Use of Intrauterine Devices

for Contraception

Amber Anderson

Objectives

1. Describe the three different types of IUDs

Used for Contraception in the U.S.
2. Identify Patients in which IUDs can be
inserted
3. List Advantages of IUD Use for Contraception
4. List Adverse Effects of IUDs.

Introduction

Intrauterine Devices (IUDs) are long acting

reversible contraceptives (LARCs) that are
considered to be one of the most effective
forms of contraception.
IUDs require a single act of motivation for
long-term use, eliminating adherence and
user-dependence from limiting
effectiveness

IUD Prevalence

IUDs are chosen by 5.5-7.7% of women using

contraception in the United States
By comparison, IUD prevalence is 14.1% in the
developing world broadly.

IUD Prevalence

In many other countries, the IUD use rate is

considerably higher
5.5-7.7% in U.S
30% in Israel
34% in China
49% in Korea
52% in Uzbekistan.

Concern with unplanned

pregnancies/Abortions in the U.S

An increase in IUD use has the potential to reduce unintended

pregnancy rates and abortions
Approximately 3 million pregnancies in the U.S. each year, 50%
of which are unplanned and thought to be secondary to
contraceptive failure.
82% unplanned pregnancies in those age 19 and younger in U.S
In 2010, 765,651 legal induced abortions were reported to CDC

First Line
Contraception

ACOG recommends that they be offered as

first-line contraceptive methods and
encouraged as options for most women.
Oral Contraceptive Pills (42%) and condoms
(20%) are currently the most common used
forms of contraception in the U.S.

% of Women Experiencing
Unintended Pregnancy in 1st Year
With Typical Use

Implant- 0.05%
Male Sterilization- 0.15%

Levonorgestrel IUD- 0.2%

Female Sterilization- 0.5%

Copper IUD- 0.8%

Injection (Depo-Provera)- 6%
Combined Pill and Progestin only pill- 9%
Patch- 9%
Vaginal Ring- 9%
Male Condom- 18%; Female Condom- 21%
Withdrawal- 22%

Intrauterine Devices

There are 3 types of IUDs that are approved

for use in the United States
1. Copper T380 A (Paragard)
2. Levonorgestrel (Mirena)
3. Levonorgestrel (Skyla)

Hesitation for use of

IUDs in
the U.S.

http://www.wired.com/2011/07/ff_iud/

IUDs first gained popularity in the U.S. in 1959 after the first major article
about this method of contraception was published in the American Journal
of Obstetrics and Gynecology . Lippes Loop first type used in U.S.
In 1971, the Dalkon Shield was released. Because it was difficult to
remove, the Dalkon Shield was designed with a multifilament string which
facilitated the ascent of bacteria from the vagina into the uterus, leading
to pelvic inflammatory disease (PID) and other adverse outcomes

Shortly after its release, reports of serious complication, including

infection and septic abortion, became widespread. More than 300,000
shield related law suits were filed

The Food and Drug Administration (FDA) advised the manufacturer of the
Dalkon Shield to remove it from the market in 1974

http://www.drugs
.com/pro/paragar
d.html

Copper T380 IUD (Paragard)

http://www.drugs.com/pro/paragard.html

T-shaped polyethylene device with 380 mm2 of

exposed surface area of copper on its arms and stem.
MOA: Released copper ions interfere with sperm
mobility and incite a foreign-body reaction that results
in a spermicidal environment

Can remain in place for up to 10 years

Levonorgestrel (Mirena)

Radiopaque T-shaped device

with 52 mg of levonorgestrel on
its arms and stem released at a
rate of 20 mcg per day.
Can remain in place for up to
five years
http://www.drugs.com/pro/mirena.html\

Levonorgestrel
(Skyla)

Consists of a T-shaped radiopaque

polyethylene device with 13.5 mg of
levonorgestrel on its arms and stem
released at a rate of 14 mcg per day.
A ring composed of 99.95% pure
silver is located at the top of the
vertical stem close to the horizontal
arms and is visible by ultrasound.
Can remain in place for up to three
years

http://www.drugs.com/pro/skyla-iud.html

Levonorgestrel

MOA:
*thickening of cervical
mucus preventing passage
of sperm into the uterus

*inhibition of sperm
capacitation or survival
*alteration of the
endometrium.
http://www.drugs.com/pro/skyla-iud.html

Insertion

IUDs can be inserted at anytime during

menstrual cycle as long as pregnancy is
excluded and there is no active pelvic
inflammation

Insertion- Postpartum

IUDs can be inserted immediately after birth (10 min after

placental separation) or abortion
Advantages
- Patients are highly motivated to use contraception
- Safe and Effective
Disadvantage
- High expulsion rate (24%)
*Benefits outweigh the risk
*Contraindicated if Chorioamnionitis, Endometritis, or
Puerperal Sepsis

IUDs and STIs

In high risk patients, physicians should screen

for STIs. Can be done same day as IUD
placement.
Insertion of IUD should be postponed if:
1. mucopurulent discharge
2. known chlamydia or gonorrhea cervicitis
3. symptoms of PID present

