INTRODUCTION Intrauterine contraception is one of the safest and most effective methods of contraception available today.

. It is considered top tier contraception because it ranks alongside implants and sterilization in efficacy and requires m inimal user effort. Modern devices for intrauterine contraception are made of pl astic and release either copper or a progestin to enhance the contraceptive acti on of the device. Several terms are used to describe intrauterine contraception, including intraut erine device (IUD) and intrauterine contraceptive (IUC); the progestin-containin g device is also referred to as an intrauterine system (IUS). In this topic, we use the term IUD for all types of intrauterine contraception. OVERVIEW OF BENEFITS Intrauterine contraception is highly effective, private, lo ng-acting, and rapidly reversible, with few side effects (table 1) [1]. It is sa fe for most women, including teens and nulliparous women; there are few contrain dications to its use [2,3]. It does not interfere with the spontaneity of sex, o ffers several noncontraceptive health benefits, has high user acceptability and continuation, and can be used by women who want or need to avoid exogenous estro gen. The IUD is among the most cost-effective contraceptive options available. I n addition, it represents an effective alternative to surgical sterilization, wh ich many women choose in order to avoid the side effects and frequent attention required by most reversible methods of contraception. PREVALENCE OF IUD USE The IUD is the most commonly used method of reversible con traception worldwide [4]. Use of IUDs has been increasing in the United States. In 2002, only 2 percent of contraceptive users in the United States chose IUDs [ 5], whereas in 2009, this number had increased to 7.5 percent [6]. However, the United States continues to lag behind other countries in IUD use. By comparison, IUDs are used by over 50 percent of contracepting women in parts of Asia [7,8] and 6 to 27 percent of female contraceptive users in Europe [9]. Concerns limiting usage Several factors have limited widespread use of the IUD i n the United States, including a history of negative publicity; misinformation a bout the risks of ectopic pregnancy, infection, and infertility; misconceptions about the mechanism of action of the IUD; lack of clinician training; and fears of litigation [10]. In the 1970s, the IUD was used by 10 percent of women in the United States using contraception. When the Dalkon Shield (a common IUD used in that era) was linked to pelvic inflammatory disease, utilization of all IUDs fe ll and litigation rose [11]. One likely explanation for the increase in infectious morbidity associated with IUDs in this period is the construction of the tail. The braided and multifilame nt tails of the plastic IUDs from this era may have acted like wicks and allowed bacteria to ascend to the upper genital tract. Coupled with the fact that no te st had yet been developed to detect asymptomatic Chlamydia infection, many women developed severe pelvic infections. Modern IUDs, which have monofilament tail strings, have not been associated with infections, nor with litigation against health care providers or the companies that manufacture IUDs [12,13]. In 2005, the US Food and Drug Administration appr oved liberalized package labeling for the copper T380A, removing any proscriptio n against its use in nulliparous women or in those with more than one sexual par tner. Actively informing women about benefits and risks of long-acting contraceptives, such as the IUD, appears to improve consideration and acceptance of the method [14]. MECHANISM OF ACTION The precise mechanism of the contraceptive action of IUDs is not known; it is likely that several factors are involved (table 2) [15-19]. Pr

egnancy appears to be prevented by a foreign body effect induced by the plastic or metal frame and by local changes resulting from the effects of locally releas ed medication (copper or levonorgestrel). IUDs work primarily by preventing fertilization, and do not act as abortifacient s (defined as interruption of an implanted pregnancy) [20]. When the uterus is e xposed to a foreign body, a sterile inflammatory reaction occurs, which is toxic to sperm and ova and impairs implantation [17,19-22]. The production of cytotox ic peptides and activation of enzymes lead to inhibition of sperm motility, redu ced sperm capacitation and survival, and sperm phagocytosis [23,24]. This primary effect of preventing fertilization is supported by three lines of e vidence [17,19,21,25-28]: Sensitive assays for human chorionic gonadotropin (HCG) in IUD users did not det ect transient "chemical" pregnancies Tubal flushing studies did not find sperm or fertilized ova in the fallopian tub es of IUD users, but commonly found them in noncontraceptors IUD users have lower rates of both intrauterine and tubal pregnancy than women n ot using contraception Additional mechanisms of contraception of medicated IUDs include: The free copper and copper salts released by in utero oxidation of copper-contai ning IUDs enhance the cytotoxic inflammatory reaction within the endometrium (eg , local prostaglandin production is increased), which is toxic to sperm and ova [21,22,29]. In vitro, copper interferes with sperm migration, viability, and acr osomal reaction [30]. Postfertilization effects also appear to contribute as a s econdary contraceptive mechanism [16,30]. The progestin secreted by progestin-releasing IUDs thickens cervical mucus, whic h creates a barrier to sperm penetration into the upper genital tract [31]. In a ddition, progestins cause endometrial decidualization and glandular atrophy, whi ch are hostile to implantation [32]. Progestins also increase expression of glyc odelin A in endometrial glands, which inhibits binding of sperm to the egg [33]. Progestin-releasing IUDs produce serum concentrations of progestin that lead to partial inhibition of ovarian follicular development and ovulation. This is not, however, a major contraceptive mechanism; one study found at least 75 percent o f women using a levonorgestrel-releasing IUD had ovulatory cycles [34]. TYPES OF IUDs The shapes, components, and construction of intrauterine devices h ave varied widely over time and across the world (picture 1). The three categori es of modern IUDs are: Copper IUDs Progestin-releasing IUDs Unmedicated (inert) IUDs The two types of IUDs currently available in the United States are the copper T3 80A (TCu380A ParaGard) and the levonorgestrel-releasing IUD (LNg IUD Mirena); addi tional copper, progestin-releasing, and inert IUDs are available worldwide. Both the LNg IUD and the TCu380A are highly effective forms of reversible contra ception (table 1) [25,35], with efficacy comparable to the 1.9 percent 10-year c umulative risk of pregnancy after tubal ligation [36]. TCu380A (copper) IUD The TCu380A (Paragard) contains a T-shaped polyethylene fram e with 380 mm2 of exposed surface consisting of fine copper wire wound around a vertical stem and copper collars on each of the horizontal arms. There is a 3 mm ball at the base of the stem to decrease the risk of cervical perforation (pict ure 2) [12]. A white or clear polyethylene monofilament string is knotted throug h this ball. The frame contains barium sulfate to make it radiopaque. The device is latex-free and clinically relevant allergy to copper is extremely rare [37].

