• The preferred copper intrauterine devices (IUDs) contain 380 mm² of copper, have banded copper on the arms, and are licensed for longer durations of use.

In depth

• The advantages, disadvantages and risks of the IUD.
• Ectopic pregnancy. The risk of ectopic pregnancy when using an IUD is lower than when using no contraception. The overall risk of ectopic pregnancy when using an IUD is very low, about 1 in 1000 in 5 years. However, if a woman becomes pregnant with the IUD in situ, the risk of ectopic pregnancy is about 1 in 20, and she should seek advice to exclude ectopic pregnancy.
• Pregnancy with the copper IUD in situ. The IUD should be removed.
• Expulsion of the copper IUD. The copper IUD can be expelled from the uterus (uncommon), sometimes without the woman knowing.
• Effect on weight, mood, libido, and cancer-risk. There is no evidence that a copper IUD affects weight. Any changes in mood and libido are similar whether using IUDs or the levonorgestrel-releasing intrauterine system (LNG-IUS), and the changes are small. There is no evidence of an increase in cancer of the cervix, endometrium or ovaries with copper IUD use.
• Managing a copper IUD when it is in place:
• Offer instruction on how to check for the copper IUD and its threads. Advise that if it is not possible to feel the threads to use an alternative method of contraception until reviewed, as the device may have been expelled.
• Advise that heavier and/or prolonged bleeding and/or pain associated with copper IUD use can be treated.
• Advise if menstrual abnormalities persist beyond the initial 6 months of use, to seek medical advice to exclude infection and gynaecological pathology.
• Advise to seek medical advice if symptoms of pelvic inflammatory disease occur, especially within the first 3–4 weeks after insertion.

• 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.
• Check the UK Medical Eligibility Criteria to ensure that the woman is eligible for insertion of a copper intrauterine device (IUD).
• 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 IUD is reinserted). If testing for sexually transmitted infections is requested, do this before inserting the device.

In depth

• Provided that it is reasonably certain that the woman is not pregnant, a copper intrauterine device (IUD) can be inserted:
• At any time during the menstrual cycle.
• Postpartum (irrespective of mode of delivery): 4 weeks after delivery.
• Immediately after first- or second-trimester abortion, or at any time thereafter.
• If there is a delay before the IUD can be fitted, combined hormonal contraception (pill, patch, or vaginal ring [not suitable post-partum if the woman is breastfeeding]), the progestogen-only pill, or the progestogen-only injectable can be used as a bridging method.
• When replacing an IUD, consider delaying replacement if the woman has recently had unprotected sexual intercourse.

In depth

• If uterine perforation at insertion is suspected, the procedure should be stopped and vital signs and the level of discomfort monitored until stable.
• Uterine perforation should also be considered if a woman returns within the first few days of insertion complaining of marked pain (which may only be intermittent), and the threads cannot be located.
• Urgent and specific follow-up should be arranged to include ultrasound scan and/or plain abdominal X-ray to locate the device if it has been left in situ.

In depth

• Review 3–6 weeks after insertion of the copper intrauterine device to exclude infection, perforation and expulsion.
• Advise the woman to return if she cannot find the threads of her device.

In depth

• The recommended duration of use for the copper intrauterine device (IUD) ranges from 5–10 years, depending on the device.
• Women who are aged 40 or more years at the time of IUD insertion may retain the device until they no longer require contraception, even if this is beyond the duration of the UK Marketing Authorisation.

In depth

• A copper intrauterine device (IUD) can be removed at any time in the menstrual cycle.
• If the woman requires uninterrupted contraception, and is:
• Switching to a hormonal method: she should start the new method with sufficient time for it to become effective before the IUD is removed — minimum 2 days for the progesterone only pill (POP); 7 days for the other methods.
• Having her copper IUD replaced with a new copper IUD: she should use an additional method for the 7 days before removal of the device.
• Having her copper IUD replaced with the levonorgestrel-releasing intrauterine system (IUS): she should use an additional method for the 7 days before removal of the IUD, and for a further 7 days after insertion of the levonorgestrel-releasing IUS.
• If unprotected sexual intercourse takes place during the 7 days before removal of the copper IUD, the woman should consider either delaying removal or using emergency contraception (for further information see the CKS topic on Contraception - emergency).
• Postmenopausal women aged < 50 years: remove copper IUD 2 years after the last menstrual period.
• Postmenopausal women aged >= 50 years: remove copper IUD 1 year after the last menstrual period.

In depth

• Assume expulsion until proved otherwise. Confirm the location of the intrauterine device (IUD) by history, clinical examination and, as necessary, by ultrasound and X-ray.
• Expelled IUD
• 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 IUD
• The options are conservative management (leaving the IUD where it is), or replacing it.
• Extrauterine IUD or IUD embedded in uterine wall
• Refer for specialist management.

