Intrauterine devices (IUD) are an effective, reliable and reversible method of contraception that does not require regular pill taking or injections. As a Long-Acting Reversible Contraceptive (LARC), it can remain in situ for 5 years, or longer in some cases. The copper IUD T-safe Cu380A has a failure rate of 0.5% and the Mirena (progesterone releasing IUD) has a failure rate of 0.2%. IUDs can also be used for emergency contraception if it is too late for Levonelle to be used.

Counselling

Women should be advised of all the contraceptive methods available, to enable them to make the correct choice for themselves. Because IUDs do not offer any protection against STIs there is an increased risk of PID therefore, a careful sexual history needs to be taken. The IUD is more suited to monogamous partners without a ‘risk taking’ lifestyle. A specially trained practitioner must fit the device and the woman should have swabs taken prior to fitting to exclude an infection. The method of fitting should also be explained and whilst it can be uncomfortable, it shouldn’t be very painful. The copper IUD may make the periods heavier, whilst the Mirena can reduce bleeding and may even stop the periods altogether. However the Mirena can sometimes cause spotting and irregular bleeding and may need a 6-month period to settle in. The Mirena is also used as a treatment for menorrhagia when a contraceptive is not required, though some patients have noticed side effects from the Levongestrel released from the device.

Types of IUD

There are 2 main types of IUDs, copper bearing and hormone releasing (Mirena). They come in various shapes and sizes and whilst frequently used in women who have had a baby, there are smaller devices more suited to nulliparous patients and useful for emergency contraception. Some women may have a third type of device situ – an inert IUD, but these are no longer fitted.

Duration of use and costs of IUDs

Type of IUD Cost Duration
Flexi T 300

 ₤ 8.95

5 yrs
Multiload250

₤ 7.50

3 yrs
Multiload375

₤ 9.24

5  yrs
T safe 380A

₤ 9.73

8 yrs
TT 380 SL

₤ 8 – 9

10 yrs
Nova T 380

₤ 13.50

5 yrs
GyneFix

₤ 25.19

5 yrs
Mirena

₤ 83.16

5 yrs

A new copper IUD has been introduced that is effective for 10 years – TT 380 Slimline.

Advantages

Disadvantages

Contra-Indications

History and Examination.

Insertion can be at any time of menstrual cycle as long as pregnancy has been excluded. Immediately after a termination, or 6 weeks post-partum. During or Immediately after a period is the best time because the cervix is softer.

Method of Action

Copper IUDs have a ‘foreign body effect’. They prevent fertilisation, have a toxic effect on sperm and prevent implantation. The Mirena has a hormonal effect on the endometrium, cervical mucous and ovarian function, preventing ovulation and implantation.

Insertion of IUD

Equipment

The Doctor inserting the IUD will use a no touch technique and the nurse will not only assist with this but also monitor the patient as vasovagal syncope (cervical shock) has been known to occur. Adequate preparation, explanation and distraction by the nurse can minimise the risk of this occurring. Having an IUD fitted has also been known to trigger an epileptic fit.

 

The woman should rest for 15 minutes after insertion and be instructed on how to feel the threads of the IUD – this should be done after each period. She also should be advised about the symptoms of PID and told to come in straight away if these problems occur (pain, discharge, intermenstrual bleeding, post-coital bleeding, pyrexia, dyspareunia, dysuria, and abdominal pain). Mirena – advise may need 6 month settling in period.

After insertion the patient should be advised to continue with another method of contraception until after the 6-week check up. That she may be uncomfortable for the next few hours and will bleed. If necessary, should take paracetamol or NSAIDs.

She should be given written instructions with the date and type of IUD that she has been fitted with and advised to return for a review following the next period or 6 weeks time.

Review

6 weeks and annually (or sooner if problems). Vaginal examination to check for threads and any tenderness. Check woman’s knowledge re self-checking threads, symptoms of PID, STI awareness and review smear status.

Removal

Duration of use – copper IUDs may be left in situ till after the menopause, if inserted after the age of 40 years. Mirena IUDs may be left in until after the menopause, if inserted after the age of 45 years (both unlicensed use).

Removal can be done at any time if the patient is intending to become pregnant. If she doesn’t intend a pregnancy then care should be taken to remove it during menstruation, unless alternative contraception has already been used for at least a week prior to removal. Visualise the cervix using a vaginal speculum, grasp the threads firmly using sponge holding or long artery forceps and apply gentle downwards traction. Usually the IUD will be withdrawn without difficulty, but if the nurse is unable to remove it easily, or there is pain or the threads break, then she should get assistance.

Potential Problems

Actinomyces Like Organisms (ALOs) – usually reported on smears

A common finding in up to 20% of women and usually does not cause problems. This should be discussed with the woman and she should be advised that if ever she does have symptoms of PID she should come in immediately. However if she is not happy with this, then she can have the IUD removed and another one fitted.

However, if symptomatic of PID then:

Lost Threads

This could be because the woman is pregnant! Exclude pregnancy and advise her to use additional contraception and refer to the GP for an examination using a sterile IUD hook and if necessary referral for a scan (USS).

Emergency Contraception

?Menopause and Mirena in situ

References