IUDs:
Dispelling the
Myths
Learning Objectives
Participants in this seminar will be able to:
• List the indications and contraindications to IUD use
• Describe the pros and cons of hormonal vs. nonhormonal IUD use
• Explain the role of higher efficacy, non-user
dependent, contraceptive methods like the IUD in
the prevention of unintended pregnancy
Contraceptive Users in the
United States
• 62 million women of
childbearing age in US.
• 43 million are sexually active
and do not want to become
pregnant.
• 62% reproductive age women
use some form of contraception.
• 6 million pregnancies per year.
Guttmacher Institute.
Unintended Pregnancy (n = 3 million)
• Contraception and unintended pregnancies:
– 25% method failure
– 25% imperfect use
– 50% no contraception
• Half of unintended pregnancies end in abortion:
– 1.06 million per year
Contraceptive Methods US
Case: Shani
• 21 year old
• Post-partum 4 weeks
• Asking about tubal
sterilization
Sterilization by Education
• If graduated college, 13%
had tubal ligation
• If some college,
29% had BTL
• If graduated HS,
42% had BTL
• If no HS graduation,
55% had BTL
Young Women and Sterilization
• 20% of women selecting sterilization
at age 30 years or younger later
express regret.
Charges for Contraception for
5 years
•
•
•
•
•
Laparoscopic BTL
Essure
Oral contraceptive
3-month injectable
IUD
– Copper
– Levonorgestrel
$3545
$2367
$2579
$2195
$1646
$1678
What about an IUD for Shani?
• Lower discontinuation rates in post-partum
women
• 4 weeks postpartum is a good time to insert
(CDC says can be done at 4 wks)
• Immediate post partum now covered by NY
Medicaid!
• Non-patient-dependent method enhances
adherence
Copper IUD
ParaGard™
Levonorgestrel IUD
Skyla™
Mirena™
Comparison
Copper IUD
(ParaGuard™)
•
•
•
No hormone
Menses continues,
slightly heavier
Long lasting: 10
years (12
evidence-based)
Levonorgestrel
52 mg IUD (Mirena™)
•
•
•
Progestin treats
menorrhagia, anemia
Causes amenorrhea
5 years (7 evidencebased)
Levonorgestrel
13.5 mg IUD (Skyla™)
•
•
No evidence yet for
menorrhagia,
anemia
Good for 3 years
Comparison of two LNGs
• 52 mg LNG
– Initially releases 20 mcg/day
– By 5 years, down to 10 mcg/day
– Continued efficacy to 7 years
• 13.5 mg LNG
– Initially releases 14 mcg/day
– By 3 years down to 5 mcg/day
– No studies yet for extended use
Mechanism of Action
IUDs
are NOT
abortifacients!
Mechanism of Action:
Copper IUD
Copper-releasing IUD (ParaGuard™):
380 mm2 copper exposed on plastic T
base 
•
•
•
Interferes with sperm motility.
Causes spermicidal foreign-body
reaction.
Alters uterine environment,
“hostile” to sperm.
Mechanism of Action:
Levonorgestrel IUD
• Hormone-releasing IUD - levonorgestrel on its arms
and stem released at decreasing rate with time
• Thickens cervical mucus (acting as a
sperm barrier)
• Inhibits sperm capacitation & survival.
• Thins uterine lining.
• Partial inhibition of ovulation.
• Presence of plastic alone may have some
efficacy
Case: Maggie
• 35 year old
• Heavy smoker
Concerns with Maggie…
and evidence for safety
• Age
– No restriction for either IUD
– CDC category “2” for women <20
• Consider expulsion risk and baseline STI
risk
• Smoking: regardless of amount
– No restriction for any IUD
CDC Categories of Safety
An IUD for Maggie
• Is discreet.
• Patient and partner do not feel IUD body.
• Although unlikely, partner may feel strings.
CDC Contraindications to IUD Use
•
•
•
•
•
•
•
•
Pregnancy
Uterine infection
Unexplained vaginal bleeding ***
Cervical or endometrial cancer (awaiting treatment) ***
Breast cancer (Progestin IUD only)
Trophoblastic disease
Current PID or STD ***
Pelvic Tuberculosis
*** Initiation is category 4, continuation is category 2
Case: Krystal
• 24 year old
• G2P1
• History of Chlamydia
as a teen
Sexually Transmitted Infections
and Pelvic Inflammatory Disease
• IUDs do not increase rates of STIs
– STIs dependent on local prevalence
– In high prevalence areas, reasonable to screen for STIs at IUD
insertion
– Do not remove IUD for STI treatment
– No need for antibiotic prophylaxis at IUD insertion
• PID may be transiently higher for 20 days after IUD
insertion, then back to baseline population levels
– Even lower PID rates with good insertion technique and low
baseline STI rate
– Modern IUD strings do not facilitate ascent of infection
– Do not remove IUD for initial PID treatment
Sexually Transmitted Infections
• Current PID or current gonorrhea or chlamydia is “4”
for insertion.
