having cervical cytology screening within the last 3 years (98).

HIV screening: Women with HIV infection can use (U.S. MEC 1) or generally can use (U.S. MEC 2) IUDs (5). Therefore, HIV screening is not necessary before IUD insertion. A systematic review did not identify any evidence regarding outcomes among women who were screened versus not screened for HIV infection before IUD insertion (57). Limited evidence suggests that IUDs are not associated with disease progression, increased infection, or other adverse health effects among women with HIV infection (99–114).

Other screening: Women with hypertension, diabetes, or thrombogenic mutations can use (U.S. MEC 1) or generally can use (U.S. MEC 2) IUDs (5). Therefore, screening for these conditions is not necessary for the safe initiation of IUDs.

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• Misoprostol is not recommended for routine use before IUD insertion. Misoprostol might be helpful in select circumstances (e.g., in women with a recent failed insertion).
• Paracervical block with lidocaine might reduce patient pain during IUD insertion.

Comments and Evidence Summary. Potential barriers to IUD use include anticipated pain with insertion and provider concerns about difficult insertion. Identifying effective approaches to ease IUD insertion might increase IUD initiation.

Evidence for misoprostol from two systematic reviews, including a total of 10 randomized controlled trials, suggests that misoprostol does not improve provider ease of insertion, reduce the need for adjunctive insertion measures, or improve insertion success (Level of evidence: I, good to fair, direct) and might increase patient pain and side effects (Level of evidence: I, high quality) (115,116). However, one randomized controlled trial examined women with a recent failed IUD insertion and found significantly higher insertion success with second insertion attempt among women pretreated with misoprostol versus placebo (Level of evidence: I, good, direct) (117).

Limited evidence for paracervical block with lidocaine from one systematic review suggests that it might reduce patient pain (115). In this review, two randomized controlled trials found significantly reduced pain at either tenaculum placement or IUD insertion among women receiving paracervical block with 1% lidocaine 3–5 minutes before IUD insertion (118,119). Neither trial found differences in side effects among women receiving paracervical block compared with controls (Level of evidence: I, moderate to low quality) (118,119).

Limited evidence on nonsteroidal antiinflammatory drugs (NSAIDs) and nitric oxide donors generally suggested no positive effect; evidence on lidocaine with administration other than paracervical block was limited and inconclusive (Level of evidence for provider ease of insertion: I, good to poor, direct; Level of evidence for need for adjunctive insertion measures: I, fair, direct; Level of evidence for patient pain: I, high to low quality; Level of evidence for side effects: I, high to low quality) (115,116).

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• Prophylactic antibiotics are generally not recommended for Cu-IUD or LNG-IUD insertion.

Comments and Evidence Summary. Theoretically, IUD insertion could induce bacterial spread and lead to complications such as PID or infective endocarditis. A metaanalysis was conducted of randomized controlled trials examining antibiotic prophylaxis versus placebo or no treatment for IUD insertion (120). Use of prophylaxis reduced the frequency of unscheduled return visits but did not significantly reduce the incidence of PID or premature IUD discontinuation. Although the risk for PID was higher within the first 20 days after insertion, the incidence of PID was low among all women who had IUDs inserted (51). In addition, the American Heart Association recommends that the use of prophylactic antibiotics solely to prevent infective endocarditis is not needed for genitourinary procedures (121). Studies have not demonstrated a conclusive link between genitourinary procedures and infective endocarditis or a preventive benefit of prophylactic antibiotics during such procedures (121).

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These recommendations address when routine follow-up is needed for safe and effective continued use of contraception for healthy women. The recommendations refer to general situations and might vary for different users and different situations. Specific populations that might benefit from more frequent follow-up visits include adolescents, persons with certain medical conditions or characteristics, and persons with multiple medical conditions.

• Advise a woman to return at any time to discuss side effects or other problems, if she wants to change the method being used, and when it is time to remove or replace the contraceptive method. No routine follow-up visit is required.
• At other routine visits, health-care providers who see IUD users should do the following:
  • Assess the woman’s satisfaction with her contraceptive method and whether she has any concerns about method use.
  • Assess any changes in health status, including medications, that would change the appropriateness of the IUD for safe and effective continued use on the basis of U.S. MEC (e.g., category 3 and 4 conditions and characteristics).
  • Consider performing an examination to check for the presence of the IUD strings.
  • Consider assessing weight changes and counseling women who are concerned about weight changes perceived to be associated with their contraceptive method.

