The recommendation grades (A to C, Good Practice Point) are defined at the end of the "Major Recommendations" field.
Which Women Are Eligible to Use Intrauterine Contraception?
- Health professionals should be familiar with UK Medical Eligibility Criteria for Contraceptive Use recommendations for intrauterine contraceptive use (Good Practice Point).
Note: Table 2 in the original guideline document summarizes the
UK Medical Eligibility Criteria for Contraceptive Use where a copper intrauterine device (Cu-IUD) and the levonorgestrel-releasing intrauterine system (LNG-IUS) are given the same UKMEC categories and highlighting where categories differ between the Cu-IUD and the LNG-IUS6.
What Should Clinicians Assess When a Woman Is Considering Intrauterine Contraception?
Clinical Assessment
- A clinical history (including sexual history) should be taken as part of the routine assessment for intrauterine contraception to assess suitability for use of the method and identify those at higher risk of sexually transmitted infections (STIs) (i.e., those aged <25 years, or >25 years with a new sexual partner or more than one partner in the last year, or if their regular partner has other partners) (Grade C).
- In advance of intrauterine contraceptive insertion women who are either at higher risk of STI or who request swabs should be tested for Chlamydia trachomatis (as a minimum) and Neisseria gonorrhoeae (if deemed necessary from the history) (Good Practice Point).
- For women at higher risk of STIs, if results are unavailable before insertion prophylactic antibiotics (at least to cover C. trachomatis) may be considered (Good Practice Point).
- In asymptomatic women attending for insertion of intrauterine contraception there is no indication to test or treat other lower genital tract organisms or delay insertion until the results of tests are available (Good Practice Point).
- Women with previous endocarditis or with a prosthetic heart valve require intravenous antibiotic prophylaxis to protect against bacterial endocarditis during intrauterine contraception insertion or removal (Grade C).
- When prophylaxis against bacterial endocarditis is required, clinicians should refer to the British National Formulary (BNF) for the most up-to-date regimen and ensure the intrauterine contraceptive procedure takes place in an appropriate setting (Good Practice Point).
What Information Should Be Given to Women When Counselling Them About Intrauterine Contraception?
Mode of Action
- Women should be informed that the primary mode of action of a Cu-IUD is prevention of fertilisation (Grade B).
- Women should be informed that the LNG-IUS works primarily by its effect on the endometrium preventing implantation. In addition, effects on cervical mucus reduce sperm penetration (Grade B).
Contraceptive Efficacy
- Women should be advised of low failure rates for intrauterine contraception at 5 years use: less than 2% with TCu380A and TCu380S and less than 1% with the LNG-IUS (Grade C).
- The TCu380S and the LNG-IUS are the most effective intrauterine devices available (Grade A).
Duration of Use
- TCu380A and TCu380S can remain in place for 10 years and other Cu-IUDs for 5 years (Grade C).
- TCu380S is recommended as a first-choice Cu-IUD to minimise the established risks associated with reinsertion (Grade C).
- After counselling (about declining fertility, risks associated with insertion and contraceptive efficacy) women who have a Cu-IUD inserted at the age of 40 years or over can retain the device for 1 year after the last menstrual period if aged over 50 years (or 2 years if under 50 years) or until contraception is no longer required (Grade C).
- Women should be informed that the LNG-IUS is licensed for 5 years of use as a contraceptive (Grade C).
- Women who have the LNG-IUS inserted at the age of 45 years or over for contraception can retain the device until the menopause is confirmed or until contraception is no longer required (Good Practice Point).
Perforation
- Women should be informed that uterine perforation associated with intrauterine contraception is up to 2 per 1000 insertions (Grade B).
Expulsion
- The risk of expulsion with intrauterine contraception is around 1 in 20 and is most common in the first year of use, particularly within 3 months of insertion (Grade B).
- In general, there are no differences in the rates of expulsion between different Cu-IUDs and between Cu-IUDs and the LNG-IUS (Grade A).
Risk of Ectopic Pregnancy
- Women should be informed that the overall risk of ectopic pregnancy is reduced with use of intrauterine contraception when compared to using no contraception and no particular device is associated with a lower rate of ectopic pregnancy (Grade A).
Return to Fertility
- Women may be advised that there is no delay in return to fertility after removal of intrauterine contraception (Grade B).