• PID, gc, chlamydia is a “2” for continuation.
• Trichimonas and Bacterial Vaginosis are a “2” for
insertion.
• HIV infected or clinically well on ARV: “2”
• Very high risk for STI or HIV, not well, “3”
Case: Kerry
• 18 year old
• Type 1 DM
• G0P0
Medical Eligibility
• Levonorgestrel IUD does not alter
glycemic control in patients with type 1
diabetes, does not affect blood pressure
• Copper IUD is approved for almost all
medical conditions: cardiovascular
disease, hypertension, migraines,
smoking, lipid disorders, diabetes…
WHO Contraindications
Nulliparity
is NOT
a contraindication
to IUD use!
Case: Tammy
• 35 year old
• Very heavy periods
• Anemia
LNG 52 mg IUD - Side Effects
• Spotting, bleeding, and
cramping: Increased in 1st 3
months
• Amenorrhea: 20% of users by
1 yr, 60% by 5 yrs
• Expulsion: 2-12% in 1st yr
• Perforation: <.01% at time of
insertion
• Headaches, acne, mastalgia:
< 3% in 1st months
LNG 52 mg IUD - Medical Advantages
•
•
•
•
•
•
Cramps & menorrhagia improve.
90% decrease in overall blood loss.
Decreases number of invasive treatments for DUB, fibroids.
Decreases risk of ectopic pregnancy.
May protect against endometrial cancer, STIs.
Decreases perimenopausal symptoms.
LNG 13.5 mg
•Only 6% have amenorrhea after one year
•No evidence that lower dose means less
progestin side effects
•Low failure rate, but of failures 50% were
ectopic pregnancies
Noncontraceptive Benefits of the
LNG 52 mg IUD
• Treatment of menorrhagia, including in women with
uterine fibroids and adenomyosis.
• Treatment of pain in women with endometriosis.
• Alternative to hysterectomy for women w/ menorrhagia
• Prevention of endometrial hyperplasia in menopausal
women using estrogen therapy.
• Prevention of endometrial proliferation and polyps in
breast cancer survivors taking tamoxifen.
Lifetime Number of Menstrual Cycles
Number
of
Cycles
500
450
400
350
300
250
200
150
100
50
0
450
160
50
Prehistoric
Colonial
America
Modern
Adapted from Coutinho EM. Is Menstruation Obsolete? 1999.
Questions about IUDs
Must IUDs be inserted during
menses?
Can the IUD be used as
emergency contraception?
Timing of IUD Insertion
• All IUDs can be inserted at any point in
menstrual cycle.
• Copper IUD can be used for emergency
contraception within 5-7 days of
unprotected sex-with nearly 100%
efficacy.
• Progestin IUD cannot be
used for EC (yet).
IUD Myths Debunked
• IUDs DO NOT cause Abortion:
– IUDs thicken cervical mucus, suppress
endometrium; progestin IUD has some
anovulatory effect
• IUDs DO NOT increase risk of PID:
– IUD itself carries no risk of infection. Transient
risk w/ insertion. Progestin IUD: may protect
against PID, 5-year PID associated removal
risk 0.8.
More IUD Myths Debunked
• IUDs DO NOT increase risk of ectopic
pregnancy.
• IUDs DO NOT increase rates of breast cancer.
• May insert at any point in the menstrual cycle.
More IUD Myths Debunked
• Okay to use in nulliparous women.
• No need for prophylactic antibiotics.
• Okay to do STI testing at time of insertion
(& treat infections w/ IUD in place)
Proactive Contraception
Rules For Success
• Encourage prompt initiation.
• Use patient-centered
counseling to enhance
adherence.
• Inform about high-efficacy
methods - don’t limit IUDs
unnecessarily.
• Educate about all
contraceptive options:
if she qualifies, let her
decide.
Troubleshooting IUD issues
• Bleeding pattern problems
– NSAIDs or OCPs plus time
• Pain problems
– NSAIDs plus time (check placement w USN)
• String issues
– Leave long (can always shorten), cut at right
angle, tuck behind cervix
• Pregnant w IUD – urgent need for USN!!!
Difficult Insertions
Sound vs Sound w dilation
Take Home Messages
•You can do this!
•IUDs are good for your patients
•The risks are minimal
•The benefits are enormous
References and Resources
• Hatcher et al, Contraceptive Technology 2011
• Managing Contraception – book online @
www.managingcontraception.org
• CDC Medical Eligibility Criteria for Contraceptive Use
• Association of Reproductive Health Professionals www.arhp.org
• Alan Guttmacher Institute www.agi-usa.org
• www.contraceptiononline.org
• Planned Parenthood www.plannedparenthood.org
• The Cochrane Collaboration www.cochrane.org
• www.Not-2-Late.com
• Reproductive Health Access Project www.reproductiveaccess.org