In depth

• Exclude ectopic pregnancy and advise that the risk of miscarriage, infection, or preterm delivery is increased if the intrauterine device (IUD) is left in place.
• Advise that removal of the IUD is recommended, but there is a small risk of miscarriage.
• If the woman agrees to removal, it should be done as soon as possible and before 12 weeks of gestation.
• If the woman does not wish to continue with the pregnancy, the IUD can be removed at the time of abortion.

In depth

• Reassure the woman that menstrual irregularities (spotting, light bleeding, heavy and/or prolonged menstruation) are common in the first 3–6 months but usually subside.
• Consider prescribing mefenamic acid for spotting/light bleeding or tranexamic acid for heavy and/or prolonged bleeding.
• To prevent anaemia, provide an iron supplement and/or encourage consumption of foods containing iron.
• 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

• 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

• Assess for symptoms of pelvic inflammatory disease:
• Symptomatic: consider investigation and treatment, or referral to specialist services; there is probably no need to remove the copper intrauterine device (IUD).
• Asymptomatic: leave IUD in place.

In depth

• The levonorgestrel intrauterine system (IUS) is a small polyethylene T-shaped frame with a reservoir around the vertical stem that slowly releases levonorgestrel into the uterus.
• One levonorgestrel-releasing IUS is licensed in the UK; it is marketed as the Mirena^® IUS.

In depth

• There is no evidence that the levonorgestrel-releasing intrauterine system causes weight gain.

In depth

• Enquire about the user's preferences and any concerns about using the levonorgestrel intrauterine system (IUS).
• 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.
• Check the UK Medical Eligibility Criteria to ensure that the woman is eligible for insertion of the levonorgestrel IUS.
• 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 testing for sexually transmitted infections is requested, do this before inserting the device.

In depth

• Starting the levonorgestrel-releasing intrauterine system (IUS):
• Ideally insert the device in the first 7 days after the onset of menstruation.
• Additional contraceptive protection will not be required.
• However, if this is not possible:
• Insert the device at any other time in the menstrual cycle provided that it is reasonably certain that a woman is not pregnant. This is an unlicensed use. Advise barrier contraception (such as condoms) for the next 7 days.
• Alternatively, use a hormonal method in the interim, so the fitting can be scheduled for any mutually convenient time.
• If there is a delay before the IUS can be fitted, combined hormonal contraception (pill, patch, or vaginal ring [not suitable post-partum if the woman is breastfeeding]), the progestogen-only pill, or the progestogen-only injectable can be used as a bridging method.
• Replacing the device:
• Insert at any time of the menstrual cycle.

In depth

• If uterine perforation at insertion is suspected, the procedure should be stopped and vital signs and the level of discomfort monitored until stable.
• Uterine perforation should also be considered if a woman returns within the first few days of insertion complaining of marked pain (which may only be intermittent), and the threads cannot be located.
• Urgent and specific follow-up should be arranged to include ultrasound scan and/or plain abdominal X-ray to locate the device if it has been left in situ.

In depth

• Follow-up after the first menses, or 3–6 weeks after insertion, to exclude infection, perforation or expulsion.
• Advise the woman to return at any time if she wants to discuss problems, if she wants to change her method of contraception, or if it is time to have the IUS removed or changed.

In depth

• The levonorgestrel-releasing intrauterine system (IUS) may be left in place for up to 5 years.
• However, women who are aged 45 or more years at the time of IUS insertion may retain the device until they no longer require contraception, even if this is beyond the duration of the UK Marketing Authorisation.

In depth

• If the woman wishes to conceive, the levonorgestrel-releasing intrauterine system (IUS) can be removed at any time.
• If the woman does not want to become pregnant, remove the device when the woman is not at risk of becoming pregnant, and ensure unbroken contraceptive cover.
• If the device is to be exchanged for a new IUS, the woman should avoid intercourse or use barrier contraception for the 7 days prior to the procedure in case reinsertion fails.
• If the device is to be changed for a hormonal contraceptive method and the woman is amenorrhoeic, the new method should be used for sufficient time for contraceptive protection to be established before removal of the IUS. Alternatively, if the hormonal contraceptive is started after the removal of IUS, she will need to abstain from sex or use additional contraceptive protection (e.g. condoms) until contraceptive protection is established.
• If the device is to be changed for a copper intrauterine device (IUD), no additional contraceptive protection is required if the copper IUD is inserted immediately after removing the IUS.

In depth

• 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

• 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

• 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

• 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

• 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:
• See the CKS topic on Pelvic inflammatory disease.

In depth