Key Learning Points: Intrauterine Contraception

Dr Toni Hazell Explains the Role of Intrauterine Devices in the Provision of Contraception, Offering 10 Key Learning Points from Updated British Guidance

Intrauterine contraception (IUC) is a method of long-acting reversible contraception (LARC) that has significant benefits for many women, but is often overlooked or poorly understood.¹ Over the past couple of decades, its use has slowly increased in the UK: 1.2% of women aged 15–49 years used IUC in 2000, rising to 1.9% in 2018.² However, the COVID-19 pandemic significantly impacted this trend, as total IUC provision fell by 78% from April–June 2019 to April–June 2020.³ To date, provision may still not have recovered to prepandemic levels.

The Faculty of Sexual & Reproductive Healthcare (FSRH) updated its guidance on IUC in July 2023.⁴ This article offers 10 key learning points for primary care practitioners on this contraceptive option, with reference to this and other relevant guidance.

A Note on Terminology

Intrauterine devices (IUDs) can be copper or can contain a progestogen (levonorgestrel). The 2023 FSRH guidance suggests using the terms ‘copper IUD (Cu-IUD)’ and ‘levonorgestrel IUD (LNG-IUD)’ to refer to these two types,⁴ so these terms and abbreviations will be used in this article. However, many resources still use the older term ‘intrauterine system (IUS)’, which is synonymous with LNG-IUD. Also, patients will often refer to ‘the copper/nonhormone coil’ and ‘the hormone coil’ during consultations.

The words woman/women and the pronouns she/her are used throughout this article as, by definition, anyone who uses an IUD is of the female sex. Some patients who use an IUD may have a gender identity that is not female, and healthcare professionals should respect their preferred gender identity and pronouns.^4,5 

1. Begin Contraception Consultations with Effective History Taking

Clinicians discussing contraception with patients must ascertain their expectations and concerns.⁶ A patient’s opening gambit of ‘I’d like to go on the pill’ can have two meanings: they may have done extensive research and decided that the pill is the right form of contraception for them, or they may be using the phrase ‘the pill’ to mean ‘some form of contraception’ and have little knowledge of the different types available. If primary care clinicians take the statement at face value and provide a prescription for the pill, they may save some time; however, that decision could be the cause of a future unwanted pregnancy or a loss of faith in contraception for the patient, because the pill was never suitable for her and she does not know that there are other options available. 

Considering Individual Priorities and Circumstances

A woman seeking contraception may have a range of priorities depending on her age, her relationship, and her future plans for pregnancy:

• for a 36-year-old woman who wants to try to conceive in 6 months when she becomes eligible for paid maternity leave, rapid reversibility will be key
• for a teenager living at home, the main priority may be that her mother does not find a packet of pills in her room
• for a woman with heavy or painful periods, a method that causes amenorrhoea would probably be welcome; however, in some cultures, amenorrhoea is disapproved of.

Therefore, a history that covers the woman’s expectations and preferences, as well as any relevant medical history that may support or contraindicate a particular contraceptive option, is essential to contraception counselling.⁶ Clinicians should prioritise helping a woman to find the right contraception for her.⁶ 

2. Inform Patients of the Practical Benefits of LARC Over Alternative Methods of Contraception

Broadly speaking, there are two different types of contraception: those which require a daily or weekly action (such as the pill or patch), and LARC methods that require administration less than once per cycle or month.⁷ LARC can be particularly useful for women who think they may forget a pill or a patch and, in general, these methods have a lower real-life failure rate than others that require regular action (see Table 1).^4,8 With typical use, only 0.8% and 0.2% of women using the Cu-IUD and LNG-IUD, respectively, experience an unintended pregnancy within the first year of use.^4,8 

Other benefits of LARC methods include needing to see a healthcare professional far less often, the immediate return to fertility on removal (with the exception of the depot injection), and in some cases immediate efficacy when inserted, if this is done at an appropriate time in the cycle.^4,9 LNG-IUDs also usually make a woman’s periods lighter, shorter, and less painful, and these methods are often particularly useful for those women for whom combined hormonal contraception is contraindicated.⁹ 

Table 1: Summary of the Efficacy of Contraceptive Methods Available in the UK⁸

3. Consider the Noncontraceptive Indications for IUDs

Many methods of contraception have other benefits, such as a reduction in menorrhagia¹⁰ or dysmenorrhoea,¹¹ treatment of endometriosis¹² and other gynaecological conditions,¹³ control or eradication of the menstrual cycle,¹⁴ and use as part of hormone-replacement therapy (HRT).^4,15 IUDs are no different. There are several reasons to use IUC, all of which should be considered by clinicians when helping a patient to choose a method of contraception.^4,9 An individual woman may use her IUD for more than one of these indications:^{4,9,10,12,16,17}

• as a highly reliable method of contraception—the Cu-IUD is particularly useful for women who have contraindications or adverse effects that preclude the use of hormonal contraception
• to treat heavy menstrual bleeding (LNG-IUD only)
• as part of treatment for endometriosis (LNG-IUD only)
• as the progestogenic component of HRT (LNG-IUD only)
• to treat endometrial hyperplasia (LNG-IUD only; unlicensed use).

