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Contraception - Management
Managing common problems when using levonorgestrel-releasing intrauterine system (IUS)

What should I do if the woman cannot feel the thread(s) of her levonorgestrel-releasing intrauterine system (IUS)?

  • Confirm the location of the intrauterine system (IUS) by history, clinical examination and, as necessary, by ultrasound and X-ray.
  • Expelled IUS
    • Arrange for the woman to resume regular contraception.
    • Consider if emergency contraception is indicated. For further information, see the CKS topic on Contraception - emergency.
  • Intrauterine IUS
    • The options are conservative management (leaving the IUS where it is), or replacing it.
  • Extrauterine IUS
    • Refer for surgical retrieval.

In depth

How should I manage abnormal vaginal bleeding associated with use of the levonorgestrel-releasing intrauterine system (IUS)?

  • Abnormal bleeding is a particular problem with the levonorgestrel-releasing intrauterine system (IUS):
    • Irregular, light, or heavy bleeding is common in the first 6 months.
    • About 65% of women have amenorrhoea or reduced bleeding at 1 year.
    • Studies have shown that 40% of the levonorgestrel load is still present in the IUS after 5 years of use. It is therefore unlikely that any change in bleeding pattern is a result of hormone 'running out'.
  • Consider managing heavy unscheduled bleeding by:
      • Treating with a combined oral contraceptive (either cyclically or continuously) for up to 3 months.
  • Exclude or manage other situations which could result in unscheduled bleeding, such as:
    • Sexually transmitted infections.
      • Risk of STI if the woman is under 25 years, or has a new sexual partner, or more than one partner in the last year.
    • Misplaced device.
    • Pregnancy.
    • Gynaecological conditions such as endometrial polyps, endometrial cancer, cervical cancer, or other gynaecological abnormality.
    • Speculum examination is warranted:
      • For persistent bleeding beyond the first 3–6 months of use.
      • For new symptoms or a change in bleeding after at least 3 months of use.
      • If the woman has not participated in a National Cervical Screening programme.
      • If requested by the woman.
      • If there are other symptoms such as pain, dyspareunia, or post coital bleeding. (Note that these symptoms also warrant pelvic examination.)
  • Refer if the cause of the bleeding cannot be determined or treated in primary care.

In depth

How should I manage a woman using a levonorgestrel-releasing intrauterine device (IUS) who may be pregnant?

  • Exclude ectopic pregnancy and advise that there is a risk of miscarriage, infection, or preterm delivery if the intrauterine system (IUS) is left in place.
  • Advise that removal of the IUS is recommended, but there is a small risk of miscarriage.
  • If the woman agrees to removal, it should be done before 12 weeks' gestation.

In depth

How should I manage pelvic inflammatory disease in a woman using a levonorgestrel-releasing intrauterine device (IUS)?

  • Take a cervical swab to test for Chlamydia trachomatis and Neisseria gonorrhoeae, and treat with appropriate antibiotics.
  • The device should be removed if the woman wishes removal or if symptoms have not resolved within 72 hours.
  • If the device is going to be removed:
    • Ask if the woman has had sexual intercourse within the last 7 days and consider offering emergency hormonal contraception. For more information see the CKS topic on Contraception - emergency.
  • Review after treatment.

In depth

How should I manage a woman who has actinomyces-like organisms on a cervical smear and is using a levonorgestrel-releasing intrauterine device (IUS)?

  • If a woman who is using the levonorgestrel-releasing intrauterine device (IUS) has actinomyces-like organisms in a cervical smear:
    • If she is asymptomatic:
      • Advise her that it is not necessary to remove the IUS unless signs or symptoms of infection occur.
    • If she is has symptoms of pelvic inflammatory disease:

In depth

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