C-Gyn 3.

2 Intrauterine contraception

FSRH link to source document (March 2023) vii

[Link]
[Link]

Purpose
To provide evidence-based guidance and expert opinion to health professionals about intrauterine
contraception.

Description of contraceptive method

Intrauterine devices (IUDs) are long-acting, reversible, highly effective methods of contraception. In Australia
and New Zealand there are two types of IUD available: copper IUDs (Cu-IUDs) and levonorgestrel-releasing
IUDs (LNG-IUDs) (19.5mg (Kyleena) and 52mg (Mirena) available in Australia and 13.5mg (Jaydess) and 52mg
(Mirena) available in New Zealand). The copper IUD is a T-shaped device made of plastic and copper that is
inserted into the uterus. A levonorgestrel releasing device is also a T-shaped device made of plastic but has
the hormone levonorgestrel incorporated into the stem which is steadily released each day (the length of
time varies according to dose) and prevents pregnancy.

Citation
FSRH Guideline (March 2023) Intrauterine Contraception. BMJ Sexual & Reproductive Health 2023; 49:Suppl
1. Published [Link] doi: 10.1136/bmjsrh-2023-IUC

Abbreviations
FSRH - Faculty of Sexual and Reproductive Health
IUC - Intrauterine contraception
Cu-IUD - Copper intrauterine device
hCG - Human chorionic gonadotrophin
LNG-IUD - Levonorgestrel intrauterine device
PoTS - Postural orthostatic tachycardia syndrome
PPIUC - Postpartum intrauterine contraception
VVC - Vulvovaginal candidiasis
PID - Pelvic inflammatory disease
USS - Ultrasound scan
COC - Combined oral contraception/contraceptive

Key for recommendations

FSRH classification Symbol/grading
Key information Based on evidence (A-D) or not ( )
Clinical Recommendations Label: A-D - FSRH Grading of Recommendations
Good Practice Points Based on clinical experience of FSRH guideline group

The FSRH Guideline had 128 recommendations. The RANZCOG version included 104 recommendations after adaptations, review for relevance and
vii

scope. Please see the source document for the full list of recommendations.

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List of recommendations: Intrauterine contraception (IUC)
Topic FSRH Recommendations and Good practice Points FSRH levels
of evidence
Key information There are two types of intrauterine contraceptives (IUC)
including available in Australia and New Zealand: copper intrauterine RANZCOG
effectiveness and devices (Cu-IUDs) and levonorgestrel intrauterine devices (LNG- adaptation
duration of use IUDs) and both are highly effective.
IUD Dose Effectiveness Failure rate Duration of
use Mixed C - D
LNG 52mg 7 days 0.2% at 1 year 8 years RANZCOG
adaptation
LNG 19mg 7 days 0.3% at 5 years 5 years
LNG 13.5mg 7 days 0.2% at 3 years 3 years
Cu 375 Immediate 1% at 1 year 5 years

Cu 380 viii Immediate 0.1-1.0% 10 years

A 52mg LNG-IUD has additional potential gynaecological benefits C

including management of heavy menstrual bleeding (HMB) and
dysmenorrhoea.
Pre-fertilisation effects are the main mode of action for both the D
Cu-IUD and the LNG-IUD.
Cu-IUD can also be used for emergency contraception. C
Any 52mg LNG-IUD inserted at age ≥45 years can be used for
contraception until age 55 years.
Any Cu-IUD with copper surface area ≥300 mm2 inserted at age
≥40 years can be used for contraception until menopause. It can
be removed 1 year after the final menstrual period if this occurs
after age 50 years.
Any 52mg LNG-IUD can be used for 5 years as endometrial
protection as part of hormone replacement therapy (HRT).
Young people, IUC can be used by young people, individuals who have never D
never pregnant or been pregnant and individuals who have never been sexually
sexually active active.
Contraception Immediate postpartum IUC (within 48 hours of childbirth) is B
after pregnancy safe, effective, convenient and associated with high continuation
rates.
When inserted within 48 hours of childbirth, the insertion
technique is different to that of standard IUC insertion and
clinicians need to be appropriately trained in this technique.
IUC insertion from 48 hours after childbirth to 4 weeks B
postpartum is not recommended as it is associated with an RANZCOG
increased risk of uterine perforation, particularly if the user is adaptation