Comments and Evidence Summary. Evidence from a systematic review about the effect of a specific follow-up visit schedule on IUD continuation is very limited and of poor quality. The evidence did not suggest that greater frequency of visits or earlier timing of the first follow-up visit after insertion improves continuation of use (122) (Level of evidence: II-2, poor, direct). Evidence from four studies from a systematic review on the incidence of PID among IUD initiators, or IUD removal as a result of PID, suggested that the incidence of PID did not differ between women using Cu-IUDs and those using DMPA, COCs, or LNG-IUDs (123) (Level of evidence: I to II-2, good, indirect). Evidence on the timing of PID after IUD insertion is mixed. Although the rate of PID was generally low, the largest study suggested that the rate of PID was significantly higher in the first 20 days after insertion (51) (Level of evidence: I to II-3, good to poor, indirect).

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• Before Cu-IUD insertion, provide counseling about potential changes in bleeding patterns during Cu-IUD use. Unscheduled spotting or light bleeding, as well as heavy or prolonged bleeding, is common during the first 3–6 months of Cu-IUD use, is generally not harmful, and decreases with continued Cu-IUD use.
• If clinically indicated, consider an underlying gynecological problem, such as Cu-IUD displacement, an STD, pregnancy, or new pathologic uterine conditions (e.g., polyps or fibroids), especially in women who have already been using the Cu-IUD for a few months or longer and who have developed a new onset of heavy or prolonged bleeding. If an underlying gynecological problem is found, treat the condition or refer for care.
• If an underlying gynecological problem is not found and the woman requests treatment, the following treatment option can be considered during days of bleeding:
  • Nonsteroidal antiinflammatory drugs (NSAIDs) for short-term treatment (5–7 days)
• If bleeding persists and the woman finds it unacceptable, counsel her on alternative contraceptive methods, and offer another method if it is desired.

Comments and Evidence Summary. During contraceptive counseling and before insertion of the Cu-IUD, information about common side effects such as unscheduled spotting or light bleeding or heavy or prolonged menstrual bleeding, especially during the first 3–6 months of use, should be discussed (64). These bleeding irregularities are generally not harmful. Enhanced counseling about expected bleeding patterns and reassurance that bleeding irregularities are generally not harmful has been shown to reduce method discontinuation in clinical trials with other contraceptives (i.e., DMPA) (124,125).

Evidence is limited on specific drugs, doses, and durations of use for effective treatments for bleeding irregularities with Cu-IUD use; therefore, although this document includes general recommendations for treatments to consider, evidence for specific regimens is lacking.

A systematic review identified 11 articles that examined various therapeutic treatments for heavy menstrual bleeding, prolonged menstrual bleeding, or both among women using Cu-IUDs (126). Nine studies examined the use of various oral NSAIDs for the treatment of heavy or prolonged menstrual bleeding among Cu-IUD users and compared them to either a placebo or a baseline cycle. Three of these trials examined the use of indomethacin (127–129), another three examined mefenamic acid (130–132), and another three examined flufenamic acid (127,128,133). Other NSAIDs used in the reported trials included alclofenac (127,128), suprofen (134), and diclofenac sodium (135). All but one NSAID study (131) demonstrated statistically significant or notable reductions in mean total menstrual blood loss with NSAID use. One study among 19 Cu-IUD users with heavy bleeding suggested that treatment with oral tranexamic acid can significantly reduce mean blood loss during treatment compared with placebo (135). Data regarding the overall safety of tranexamic acid are limited; an FDA warning states that tranexamic acid is contraindicated in women with active thromboembolic disease or with a history or intrinsic risk for thrombosis or thromboembolism (136,137). Treatment with aspirin demonstrated no statistically significant change in mean blood loss among women whose pretreatment menstrual blood loss was >80 mL or 60–80 mL; treatment resulted in a significant increase among women whose pretreatment menstrual blood loss was <60 mL (138). One study examined the use of a synthetic form of vasopressin, intranasal desmopressin (300 µg/day), for the first 5 days of menses for three treatment cycles and found a significant reduction in mean blood loss compared with baseline (130) (Level of evidence: I to II-3, poor to fair, direct). Only one small study examined treatment of spotting with three separate NSAIDs and did not observe improvements in spotting in any of the groups (127) (Level of evidence: I, poor, direct).

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• Before LNG-IUD insertion, provide counseling about potential changes in bleeding patterns during LNG-IUD use. Unscheduled spotting or light bleeding is expected during the first 3–6 months of LNG-IUD use, is generally not harmful, and decreases with continued LNG-IUD use. Over time, bleeding generally decreases with LNG-IUD use, and many women experience only light menstrual bleeding or amenorrhea. Heavy or prolonged bleeding, either unscheduled or menstrual, is uncommon during LNG-IUD use.

Irregular Bleeding (Spotting, Light Bleeding, or Heavy or Prolonged Bleeding)

• If clinically indicated, consider an underlying gynecological problem, such as LNG-IUD displacement, an STD, pregnancy, or new pathologic uterine conditions (e.g., polyps or fibroids). If an underlying gynecological problem is found, treat the condition or refer for care.
• If bleeding persists and the woman finds it unacceptable, counsel her on alternative contraceptive methods, and offer another method if it is desired.