There are various brands of LNG-IUD available in the UK, which have different licensed indications and doses (see Table 2).^4,18,19 There are also various brands of Cu-IUD available which vary in terms of licensed use duration.^4,20 In routine practice, the main reason to choose a shorter-duration device would be that they tend to have a smaller frame, which can be useful if fitting is difficult for any reason.^4,20

The 2023 update of the FSRH IUC guideline advises that all 52-mg LNG-IUDs can be used for the progestogenic component of HRT.^4,18 FSRH guidance is generally considered the gold standard in the UK, so it is reasonable for clinicians to follow this. However, it is worth noting that two of the three 52-mg LNG-IUDs available do not have a licence for this use (Benilexa® and Levosert®).^4,18,19

Table 2: LNG-IUDs Available in the UK^4,18,19

4. Debunk Myths About Who Cannot Have an IUD…

Contrary to common misconceptions, IUDs can be used by all of the following groups:^4,21

• adolescents
• women who have never had sex (although fitting may be technically more challenging)
• women who have never given birth vaginally
• trans men who wish to control periods that may trigger gender dysphoria and/or who need contraception
• women who have had a previous ectopic pregnancy
• women who have had pelvic inflammatory disease (PID) in the past
• women who are having an abortion—an IUD can be fitted during a surgical abortion; it can also be fitted at the time of surgical management of a miscarriage or ectopic pregnancy
• women who have fibroids, as long as they are less than 3 cm in size and there is no cavity distortion; fitting may be possible with larger fibroids, but would usually be done in secondary care
• women who have had an endometrial ablation, if done in secondary care with ultrasound and hysteroscopy available
• women who are immunosuppressed (advice should be sought from their specialist as to whether prophylactic antibiotics are needed at the time of fitting)
• women with adrenal insufficiency (who should have the fitting scheduled for the early morning and increase their steroid dose before, and for 24 hours after, fitting)
• women with cardiac disease, although there are certain exceptions and this decision should be discussed with their cardiologist; fitting may need to be done in hospital
• women who are anticoagulated, provided that the fitter is experienced and haemostatic agents are available; for those with an inherited bleeding disorder, advice should be sought from their haematologist.

Ectopic Pregnancy

It is often said that IUC increases the risk of ectopic pregnancy, but this is not correct. The risk of any type of pregnancy is very low when an IUD is in situ, and the absolute risk of an ectopic pregnancy in women with an IUD is much lower than in those using no contraception.⁴ However, should the device fail, the proportion of pregnancies that are ectopic is much higher than in women who are pregnant but do not have a device in situ—as high as 53% in one cross-sectional study,²² compared with 1.1% among all UK pregnancies.⁴ Pregnancies that occur in spite of the presence of an IUD are also more likely to have other adverse outcomes, such as miscarriage, premature delivery, and septic abortion.⁴

A positive pregnancy test in a woman with an IUD fitted should therefore prompt urgent assessment to confirm the site of the pregnancy.⁴ If the pregnancy is intrauterine, removal is possible before 12 weeks’ gestation, and if the IUD’s threads are visible, the device should usually be removed.⁴ Removal (or the decision not to remove) should be handled by a specialist.⁴

5. …But Be Conscious of the True Contraindications for IUDs 

Table 3 lists the key reasons not to fit an IUD.^4,21 Details on contraindications to all contraceptive methods are outside of the scope of this article, but the UK Medical Eligibility Criteria for Contraceptive Use (UKMEC)²¹ is the gold standard and can be found online.²³ If in doubt, the UKMEC should be consulted.^21,23 

Of note, Wilson’s disease is not mentioned in the UKMEC.²¹ This is a rare genetic disease of copper metabolism, where copper is accumulated in the organs and tissues. The FSRH guidance discusses Wilson’s disease, noting that there is very limited evidence as to whether the use of a Cu-IUD would contribute to copper accumulation in the body, and that most studies do not show a significant increase in copper levels in users of a Cu-IUD.⁴ The guidance concludes that, to avoid any potential risk, a Cu-IUD should not be used in someone with Wilson’s disease.⁴ 

Table 3: Contraindications for IUDs^4,21

6. Offer Cu-IUDs as Emergency Contraception

The Cu-IUD is more effective as emergency contraception (EC) than any oral method currently available, and should always be offered.²⁴ For women with regular cycles, the Cu-IUD can be fitted for this reason up to 5 days after the earliest estimated date of ovulation or the first instance of unprotected sex in a menstrual cycle, and can cover multiple episodes of unprotected sex in that cycle.²⁴ It can then be kept for ongoing contraception, or removed after the next period if not wanted for that reason.^4,24 The LNG-IUD cannot be used for EC.²⁴