viii Short and standard

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 breastfeeding. The risk of uterine perforation from 28 days after
childbirth remains higher if breastfeeding but overall is small.
Expulsion rates are higher when IUC is inserted within 48 hours C
after childbirth compared with interval insertion at 4 – 8 weeks. RANZCOG
Expulsion rates are higher when IUC is inserted after vaginal adaptation
birth compared with caesarean birth.
IUC insertion after abortion is convenient and acceptable and B
has been associated with high continuation rates and reduced
likelihood of another abortion within the next 2 years.
After medical abortion, or medical or expectant management of D
miscarriage, IUC can be inserted any time after expulsion of the RANZCOG
pregnancy, providing there is no clinical suspicion of products adaptation
still in the cavity, sepsis and no new risk of pregnancy.
IUC can be inserted immediately after surgical abortion or A
surgical management of miscarriage or ectopic pregnancy,
providing there is no clinical suspicion of sepsis.
If >48 hours have passed since childbirth, insertion should be B
delayed until 28 days after childbirth (interval insertion). The
risks of insertion from 48 hours until 28 days after childbirth
generally outweigh the benefits. (See p.23 for UKMEC).
Perimenopause Additional investigations may be indicated prior to or at the time
as IUC insertion in individuals with abnormal uterine bleeding, or
if an individual has risk factors for gynaecological disease.

The FSRH supports the use of any 52mg LNG-IUD for

endometrial protection as part of HRT for 5 years.
Uterine For individuals with known distortion of the uterine cavity ix, risks D
malformations associated with IUC insertion generally outweigh the benefits.
(See p.23 for UKMEC).
The decision to insert an IUC in an individual with uterine cavity
distortion should be made on an individualised basis,
considering degree of distortion, uterine cavity size, accuracy of
imaging available, indication for use and other suitable
alternatives, type of device being inserted and potential
consequence of complications for that particular individual.
IUC insertion for an individual with uterine cavity distortion due
to fibroids or uterine malformation should be undertaken in a
specialist setting with access to concurrent ultrasound or
hysteroscopy.
The uncertainty around the safety and contraceptive
effectiveness of IUC in individuals with uterine cavity distortion
should be explained to the individual, with advice on how and
when to seek review.
Endometrial The decision to insert IUC at an interval following endometrial
ablation ablation should be made on an individualised basis, considering
indication for IUC insertion, need for a reliable concurrent

ix For recommendations about IUC following endometrial ablation and Lletz – see FSRH source document.

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 endometrial biopsy, and ultrasound appearance of the
endometrium.
If IUC insertion is considered for an individual who has previously
undergone endometrial ablation, the procedure should be
undertaken in a specialist setting, with ultrasound or
hysteroscopic assessment of the cavity to determine suitability.
Risk of infection Current pelvic inflammatory disease, postpartum or post- D
abortion sepsis, known gonorrhoea infection, symptomatic
chlamydial infection, and purulent cervicitis are all
contraindications to IUC insertion. (See p.23 for UKMEC).
If IUC insertion has to be delayed due to infection, bridging
contraception should be offered.
A sexual history should be taken prior to IUC insertion and
screening offered to individuals at risk of sexually transmitted
infections. Screening can be performed at the time of insertion.
Antibiotic Antibiotic prophylaxis is not routinely recommended when an C
prophylaxis individual at increased risk of developing infective endocarditis
has an IUC procedure.
Vasovagal There is a small risk of vasovagal reaction during IUC procedures. D
reaction
Cardiac disease The majority of IUC insertions in individuals with postural
and orthostatic tachycardia syndrome (PoTS) should be
anticoagulation x straightforward and low risk, providing precautions (adequate
hydration, salt intake and postural awareness) are in place.
Contraception choice for individuals with cardiac disease will
often require a multidisciplinary approach and discussion with
the individual’s cardiologist is recommended.
For individuals with pre-existing arrhythmia, Eisenmenger
physiology, single ventricle (or Fontan) circulation, long QT
syndrome or impaired ventricular function a vasovagal reaction
could pose a serious risk of a significant cardiac event and
therefore IUC procedures should be undertaken in a hospital
setting.
If an individual with PoTS has a history of postural syncope,
advice should be sought from their cardiologist as it may be
recommended that insertion should be undertaken in a hospital
setting.
IUC insertion for an individual who is anticoagulated should be
undertaken by an experienced clinician, with consideration given
to the timing, as well as ensuring availability of haemostatic
agents/equipment.
Inherited bleeding When an individual with an inherited bleeding disorder requests
disorders IUC insertion, clinicians should take advice from the individual’s
haematologist as to the appropriateness of the method, where

x
Recommendations about immunosuppression, adrenal sufficiency, Ehlers-Danlos, allergy and hypersensitivity, Wilson’s Disease were not included in
this summary but are available in the full FSRH source document.