Amenorrhea

• Amenorrhea does not require any medical treatment. Provide reassurance.
  • If a woman’s regular bleeding pattern changes abruptly to amenorrhea, consider ruling out pregnancy if clinically indicated.
• If amenorrhea persists and the woman finds it unacceptable, counsel her on alternative contraceptive methods, and offer another method if it is desired

Comments and Evidence Summary. During contraceptive counseling and before insertion of the LNG-IUD, information about common side effects such as unscheduled spotting or light bleeding, especially during the first 3–6 months of use, should be discussed. Approximately half of LNG-IUD users are likely to experience amenorrhea or oligomenorrhea by 2 years of use (139). These bleeding irregularities are generally not harmful. Enhanced counseling about expected bleeding patterns and reassurance that bleeding irregularities are generally not harmful has been shown to reduce method discontinuation in clinical trials with other hormonal contraceptives (i.e., DMPA) (124,125). No direct evidence was found regarding therapeutic treatments for bleeding irregularities during LNG-IUD use.

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• Treat the PID according to the CDC Sexually Transmitted Diseases Treatment Guidelines (15).
• Provide comprehensive management for STDs, including counseling about condom use.
• The IUD does not need to be removed immediately if the woman needs ongoing contraception.
• Reassess the woman in 48–72 hours. If no clinical improvement occurs, continue antibiotics and consider removal of the IUD.
• If the woman wants to discontinue use, remove the IUD sometime after antibiotics have been started to avoid the potential risk for bacterial spread resulting from the removal procedure.
• If the IUD is removed, consider ECPs if appropriate. Counsel the woman on alternative contraceptive methods, and offer another method if it is desired.
• A summary of IUD management in women with PID is provided (Appendix F).

Comments and Evidence Summary. Treatment outcomes do not generally differ between women with PID who retain the IUD and those who have the IUD removed; however, appropriate antibiotic treatment and close clinical follow-up are necessary.

A systematic review identified four studies that included women using copper or nonhormonal IUDs who developed PID and compared outcomes between women who had the IUD removed or did not (140). One randomized trial showed that women with IUDs removed had longer hospitalizations than those who did not, although no differences in PID recurrences or subsequent pregnancies were observed (141). Another randomized trial showed no differences in laboratory findings among women who removed the IUD compared with those who did not (142). One prospective cohort study showed no differences in clinical or laboratory findings during hospitalization; however, the IUD removal group had longer hospitalizations (143). One randomized trial showed that the rate of recovery for most clinical signs and symptoms was higher among women who had the IUD removed than among women who did not (144). No evidence was found regarding women using LNG-IUDs (Level of evidence: I to II-2, fair, direct).

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• Evaluate for possible ectopic pregnancy.
• Advise the woman that she has an increased risk for spontaneous abortion (including septic abortion that might be life threatening) and of preterm delivery if the IUD is left in place. The removal of the IUD reduces these risks but might not decrease the risk to the baseline level of a pregnancy without an IUD.
  • If she does not want to continue the pregnancy, counsel her about options.
  • If she wants to continue the pregnancy, advise her to seek care promptly if she has heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever.

IUD Strings Are Visible or Can Be Retrieved Safely from the Cervical Canal

• Advise the woman that the IUD should be removed as soon as possible.
  • If the IUD is to be removed, remove it by pulling on the strings gently.
  • Advise the woman that she should return promptly if she has heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever.
• If she chooses to keep the IUD, advise her to seek care promptly if she has heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever.

IUD Strings Are Not Visible and Cannot Be Retrieved Safely

• If ultrasonography is available, consider performing or referring for ultrasound examination to determine the location of the IUD. If the IUD cannot be located, it might have been expelled or have perforated the uterine wall.
• If ultrasonography is not possible or the IUD is determined by ultrasound to be inside the uterus, advise the woman to seek care promptly if she has heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever.

Comments and Evidence Summary. Removing the IUD improves the pregnancy outcome if the IUD strings are visible or the device can be retrieved safely from the cervical canal. Risks for spontaneous abortion, preterm delivery, and infection are substantial if the IUD is left in place.

Theoretically, the fetus might be affected by hormonal exposure from an LNG-IUD; however, whether this exposure increases the risk for fetal abnormalities is unknown.

A systematic review identified nine studies suggesting that women who did not remove their IUDs during pregnancy were at greater risk for adverse pregnancy outcomes (including spontaneous abortion, septic abortion, preterm delivery, and chorioamnionitis) compared with women who had their IUDs removed or who did not have an IUD (41). Cu-IUD removal decreased risks but not to the baseline risk for pregnancies without an IUD. One case series examined LNG-IUDs. When they were not removed, eight in 10 pregnancies ended in spontaneous abortions (Level of evidence: II-2, fair, direct).

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