Pelvic Infection
- Women should be advised there may be an increased risk of pelvic infection in the 20 days following insertion of intrauterine contraception but the risk is the same as the non-IUD-using population thereafter (Grade B).
Bleeding Patterns and Pain
- Women should be informed that spotting, light bleeding, heavier or prolonged bleeding are common in the first 3 to 6 months of Cu-IUD use (Grade C).
- Women can be informed that discontinuation due to bleeding and pain are similar for different types of framed and unframed Cu-IUDs (Grade A).
- Women should be informed that irregular bleeding and spotting is common in the first 6 months after insertion of the LNG-IUS but by 1 year amenorrhoea or light bleeding is usual (Grade B).
Hormonal Side Effects
- Women considering the LNG-IUS can be informed that systemic absorption of progestogen occurs; however, rates of discontinuation due to side effects (such as acne and headache) are not significantly different from Cu-IUD users (Grade C).
Ovarian Cysts
- Women may be informed that although ovarian cysts may occur when using the LNG-IUS they are rarely a clinical problem (Grade B).
Non-Contraceptive Benefits
- The LNG-IUS can be used in the management of idiopathic menorrhagia and/or to provide endometrial protection in conjunction with estrogen therapy (Grade B).
Information About the Insertion Procedure
- Discomfort during and/or after intrauterine contraceptive insertion should be discussed with women during counselling (Good Practice Point).
Choice of Device
- Health care professionals should enable women to choose an intrauterine method based on medical eligibility and the woman's preference (Good Practice Point).
- If women choose a Cu-IUD the TCu380S is recommended as it is the most effective and has the longest duration of use (Grade A).
When Can Intrauterine Contraception Be Safely Inserted?
- A Cu-IUD can be inserted at any time in the menstrual cycle if it is reasonably certain the woman is not pregnant (Grade C). See table below.
- The LNG-IUS can be inserted at any time in the menstrual cycle if it is reasonably certain the woman is not pregnant and the clinician is reasonably certain there has been no risk of conception (Good Practice Point).
- After counselling, and when intrauterine contraception is the preferred method, it may be inserted by an experienced clinician any time after abortion if there is no suspicion that the pregnancy is ongoing (Good Practice Point).
Table. Recommendations for Timing Insertion of Intrauterine Contraception as a Long-term Contraceptive Option
| Circumstances When Intrauterine Contraception Can Be Inserted |
Recommendations for Timing of Insertion |
| In all circumstances |
A Cu-IUD can be inserted at any time in the menstrual cycle if it is reasonably certaina the woman is not pregnant. A Cu-IUD is effective immediately
The LNG-IUS can be inserted at any time in the menstrual cycle if it is reasonably certaina the woman is not pregnant and the clinician is reasonably certain there is no risk of conception. Condoms or abstinence should be advised for 7 days after inserting the LNG-IUS unless inserted in the first 7 days of the cycle
|
| Postpartum (including post-Caesarean section and breastfeeding) |
Insert from 4 weeks postpartum as above |
| Following abortion |
Ideally insert at the time of a first- or second-trimester surgical abortion for immediate contraceptive effect
Following medical or surgical abortion ideally insert within the first 48 hours or delay until 4 weeks postpartum. However, waiting until 4 or more weeks post-termination may put women at risk of pregnancy. After counselling and when intrauterine contraception is the preferred method it can be inserted by an experienced clinician at any time post-abortion if there is no concern that the pregnancy is ongoing
|
| Switching from another method of contraception |
Intrauterine contraception can be inserted at any time if another method of contraception has been used consistently and correctly. Insert any time if it is reasonably certaina that the woman is not pregnant. There is no need to wait for the next menstrual period or withdrawal bleed
A Cu-IUD is effective immediately. Condoms or abstinence may need to be advised for 7 days after inserting the LNG-IUS unless the current contraceptive method is still effective (e.g., <12 weeks since last progestogen-only injection; within 3 years of insertion of a subdermal implant; no later than Day 1 of the hormone-free interval for pills or patch)
|
aA provider can be reasonably certain a woman is not pregnant if she has no symptoms or signs of pregnancy and meets any of the following criteria:
- Has not had intercourse since last normal menses
- Has been correctly and consistently using a reliable method of contraception
- Is within the first 7 days after normal menses
- Is within the first 7 days post-abortion or miscarriage
- Is fully or nearly fully breastfeeding, amenorrhoeic, and less than 6 months postpartum.
