To assess a woman's eligibility for use of the levonorgestrel-releasing intrauterine system (IUS):

• Enquire about the user's preferences and any concerns.
• In young women and women with special needs, assess their competence to decide, and support them in making their own decisions about contraception.
• Exclude pregnancy:
• If pregnancy is possible, do not insert the levonorgestrel-releasing intrauterine system (IUS). Advise use of a barrier method until pregnancy can be excluded.
• Assess the risk for sexually transmitted infection and, when appropriate, advise testing, promote safer sex, and/or refer for counselling (also consider each time the IUS is reinserted).
• If the woman is at increased risk for sexually transmitted infection:
• Counsel her (or arrange for counselling) about risky sexual practices.
• Review her decision for choice of contraception, and discuss alternative contraceptive methods.
• Test for Chlamydia trachomatis.
• Test for Neisseria gonorrhoeae in women from areas where the disease is prevalent.
• If results of laboratory tests are not available, consider prophylactic antibiotics before inserting the device.
• If the woman requests testing for sexually transmitted infection:
• Perform testing before inserting the device.
• If the woman has unexplained vaginal bleeding that suggests an underlying medical condition (e.g. between her periods or after sexual intercourse):
• Do not insert the IUS until the cause of bleeding has been diagnosed. Offer an alternative contraceptive method.
• If the woman has given birth or had an abortion between 48 hours and 4 weeks ago:
• Delay inserting the IUS at least 4 weeks after childbirth/abortion. Advise use of a barrier method until then.
• If the woman has had puerperal sepsis or a septic abortion and has not yet fully recovered:
• Offer an alternative contraceptive method and consider referral, investigation, treatment, and/or prophylactic antibiotics at the time of insertion.
• If the woman has a history of endocarditis or a prosthetic heart valve:
• Intravenous antibiotic prophylaxis is required at the time of insertion.
• Check the woman's blood pressure.
• Check the UK Medical Eligibility Criteria to ensure that the woman is eligible for insertion of the levonorgestrel-releasing IUS. This requires information from the medical record, clinical history, and clinical examination, which should include bimanual pelvic examination.
• Women should not use the levonorgestrel-releasing IUS (UKMEC 4) in the following situations:
• Pregnancy
• Postpartum: puerperal sepsis
• Post abortion: septic abortion
• Current breast cancer
• Unexplained vaginal bleeding: before evaluation
• Gestational trophoblastic disease when the human chorionic gonadotropin level is persistently elevated or in malignant disease
• Cervical cancer: awaiting treatment (when considering inserting the IUS)
• Endometrial cancer (when considering inserting the IUS)
• Ovarian cancer (when considering inserting the IUS)
• Pelvic inflammatory disease: current (when considering inserting the IUS)
• Sexually transmitted infections: current purulent cervicitis, or gonorrhoea, symptomatic or asymptomatic chlamydial infection (when considering inserting the IUS)
• Known pelvic tuberculosis (when considering inserting the IUS)
• Women should use the levonorgestrel-releasing IUS only after consultation with an expert (UKMEC 3) in the following situations:
• Postpartum: 48 hours to less than 4 weeks
• Current or history of ischaemic heart disease while fitted with the IUS
• Stroke or transient ischaemic attack while fitted with the IUS
• Past history of breast cancer with no recurrence in the last 5 years
• Uterine fibroids with distortion of the uterine cavity
• Distorted uterine cavity (any congenital or acquired uterine abnormality distorting the uterine cavity in a manner that is incompatible with IUS insertion)
• Tuberculosis: known pelvic while fitted with the IUS
• Cirrhosis: severe (decompensated)
• Liver tumours: benign (hepatocellular adenoma) and malignant (hepatoma)
• Systemic lupus erythematosus: positive (or unknown) antiphospholipid antibodies
• HIV infected: using antiretroviral therapy (see Selected concurrent medications)

• Contraception for young women and women with learning disabilities:
• Contraception should be seen in terms of the needs of the individual rather than in terms of relieving the anxieties of carers or relatives.
• When a woman with a learning disability is unable to understand and take responsibility for decisions about contraception, carers and other involved parties should meet to address issues around the woman's contraceptive need and to establish a care plan.
• See Considerations for girls under 16.
• Bimanual pelvic examination:
• This is necessary to assess the size, shape, position, and tenderness of the uterus before insertion of the levonorgestrel-releasing intrauterine system (IUS).
• Assessment of sexually transmitted infections (STIs) and testing:
• STI risk should be assessed from both the history and clinical examination.
• Ideally, for women assessed as at higher risk of STI, the results of tests should be available (and appropriate treatment provided) prior to IUS insertion.
• The following examinations and laboratory tests are not required to assess eligibility for the levonorgestrel-releasing IUS:
• Breast examination.
• Cervical screening.
• Routine laboratory tests, including haemoglobin.
• Blood pressure screening.
• Training
• Healthcare professionals providing intrauterine or subdermal contraceptives should receive training to develop and maintain the relevant skills to provide these methods.
• IUDs and the levonorgestrel intrauterine system (IUS) should only be fitted by trained personnel with continuing experience of inserting at least one IUD or one IUS a month.

• These recommendations for assessing a woman before starting a levonorgestrel-releasing intrauterine system (IUS) are based on the UK medical eligibility criteria for contraceptive use issued by the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC) [FSRH, 2009b].
• These recommendations are also based on the guidelines published by 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) [FFPRHC, 2004d; National Collaborating Centre for Women's and Children's Health, 2005].
• The recommendations about referring women at higher risk for sexually transmitted infections for counselling are based on guidelines from NICE [NICE, 2007a]. The guidelines include:
• Consultations on contraception should opportunistically screen (using a sexual history) for individuals at high risk of sexually transmitted infections.
• Individuals at high risk of sexually transmitted infection should be offered one to one structured discussions with a practitioner trained in sexual health.