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 the procedure should be undertaken and whether any additional
precautions are required.
Health risks The available evidence suggests a possible association between D
associated with current or recent use of hormonal contraception (including LNG-
IUC use IUDs) and a small increase in risk of breast cancer; absolute risk
remains very small.
Although incidence of ovarian cysts may be elevated during LNG- D
IUD use, this does not appear to be clinically significant.
Presence of (or history of) ovarian cysts or polycystic ovary D
syndrome is not a contraindication to IUC use.
The limited evidence available suggests that IUC use has no D
significant effect on serum estradiol levels or bone mineral
density.
Bleeding patterns Cu-IUD use is associated with an increase in menstrual blood C
with IUC use loss and intermenstrual bleeding compared with natural
D menstrual cycles in individuals without Cu-IUD.

C Increased menstrual bleeding associated with Cu-IUD use will D

often decrease over time.
C
Altered bleeding patterns are common after LNG-IUD insertion. C
With the LNG-IUD there is a trend towards decreased bleeding C
over time.
Individuals should be informed about the expected changes in
bleeding pattern with an IUC.

Hormonal side Acne, breast tenderness, headache and mood changes are D
effects reported by some individuals using LNG-IUD. However, evidence
is too limited to confirm or exclude a causative effect. When
present these symptoms appear to be more prevalent in the first
few months after insertion but decrease with time.
Prior to insertion Prior to insertion of their chosen IUC, individuals should be
of IUC advised about: RANZCOG
• the type and name of device adaptation
(See p.21 for • contraceptive effectiveness
Intrauterine pre- • duration of use
insertion • potential bleeding patterns and side effects
checklist) • any non-contraceptive benefits
• the procedure (including associated risks)
• analgesia options
• checking threads and when to seek review.
The expiry date on the IUC ± anaesthetic/analgesia should be
checked prior to use.
Ideally, an appropriately trained assistant should be present
during all uterine instrumentation procedures.
The insertion for immediate PPIUC is different to that for
standard IUC insertion and should only be performed by those
trained in this technique.

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Management of Analgesia options should be discussed and offered to all
pain during individuals having IUC inserted. Taking oral pain relief one hour RANZCOG
procedure prior to the procedure may be helpful. adaptation
Individuals should be advised that during the procedure:
• most IUC insertions are associated with mild-to- RANZCOG
moderate discomfort or pain (associated with speculum adaptation
insertion, tenaculum placement, uterine sounding and
device placement).
• pain may range from none to severe and occur at any
time in the procedure.
• they may ask for the procedure to be paused or stopped
at any time.
Referral processes should be in place for circumstances where
an individual requests an analgesia option that the clinician is
unable to provide.
A bimanual pelvic examination should be performed prior to
inserting IUC.
To reduce the risk of perforation and facilitate fundal placement
of the device, tissue forceps should usually be used to stabilise
cervix and straighten the uterine cavity, and a uterine sound
used for cavity length prior to insertion.
Paracervical block, intracervical local anaesthetic injection, 10% D
lidocaine spray or cream containing 2.5% lidocaine plus 2.5%
prilocaine appear to be beneficial in reducing insertion-related
pain.
After care advice Where IUC has been inserted outside of product licence or as
and follow up emergency contraception, information about how and when to
perform a pregnancy test should be given.
Individuals should be advised that it is common to have mild-to-
moderate pain or discomfort following most IUC insertions, but RANZCOG
that pain can range from none to severe. addition
With the exception of post-partum IUC, routine post-insertion
check-ups with a clinician are not required.
When IUC has been inserted within 48 hours of a vaginal or
caesarean birth (PPIUC), an IUC check-up with a clinician 4–6
weeks after insertion is recommended.
IUC users should be advised to feel for their threads within the
first 4–6 weeks after insertion and then at regular intervals (e.g.
monthly or after menses).
Unscheduled Tranexamic acid or nonsteroidal anti-inflammatory drugs D
bleeding (NSAIDs) can be offered for management of HMB during use of
IUC.
A 3-month trial of COC can be offered to medically eligible
individuals with problematic bleeding during use of IUC.
Pelvic pain New-onset pelvic pain in an IUC user should be assessed, and
pregnancy should be excluded.