Cu-IUD, copper intrauterine device; LNG-IUS, levonorgestrel intrauterine system.
How Can Safe Insertion of Intrauterine Contraception Be facilitated?
Training
- Clinicians who insert intrauterine contraception should be appropriately trained, maintain competence and attend regular updates in dealing with emergencies (Grade C).
Informed Consent
- Informed consent should be given by women prior to insertion of intrauterine contraception (Good Practice Point).
Assistants and Chaperones
- An appropriate trained assistant who can monitor the condition of the patient and assist in an emergency should be present during insertion of intrauterine contraception (Good Practice Point).
Pain Relief
- The need for pain relief during insertion of intrauterine contraception should be discussed with the woman in advance and administered when appropriate (Good Practice Point).
Emergency Management for Problems at Intrauterine Device Insertion
- Emergency equipment must be available in all settings where intrauterine contraception is being inserted and local referral protocols must be in place for women who require further medical input (Grade C).
Note: See Table 5 in the original guideline document 'Emergencies and insertion of intrauterine contraception: resuscitation measures and contents of an emergency pack'.
Practical Procedures for Intrauterine Insertions
Bimanual Examination
- A bimanual pelvic examination should be performed on all women before inserting intrauterine contraception (Grade C).
Measurement of Pulse Rate and Blood Pressure
- Pulse rate and blood pressure should be assessed and documented when appropriate and depending on the clinical situation when inserting intrauterine contraception (Good Practice Point).
Cervical Cleansing
- Cleansing the ectocervix prior to insertion of intrauterine contraception has no proven benefit (Good Practice Point).
Sterile Gloves
- A 'no-touch' technique should be used when sounding the uterine cavity and inserting intrauterine contraception. If this technique is used then sterile gloves are not required (Good Practice Point).
Use of Forceps and Assessment of the Uterine Cavity
- During insertion of intrauterine contraception clinicians should stabilise the cervix with forceps and assess the length of the uterine cavity to facilitate fundal placement and reduce the risk of perforation (Grade C).
Documentation
- Documentation should be made in the case notes to record appropriate pre- and post-insertion counselling, the insertion procedure and the type of device inserted (Grade C).
Note: See Box 1 in the original guideline document for appropriate information to document when inserting intrauterine contraception.
What Information Should Be Given to Women About Ongoing Use of Intrauterine
Contraception and Follow-Up?
Information About the Device
- Women should be given information (oral and written) about the device inserted and the expected duration of use (Good Practice Point).
Checking Threads and Device
- Women should be offered instruction on how to check for the intrauterine contraceptive and its threads and advised that if they are unable to feel them it may be that the device has been expelled. Alternative contraception should then be used until they seek medical advice (Good Practice Point).
Reducing the Risk of STIs
- If a woman chooses intrauterine contraception and is at higher risk of STIs (i.e., aged <25 years, or aged >25 years with a new sexual partner, or more than one partner in the last year, or if their regular partner has other partners) she should be advised to use condoms in addition to the intrauterine method (Good Practice Point).
Symptoms Requiring Medical Attention
- Women should be advised to seek medical assistance at any time if they develop symptoms of pelvic infection, pain, persistent menstrual abnormalities, missed period, non-palpable threads or can feel the stem of the intrauterine device (Grade C).
Routine Follow-Up
- A routine follow-up visit should be advised after the first menses following insertion of intrauterine contraception or 3 to 6 weeks later (Grade C).
Managing Problems Associated with Intrauterine Contraception
Recommendations and good practice points for managing problems associated with intrauterine contraception are summarised in the table below.
