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Contraception - Management
What are the advantages, disadvantages, and risks of the copper intrauterine device (IUD)?

  • Advantages:
    • Very safe.
    • Very effective — over 5 years, less than 20 out of 1000 women would become pregnant.
    • Effective immediately after insertion; it can therefore also be used for emergency contraception.
    • Does not work by causing an abortion.
    • Long-lasting: 5–10 years, depending on the product.
    • A single decision leads to effective long-term prevention of pregnancy. There is little for the user to remember.
    • Sex need not be interrupted to use contraception.
    • There are no hormonal side effects.
    • Immediately reversible; normal fertility returns as soon as it is removed.
    • Can be used with breastfeeding.
    • Can be inserted from 4 weeks after child birth (irrespective of mode of delivery) or immediately after first- or second-trimester abortion.
    • Can be used by women of any age, and can be continued through the menopause.
    • There are no interactions with any medicines.
  • Disadvantages and complications:
    • Adverse effects (common):
      • There may be pain or discomfort for a few hours after insertion. This can be treated with an analgesic such as paracetamol or ibuprofen.
      • Menstrual changes are common in the first 3 to 6 months but are likely to lessen after this time: longer and heavier menstrual periods occur in most women, often with bleeding or spotting between periods, and more cramps or pain during periods.
      • Up to 50% of women have their copper intrauterine device (IUD) removed within 5 years, most commonly because of unacceptable vaginal bleeding and pain.
    • Complications (uncommon risk):
      • Severe cramps and pain beyond the first 3–5 days after insertion.
      • Heavy menstrual bleeding or bleeding between periods, possibly contributing to anaemia. Nonsteroidal anti-inflammatory drugs and tranexamic acid are effective in the treatment of heavy bleeding with IUD use.
      • Perforation of the wall of the uterus is rare, and depends on the skill of the operator.
      • The risk of developing pelvic inflammatory disease (PID) following IUD insertion is very low (less than 1 in 100) in women who are at low risk of sexually transmitted infections. There is an increased risk of infection in the first 20 days following insertion. Thereafter, the risk of infection is as background risk, conveyed by sexual behaviour and other factors. For further information, see the CKS topic on Pelvic inflammatory disease.
  • Other considerations:
    • An internal (pelvic) examination, prior to insertion of the device, is needed to check that a copper IUD would be suitable.
    • Occasionally, a woman faints during the insertion procedure.
    • The woman cannot discontinue use on her own. A trained healthcare provider must remove the device.
    • Some pain and bleeding, or spotting, may occur immediately after copper IUD insertion. This usually resolves in a day or two.
    • The copper IUD does not protect against sexually transmitted infections, including HIV. However, the risk of HIV is not increased.
    • The IUD can be expelled from the uterus, but this is uncommon: less than 1 in 20 women in 5 years. The IUD can be expelled without without the woman knowing. It is important therefore that she checks the presence of the threads regularly (e.g. after every menstrual period). Some women may not want to do this internal examination.
Clarification / Additional information
  • Guidelines from the National Institute for Health and Clinical Excellence (NICE) and the Faculty of Sexual and Reproductive Healthcare (FSRH), (formerly the Faculty of Family Planning and Reproductive Healthcare [FFPRHC]), recommend that a woman who is considering the copper intrauterine device (IUD) should be given the following information:
    • Contraceptive efficacy:
      • Copper IUDs act primarily by preventing fertilization. Prevention of implantation may occur on the rare occasion that fertilisation occurs.
      • The licensed duration of use for IUDs containing 380 mm2 copper ranges from 5–10 years, depending on the type of device.
      • The pregnancy rate associated with the use of IUDs containing 380 mm2 copper is very low (fewer than 20 in 1000 over 5 years) — see Effectiveness of contraceptives.
      • There is no evidence that following removal or expulsion of a copper IUD it is more difficult than usual to conceive.
    • Menstrual irregularities:
      • Heavier bleeding and/or dysmenorrhoea (painful periods) are likely when using a copper IUD.
      • Up to 50% of women stop using copper IUDs within 5 years; the most common reasons for discontinuation are unacceptable vaginal bleeding and pain.
    • Ectopic pregnancy:
      • The risk of ectopic pregnancy when using a copper IUD is lower than when using no contraception.
      • The overall risk of ectopic pregnancy when using the copper IUD is very low (about 1 in 1000 women, in 5 years).
      • If a woman becomes pregnant with the copper IUD in situ, the risk of ectopic pregnancy is about 1 in 20 women, and she should seek advice to exclude ectopic pregnancy.
    • Pregnancy with the copper IUD in situ:
      • Risks of second-trimester miscarriage, preterm delivery, and infection are increased if the copper IUD is left in situ.
      • The copper IUD should be removed within the first 12 weeks of gestation.
      • For more information see Managing women who may be pregnant.
    • Expulsion of the copper IUD:
      • A copper IUD may be expelled from the uterus, possibly without the woman knowing.
      • Expulsion from the uterus occurs in less than 1 in 20 women during 5 years' use.
      • Expulsion is more common when the device is inserted soon after childbirth.
    • Effect on weight, mood, libido, and cancer (which are common concerns of women):
      • There is no evidence that copper IUDs affect body weight.
      • Any changes in mood and libido are similar whether using copper IUDs or the levonorgestrel-releasing intrauterine system (IUS), and are small.
      • There is no evidence of an increase in cancer of the cervix, endometrium, or ovaries.
    • Perforation of the uterus:
      • The risk of uterine perforation at the time of copper IUD insertion is very low (less than 1 in 1000 women).
    • Pelvic inflammatory disease:
      • The risk of developing pelvic inflammatory disease following copper IUD insertion is very low (less than 1 in 100 women) in those at low risk of sexually transmitted infections.
    • Managing a copper IUD when it is in place:
      • Women should be offered instruction on how to check for the threads. Women should be advised that, if they are unable to feel the threads, it may be that the device has been expelled, and another contraceptive method should be used until advice has been obtained from a healthcare professional.
      • Heavier or prolonged bleeding can be treated.
      • If menstrual abnormalities persist beyond the initial 6 months of use the woman should seek medical advice to exclude infection and gynaecological pathology.
      • The woman should be taught to recognize the features of pelvic inflammatory disease (pain/tenderness in the lower abdomen, fever, abnormal/smelly vaginal discharge), and to seek medical advice if these symptoms occur, especially within the first 3–4 weeks after insertion of the copper IUD.
Basis for recommendation

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