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Contraception - Management
What are the advantages, disadvantages, and risks of the levonorgestrel-releasing intrauterine system (IUS)?

  • Advantages:
    • Very safe.
    • Very effective — over 5 years, less than 10 out of 1000 women would become pregnant.
    • Effective treatment for heavy menstrual bleeding.
    • A single decision leads to effective long-term prevention of pregnancy.
    • Long-lasting (5 years).
    • Little to remember.
    • Sex need not be interrupted to use contraception.
    • Periods usually become lighter and shorter, and sometimes less painful. They may stop completely after the first year of use. Therefore, the levonorgestrel intrauterine system (IUS) can be useful for women with heavy, painful periods.
    • Immediately reversible; normal fertility returns as soon as the device is removed.
    • Can be used in women of any age, whether or not they have previously been pregnant.
    • Can be inserted from 4 weeks after delivery.
    • Can be used with breastfeeding.
    • Can be used through the menopause.
    • There are no known interactions with any medicines.
    • Can be used when combined oral contraceptives (COCs) are contraindicated, for example, in women who have:
      • Migraine.
      • Venous thromboembolism: women with current venous thromboembolism who need hormonal contraception during anticoagulant treatment should be referred to a specialist in contraceptive care.
  • Disadvantages and risks:
    • Adverse effects (common):
      • There may be pain or discomfort for a few hours after insertion; this can be treated with an analgesic such paracetamol or ibuprofen.
      • Menstrual changes are common in the first 6 months. Periods may become lighter than usual or may continue to be irregular, and many women find that their periods stop altogether by the end of the first year of use. Some women consider this an advantage.
      • Up to 60% of women stop using the levonorgestrel-releasing IUS within 5 years. The most common reasons for discontinuation are unacceptable vaginal bleeding and pain. A less common reason for discontinuation is hormonal (non-bleeding) problems.
      • Other adverse effects may include acne and headaches. Some women report that their breasts have become tender.
      • Some women develop functional ovarian cysts; this does not usually need to be treated, as the cysts tend to resolve spontaneously. Often, there are no symptoms, but some women may experience pelvic pain.
    • Risks (uncommon):
      • Perforation of the wall of the uterus — rare; this happens in less than 1 in 1000 women and is dependent on the skills of the operator.
      • Pelvic inflammatory disease follows insertion rarely (less than 1 in 100 women who are at low risk of sexually transmitted infections).
      • Ectopic pregnancy — pregnancy with the device in place is rare, but when it does occur, the risk of it being ectopic is about 1 in 20.
    • Other considerations:
      • An internal (pelvic) examination is needed to check that the levonorgestrel-releasing IUS is suitable and to insert the device.
      • Occasionally, the woman faints during the insertion procedure.
      • The woman cannot stop using the device on her own. A trained healthcare provider must remove it.
      • Some pain and bleeding or spotting may occur immediately after insertion. Usually this goes away in a day or two.
      • It does not protect against sexually transmitted infections, including HIV. However, the risk of HIV is not increased.
      • The IUS can be expelled from the uterus, but this is uncommon: less than 1 in 20 women in 5 years. The IUS can be expelled 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.
Basis for recommendation

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