Table. Managing Common Problems Associated with Intrauterine Contraception
| Problems Associated with Intrauterine Contraception |
Management |
| Suspected perforation at the time of insertion |
The procedure should be stopped and vital signs (blood pressure and pulse rate) and level of discomfort monitored until stable
An ultrasound scan and/or plain abdominal X-ray to locate the device if it has been left in situ should be arranged as soon as possible
|
| 'Lost threads' |
Advise women to use another method (condoms or abstinence) until medical review. Consider the need for emergency hormonal contraception
If no threads are seen and uterine placement of the intrauterine method cannot be confirmed clinically, an ultrasound scan should be arranged to locate the device and alternative contraception recommended until this information is available
If an ultrasound scan cannot locate the intrauterine method and there is no definite evidence of expulsion, a plain abdominal X-ray should be arranged to identify an extrauterine device
If the intrauterine method is not confirmed on an ultrasound scan clinicians should not assume it has been expelled until a negative X-ray is obtained (unless the woman has witnessed expulsion)
Hysteroscopy is not readily available in all settings but can be useful if the ultrasound scan is equivocal. Surgical retrieval of an extrauterine device is advised
|
| Abnormal bleeding |
Gynaecological pathology and infections should be excluded if abnormal bleeding persists beyond the first 6 months following insertion of intrauterine contraception
Women using the LNG-IUS who present with a change in pattern of bleeding should be advised to return for further investigation to exclude infections, pregnancy and gynaecological pathology
For women using a Cu-IUD, non-steroidal anti-inflammatory drugs can be used to treat spotting, light bleeding heavy or prolonged menstruation. In addition antifibrinolytics (such as tranexamic acid) may be used for heavy or prolonged menstruation
|
| Pregnancy |
Most pregnancies in women using intrauterine contraception will be intrauterine but an ectopic pregnancy must be excluded
Women who become pregnant with an intrauterine contraception in situ should be informed of the increased risks of second-trimester miscarriage, preterm delivery and infection if the intrauterine method is left in situ. Removal would reduce adverse outcomes but is associated with a small risk of miscarriage
If the threads are visible, or can easily be retrieved from the endocervical canal, the intrauterine contraceptive should be removed up to 12 weeks' gestation
If there is no evidence that the intrauterine method was expelled prior to pregnancy it should be sought at delivery or termination and, if not identified, a plain abdominal X-ray should be arranged to determine if the intrauterine method is extrauterine
|
| Suspected pelvic infection |
For women using intrauterine contraception with symptoms and signs suggestive of pelvic infection appropriate antibiotics should be started. There is no need to remove the intrauterine method unless symptoms fail to resolve within the following 72 hours or unless the woman wishes removal
All women with confirmed or suspected PID should be followed up to ensure: resolution of symptoms and signs, their partner has also been treated when appropriate, completion of the course of antibiotics, STI risk assessment, counselling regarding safer sex and partner notification
|
| Presence of actinomyces-like organisms (ALO) |
Intrauterine contraceptive users with ALO detected on a swab who have no symptoms should be advised there is no reason to remove the intrauterine method unless signs or symptoms of infection occur. There is no indication for follow-up screening. If symptoms of pelvic pain occur women should be advised to seek medical advice. Other causes of infection (in particular STIs) should be considered and it may be appropriate to remove the intrauterine method |
Timing the Removal of Intrauterine Contraception
Advice regarding the removal of intrauterine contraception varies depending on the reason for removal and if there is any wish to continue to avoid pregnancy (See Table below).
Table. Recommendations for Removal of Intrauterine Contraception
| Reason for Removal |
Recommendations for Removal |
| For a planned pregnancy |
Remove at any time in the menstrual cycle (offer pre-pregnancy advice regarding folic acid, rubella immunity) |
| When removal and replacement is at the end of the licensed duration of use |
Remove at any time in the menstrual cycle. If pregnancy is to be avoided remove in the first few days after the onset of menstruation or advise condoms or abstinence from sexual intercourse for at least 7 days before the procedure in case re-insertion is not possible |
| When removal and replacement is outside the licensed duration of use |
Postmenopausal Removal
A Cu-IUD inserted at or after the age of 40 years can be retained until 1 year after the LMP if this occurs when the woman is over the age of 50 years
A Cu-IUD inserted at or after the age of 40 years can retained until after the LMP but if this occurs under the age of 50 years the device should be retained for a further 2 years
The LNG-IUS can continue to be used as contraception for 7 years if inserted at or after the age of 45 years. Use beyond this time can be discussed with individual patients
Management of Menorrhagia
If the LNG-IUS is being used in the management of menorrhagia (and not for contraception or with estrogen-replacement therapy) it can be retained beyond the 5-year licensed duration of use if bleeding patterns are acceptable
|
Definitions:
Grades of Recommendations
A: Evidence based on randomised controlled trials (RCTs)
B: Evidence based on other robust experimental or observational studies
C: Evidence is limited but the advice relies on expert opinion and has the endorsement of respected authorities
Good Practice Point: Where no evidence exists but where best practice is based on the clinical experience of the Multidisciplinary Group