7. Discuss the Reasons for Choosing an IUD, and Explain How Long the Device Can Be Used for

An IUD’s duration of use varies ranges from 3–10 years depending on the type of device, the dose of levonorgestrel (for an LNG-IUD), and the patient's age at fitting.^4,18,20,25 With this in mind, it is important that women are made aware of the duration indicated for their IUC, as well as any other relevant information regarding its use.⁴ Women using a device for two reasons with different durations should have the device replaced at the earlier duration—for example, a perimenopausal woman using a 52-mg LNG-IUD for contraception and as part of HRT should have it replaced within 5 years (as recommended for HRT use), not 6.⁴

The durations in Table 4 are as recommended in the 2023 FSRH guideline⁴ rather than the product licence, which is in some cases shorter.¹⁸ For a woman who is using the LNG-IUD purely for heavy bleeding, with no need for contraception or HRT, it can stay in for as long as it is controlling the symptoms.²⁶ 

Table 4: FSRH Recommended Durations of Use for IUDs^4,18

8. Counsel Women on the Possible Risks of an IUD

Before an IUD is fitted, the patient must be informed not only about the device itself, but also about potential side effects, risks associated with the procedure, and actions to take once the IUD is in situ.⁴ The key risks associated with IUD fitting are as follows:^4,9

• there is a very small risk of pelvic infection in the 3 weeks after fitting—this is likely to be less than 1%, but patients should be advised to report any symptoms of pelvic infection, such as high temperature, pelvic pain, or unusual vaginal discharge
• there is a small risk of perforation of the uterus (approximately 1–2 per 1000 women), which is increased if the woman is 2–28 days postnatal or if she is breastfeeding
• the overall risk of expulsion of the device is around 5%; this is most common in the first 3 months after fitting, and women should check for the threads regularly (for example, monthly or after menses); if threads cannot be felt, they should see a healthcare professional and use another means of contraception until this can be arranged.

Patients should also be informed that their bleeding patterns are likely to change with IUD use.⁴ The Cu-IUD is associated with heavier periods and intermenstrual bleeding, which often decreases over time; with the LNG-IUD, there is an altered bleeding pattern that also decreases over time, with a trend towards amenorrhoea or infrequent bleeding that is more likely for the higher-dose devices.^4,9

9. Do Not Give All Women a Chlamydia Swab Before an IUD Fitting

For many years, it has been considered good practice to fit an IUD (with the exception of emergency fitting) only if there is a negative chlamydia swab in a patient’s notes. However, the latest FSRH guidance does not recommend routine chlamydia screening.⁴

In terms of infection, IUC fitting is contraindicated if the patient has current PID, known gonorrhoea, symptomatic chlamydia, purulent cervicitis, or postpartum or postabortion sepsis (see Table 3).^4,21 Even if none of these is present and the person has no contraindications or symptoms related to a sexually transmitted infection (STI), a sexual history should still be taken before the IUD is fitted.^4,21 If there are risk factors for STI but no symptoms, the IUD can still be fitted without the need for prophylactic antibiotic treatment, with a swab taken for screening at the time of insertion.⁴ Routine screening is otherwise unnecessary.⁴ 

If an individual has symptoms of an STI or PID, intrauterine fitting should ideally be delayed until test results are available and any infection has been treated.⁴ However, if a Cu-IUD is being used for EC, this delay is not possible.⁴ In this situation, if the individual has a partner with known gonorrhoea or chlamydia, or they have symptoms for which chlamydia and gonorrhoea cannot be excluded as a cause, prophylactic antibiotics could be given on the same day as the EC Cu-IUD fitting.⁴ For known chlamydia, the emergency Cu-IUD can be fitted on the same day as treatment initiation.⁴

10. Consider Learning to Fit IUDs in General Practice

To fit an IUD, a practitioner must hold the FSRH Letter of Competence Intrauterine Techniques (LoC IUT), or must have an equivalent recognised accreditation.⁴ The FSRH will accredit a variety of healthcare professionals to do this training, as long as they have the appropriate experience and skills and are registered with one of the regulatory bodies listed on the FSRH website.²⁷ These include the General Medical Council and the Nursing & Midwifery Council.²⁷ Holding the diploma of the FSRH is no longer a prerequisite for doing the LoC IUT.²⁷

Summary

Provision of contraception is an everyday part of general practice, and it is important that GPs and other primary care practitioners are aware of the advantages and disadvantages of different methods. With effective contraceptive counselling, practitioners can discuss each patient’s needs and help them to find the right method for them. In many cases, this will be an IUD.