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Pregnancy with an The risk of any pregnancy, including ectopic pregnancy, during C
IUC use of IUC and after insertion of a Cu-IUD for EC is very low.
In the unlikely event that pregnancy occurs with IUD in situ, the C
likelihood of it being ectopic is greater than if a pregnancy was RANZCOG
to occur without IUD in situ. adaptation
A previous ectopic pregnancy is not a contraindication to use of D
intrauterine methods of contraception.
If an individual with an IUC in situ has a positive pregnancy test,
local early pregnancy assessment pathways should be followed
to determine the location of the pregnancy.
When an intrauterine pregnancy is less than 12 weeks gestation, D
the IUC should usually be removed, if the threads are visible, as
this could improve later pregnancy outcomes.
Infection following The risk of pelvic infection appears to increase in the first 3 C
an IUC insertion weeks after IUC insertion, but overall, the risk is very low (<1%).
The evidence pertaining to effect of IUC use on risk of D
vulvovaginal candidiasis (VVC) and/or bacterial vaginosis is
limited and conflicting.
Pelvic actinomycosis is a very rare, chronic bacterial pelvic D
infection that is associated with long-term IUC use.
Individuals with mild-to-moderate PID and IUC in situ, whose D
clinical condition is improving over the first 48–72 hours, can
retain their IUC.
Individuals with pelvic inflammatory disease (PID) and IUC in situ D
should be given antibiotic treatment, managed in accordance RANZCOG
with local treatment policies and reviewed after 48–72 hours. adaptation
Individuals whose clinical condition does not improve after 48– D
72 hours of antibiotics should usually have their IUC removed,
but this decision should be considered alongside any potential
risk of pregnancy if there has been unprotected vaginal sex
within the preceding 7 days. EC and follow-up pregnancy testing
should be considered if indicated.
IUC users with symptomatic, recurrent VVC or bacterial vaginosis D
not controlled by standard treatment may wish to switch to an
alternative method of contraception.
Asymptomatic individuals with positive actinomyces-like D
organisms on cervical cytology are more likely to be colonised
than infected, and there is no need to remove the IUC or to
commence antibiotic treatment.
If actinomycosis is suspected, further investigation and D
management should be discussed on an individual basis with
local radiology, microbiology and/or gynaecology teams.
Incorrect Correct IUC position at the fundus may be necessary for D
placement of IUC maximum contraceptive effectiveness and incorrect placement
may be associated with increased risk of contraceptive failure.

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 There is insufficient evidence to definitively guide whether a D
malpositioned IUC (hormonal or non-hormonal) should be left in RANZCOG
situ or removed and replaced, and clinicians should consider adaptation
each case on an individual basis.
The guideline development group (GDG) suggests that IUC
should be removed and replaced if >2 cm from the fundus. RANZCOG
However the efficacy of the hormonal-IUD may be less affected adaptation
by its position in the uterine cavity than a copper IUD. The need
for replacement is recommended if any IUD is lying within the
cervical canal (fully or partially); or where the malposition is
associated with symptoms such as pain or bleeding. The decision
to remove a hormonal IUD located >2cm from the fundus, but
not within the cervical canal, should be made on the basis of
clinical symptoms such as pain and extended periods of bleeding
with consideration to the ultrasound findings.
Clinicians should consider the need for EC and follow-up D
pregnancy testing when an IUC is found to be malpositioned.
Expulsion The overall risk of IUC expulsion is approximately 5% at five C
years and expulsion appears to be most common in the first year RANZCOG
of use, particularly within 3 months after insertion and if the adaptation
insertion was postpartum.
Expulsion rates are higher when inserted immediately C
postpartum compared with interval postpartum insertion or
insertion in individuals who have not had a recent pregnancy.
Expulsion rates may be higher in adolescents, those who have D
IUC inserted after late first-trimester or second-trimester
surgical abortions, individuals with fibroids and HMB, individuals
with uterine cavity distortion, individuals concurrently using a
menstrual cup with IUC, and those who have had a previous
expulsion.
If there have been ≥2 IUC expulsions, a pelvic ultrasound to
assess the uterine cavity may be helpful prior to insertion of a
further IUC.
Post-insertion ultrasound scan (USS) is not predictive of the
likelihood of further expulsion but can provide immediate
confirmation of correct positioning.
Perforation The rate of uterine perforation associated with IUC use is very C
low, with an overall risk of perforation in the general population
of 1–2 in 1000.
Postpartum interval IUC insertion (from 48 hours after C
childbirth) is associated with an increased risk of uterine
perforation, particularly if the user is breastfeeding.
Uterine perforation may be identified at the time of insertion or D
at a later date.
Lower abdominal pain, non-visible threads or changes in D
bleeding may indicate uterine perforation.

