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.
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||
|T safe 380A||
|TT 380 SL||
₤ 8 – 9
|Nova T 380||
A new copper IUD has been introduced that is effective for 10 years – TT 380 Slimline.
- Effective and reversible
- Particularly suitable for monogamous couples, between or after children.
- Long acting, without the need for remembering to take pills or use before intercourse.
- Copper IUD effective immediately (Mirena 7 days after introduction)
- Less risk of ectopic pregnancy (but if pregnancy occurs – then higher risk of ectopic)
- Mirena only – may improve menorrhagia, dysmenorrhoea, PMS. (6 months settling in)
- Mirena only – provides progesterone component of HRT
- Mirena only – may reduce size of fibroids, endometrial hyperplasia, and pain in endometriosis.
- Copper IUD – periods could be heavier and more uncomfortable.
- Mirena only – irregular, spotting and cessation of periods.
- Mirena only – headaches, breast pain, nausea, mood change, acne.
- PID – very low risk of PID unless woman at high risk of STIs
- Expulsion – more likely in first year
- Perforation – very rare, needs a specially trained practitioner to insert device.
- Copper IUD only – increased blood loss in bleeding disorders, warfarin use and anaemia.
- Bacterial endocarditis risk in valvular heart disease, needs antibiotic cover at fitting.
- Undiagnosed abnormal bleeding
- Malignancy of genital tract
- Active or recent STI or PID (within last 3 months)
- Distorted uterus – large fibroids, bi-cornate.
- Copper coil only -Wilson’s disease or copper allergy
- Mirena only - Allergy or intolerance of progesterone
History and Examination.
- Menstrual and Obstetric History
- Sexual History and Contraceptive History
- Relevant Medical History eg epilepsy.
- Endo-cervical and vaginal swabs taken.
- Vaginal and pelvic examination to exclude abnormalities
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
- Resuscitation equipment includes an assistant!
- Oxygen equipment; face mask; airway; sphygmomanometer; atropine; epinephrine; diazepam; needles and syringes; defibrillator.
- Light source
- Sterile kidney dish
- Swabs (if not taken previously eg UPSI)
- Sterile 10” sponge-holding forceps
- Cotton wool balls
- Sterile 12” scissors
- Antiseptic solution
- Sterile 12” tenaculum forceps – blunt tips
- Sterile gloves
- Sterile uterine sound
- Waste disposal bags
- Sterile vaginal speculum
- Pain killers, surface analgesia may be required.
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.
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.
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.
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:
- Test for STIs
- Remove IUD and send for culture
- Treat with antibiotics
- Arrange alternative contraception
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).
- Can be fitted up to 5 days after single episode of UPSI
- Up to 5 days after earliest calculated date of ovulation (= Day 19 in a 28 day cycle) regardless of number of episode of UPSI.
- Up to day 15 of a prolonged pill free interval
?Menopause and Mirena in situ
- Check FSH on two occasions, 2 weeks apart. If both results show >30, then probably menopausal – And if aged >45 and also period free for 2 years then remove Mirena.
- If aged >50 and also period free for 1 year then Mirena can be removed.
- Glasier,A Bebbie,A Family Planning and Reproductive Health Churchill Livingstone
- Guillebaud,J Contraception Today. Taylor and Francis