Back-Up Contraception after

Insertion

No back-up method of contraception required

after Copper IUD
Should use back-up for Levonorgestrol IUD for
7 days, unless
1. Inserted within 5 days of menses initiation
2. immediately after birth or abortion
3. Immediately after switching from another hormonal
contraceptives

Advantages of Intrauterine
Devices

High effectiveness, continuation rates, and user satisfaction

Highly cost-effective, long term
Reversible, with rapid return to fertility after removal
Do not require:
- user motivation and adherence
- frequent visits for resupply
- additional funding for consistent use once placed

Common Adverse Effects,

>5%

Copper IUD
Heavy Menstrual bleeding/Abdominal PainCramping(from 11.9% in the first year to 2.2% in
year 9)
Expulsion (5.7%)

Common Adverse Effects,

>5%

Mirena
Amenorrhea (23.9%)
Intermenstrual bleeding and
spotting (23.4%)
Abdominal/pelvic pain (12.8%)
Ovarian cysts (12%),
Headache/migraine (7.7%)
Acne (7.2%)
Depressed/altered mood (6.4%)
Menorrhagia (6.3%)
Breast tenderness/pain (4.9%)
Vaginal discharge (4.9%)
IUD expulsion (4.9%).

Skyla
Vulvovaginitis (20.2 %)
Abdominal/pelvic pain
(18.9%)
Acne/seborrhea (15.0%)
Ovarian cyst (13.2 %)
Headache (12.4%)
Dysmenorrhea (8.6%)
Breast pain/discomfort (8.6%)
Increased bleeding (7.8%)
Nausea (5.5%)

Complications

1. Expulsion: 2-10% in the 1st year

2. Method Failure: 0.2-0.8% in the 1st year (this
small population with increased risk of ectopic
pregnancy)
3. Perforation: 1/1000 or less

Barriers to Use

Physician Knowledge, Skill and Comfort

Low Patient Awareness
High Upfront Costs

Misconceptions
of IUD
use

Cannot be used in nulliparous women or adolescents

Associated with infertility and ectopic pregnancy
Causes Pelvic Inflammatory Disease
Before inserting, you must screen for STIs and have
negative results
Must be placed during menses

Key Points

Long-acting reversible contraceptive methods have few contraindications,

and almost all women are eligible for implants and IUDs.
Nulliparous women and adolescents can also be offered IUDs.
Insertion of an IUD or an implant may occur at any time during the
menstrual cycle as long as pregnancy may be excluded.
Immediate postpartum IUD insertion, which is an insertion within 10 minutes
of placental separation, appears safe and effective.
For women at high risk of STIs, it is reasonable to screen for STIs and place
the IUD on the same day.
No Screening for STIs required in low risk patients

References

1. American College of Obstetricians and Gynecologists. Increasing Use of Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy.
ACOG. 2009. Available at: http://
www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Gynecologic_Practice/Increasing_Use_of_Contraceptive_Implants_and_Intraut
erine_Devices_To_Reduce_Unintended_Pregnancy

2. American College of Obstetricians and Gynecologist. Long Acting Reversible Contraception: Implants and Intrauterine Devices. ACOG 2011. Available at:
http://www.acog.org/Resources_And_Publications/Practice_Bulletins/Committee_on_Practice_Bulletins_--_Gynecology/Long-Acting_Reversible_Contraception_--_
Implants_and_Intrauterine_Devices

3. Anderson SL, Borgelt, LM. Case Report: Risk of Uterine Perforation from IUDs Is Greatest During Postpartum Period. Am Fam Physician. 2013 Nov 13; 88
(10): 634-636

4. Carr S, Espey E. Intrauterine Devices and Pelvic Inflammatory Disease Among Adolescents. Journal of Adolescent Health. 2013 April; 52 (4). 22-28.

5. Heinbert EM et al. The Perforated Intrauterine Device: Endoscopic Retrieval. JSLS. 2008; 12:97-100.

6. Johnson BA. Insertion and Removal of Intrauterine Devices. Am Fam Physician. 2005 Jan 1; 71 (1): 95-102.

7. McNicholas C, Peipert JF. Initiation of Long-Acting Reversible Contraceptive Methods (IUDs and Implant) at Pregnancy Termination Reduces Repeat Abortion.
Eved Based Med. 2012- 101023.

8. Randel A. Guidelines for the Use of Long-Acting Reversible Contraceptives. Am Fam Physician. 2012 Feb 15; 85 (4):403-404.

9. Williams DD. IUDs, Implants Most Effective Birth Control. Scientific Daily. 2012. Available at::
http://www.sciencedaily.com/releases/2012/05/120523200255.htm

Websites

10. http://www.drugs.com/pro/skyla-iud.html

11. http://www.drugs.com/pro/mirena.html\

12. http://www.drugs.com/pro/paragard.html

Questions?