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 If perforation is suspected, an ultrasound scan ± plain abdominal
and pelvic X-ray should be arranged as soon as possible in order
to locate the device. EC and pregnancy testing should be
considered, and ongoing contraception provided.
Following confirmed or suspected uterine perforation, the GDG
suggests waiting at least 6 weeks before inserting a subsequent
IUC. Referral to a specialist service, where ultrasound is
available, is suggested for the subsequent insertion.
Thread problems IUC threads may not be visible in the vagina as a result of IUC D
expulsion, perforation or pregnancy, or device being correctly
(See p.22 for sited but with threads within the cervical canal or uterus.
Management of
individuals when If no threads are visible on speculum examination, pregnancy
intrauterine should be excluded, emergency contraception considered,
contraceptive alternative contraception provided and an ultrasound
(IUC) threads are undertaken to locate the device.
not visible on If the IUC is confirmed to be correctly sited within the uterine
speculum cavity, the user can be reassured and the device left in situ.
examination)
The uterus should only be instrumented by a clinician with
appropriate training to do so, and it is not advisable to
instrument the uterine cavity without first confirming the
intrauterine location of the device and excluding pregnancy.
As threads may descend into the vagina after PPIUC insertion,
they may need to be trimmed at a subsequent IUC check
Timing of removal Individuals who do not wish to become pregnant should be D
or replacement advised to avoid unprotected sexual intercourse (UPSI) for 7
days prior to IUC removal.
Individuals should be advised to avoid UPSI for 7 days prior to
IUC removal and replacement in case it is not possible to insert
the new device.
Unexpected On removal the IUC should be checked to ensure it is intact and
findings is the expected device.
Difficult removals Where there is difficulty in removing an IUC a referral should be
made to an experienced provider.

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Supplementary materials
1. FSRH Grading of Recommendations
FSRH Grade Explanation
A At least one meta-analysis, systematic review or randomized control trial (RCT) rated as
1++, and directly applicable to the target population; or
A systematic review of RCTs or a body of evidence consisting principally of studies rated
as 1+, directly applicable to the target population and demonstrating overall consistency
of results.
B A body of evidence including studies rated as 2++ directly applicable to the target
population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+.
C A body of evidence including studies rates as 2+ directly applicable to the target
population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++.
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+.
Good Practice Point based on the clinical experience of the guideline development
group.

2. Intrauterine pre-insertion checklist

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3. Management of individuals when intrauterine contraceptive (IUC) threads are not visible on
speculum examination

IUC seen outside

uterus

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4. Medical conditions that are UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) 3 or 4
for intrauterine contraception
(Tables 4-11 summarised by RANZCOG from source document)

Condition Device UKMEC category

Breast cancer – current and past LNG-IUD only 4
Chlamydia infection - symptomatic All 4 - initiation
Chlamydia infection - asymptomatic All 3 - initiation
Gestational trophoblastic disease with decreasing hCG levels All 3
Gestational trophoblastic disease with persistently elevated All 4
hCG levels or malignancy
Gonorrhoea – symptomatic or asymptomatic All 4 - initiation
Known long QT syndrome All 4 - initiation
Ischaemic heart disease or stroke All 3 - continuation
Pelvic inflammatory disease - current All 4 - initiation
Postpartum >48 hours to <4 weeks All 3
Postpartum sepsis - current All 4
Postabortion sepsis - current All 4
Purulent cervicitis All 4 - initiation
Uterine cavity distortion All 3
Initiation: Starting a method by an individual with a specific medical condition.
Continuation: Continuing with the method already being used by an individual who develops a new medical condition.

5. United Kingdom Medical eligibility criteria (UKMEC)

UKMEC Definition of UKMEC category
Category 1 A condition for which there is no restriction for the use of the method.
A condition where the advantages of using the method generally outweigh the theoretical or
Category 2
proven risks.
A condition where the theoretical or proven risks usually outweigh the advantages of using the
method. The provision of a method requires expert clinical judgement and/or referral to a
Category 3
specialist contraceptive provider, since use of the method is not usually recommended unless
other more appropriate methods are not available or not acceptable.

Category 4 A condition which represents an unacceptable health risk if the method is used.

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