Serum copper levels are higher in TCu380A users compared with nonusers and abov e the normal blood copper level range; however, this increase in circulating cop per does not have a negative clinical impact [38]. Duration of use The TCu380A is approved to remain in place for 10 years, but app ears to be both safe and highly effective for up to 20 years [35,39]. Efficacy With perfect use (in which the user checks the strings regularly to det ect expulsion), the probability of pregnancy in the first year is 0.6 percent; w ith typical use, the first-year pregnancy rate is 0.5 to 0.8 percent (table 1) [ 20,40]. After prolonged continuous use, the cumulative pregnancy rate is 1.6 per cent at seven years [41], and 2.2 percent at 8 and 12 years [35]. Overall, the f ailure rate is substantially less than one per 100 women per year, except in wom en under age 25 who experience a slightly higher failure rate, most likely becau se they are more fertile than older women [20,40]. IUDs with less than 380 mm2 of copper and inert IUDs are less effective than tho se containing 380 mm2 or more of copper [42,43]. Of note, providers and consumers should be aware that counterfeit IUDs, as well as other drugs, are sometimes sold by on-line pharmacies. Levonorgestrel-releasing IUD The levonorgestrel (LNg) IUD (picture 3) consists o f a T-shaped polyethylene frame with a collar containing 52 mg of levonorgestrel dispersed in polydimethylsiloxane attached to a vertical stem. In vivo, the LNg IUD initially releases 20 mcg of levonorgestrel daily, declining to 10 to 14 mc g per day after five years. Like the copper IUD, the stem contains barium sulfat e so it can be detected by x-ray, and it does not contain latex. The progestin effect is primarily local [44]. The endometrial concentration of l evonorgestrel is 1000 times higher than that observed with the levonorgestrel su bdermal implant [45]. The plasma concentration of levonorgestrel is far lower th an the endometrial concentration and varies among patients. It is 100 to 200 pg/ mL within the first few weeks of use, with a gradual decline over time and wide individual variation [46,47]. This level is half that seen with progestin implan ts and much less than that associated with progestogen-only pills, but high enou gh to cause systemic side effects in some users [12]. Serum estradiol levels are not affected [47]. Duration of use The LNg IUD is approved for up to five years of use, but appears to be effective for up to seven years [25]. Efficacy With perfect use, the probability of pregnancy in the first year is 0.1 percent; with typical use, the first-year pregnancy rate is 0.1 to 0.2 percent [25]. This is comparable to that with sterilization procedures. With seven years of continuous use, the cumulative pregnancy rate is 1.1 percent (table 1) [25]. Inert IUDs Although unmedicated IUDs are not approved for use in the United Stat es, providers in this country may encounter these contraceptive devices among pa tients who have lived abroad. Unmedicated IUDs are composed of inert materials s uch as stainless steel or plastic. The Lippes Loop, a polyethylene device contai ning barium sulfate with a single filament tail, is used throughout the world. F lexible stainless steel rings visible on x-ray, but with no string, are widely u sed in China [12,20]. An advantage of inert IUDs is that they never need to be replaced. However, many practitioners recommend replacing them with hormone releasing or copper IUDs be cause medicated IUDs are more effective [12]. Frameless IUDs Frameless IUDs are available in several countries, but not the Un

ited States. The GyneFix 330 is made up of several copper cylinders threaded ont o a polypropylene suture and without the plastic frame common to other IUDs [48, 49]. The FibroPlant is a frameless levonorgestrel-releasing IUD consisting of a nonresorbable thread attached to a fibrous delivery system that releases 14 or 2 0 mcg of levonorgestrel per day [50]. Early generation frameless devices (before 1996) were associated with a high rat e of expulsion in the first year [51], but modifications to the introducer syste ms that anchor the device to the myometrium appear to have overcome this problem , although data are sparse [52]. Advantages of these systems are that they are small, effective, and well tolerat ed. They are as effective as conventional IUDs and probably more adaptable to va riations in the shape of the uterine cavity [51]. The major disadvantage of fram eless IUDs is that they require additional training to learn the insertion techn ique, which is different from that for other IUDs. GENERAL APPROACH TO CHOOSING AN IUD For women who are appropriate candidates for IUD use, this method is an excellent choice because it is highly effective, pri vate, coitus-independent, long-acting, rapidly reversible, cost-effective, and h as few side effects. It offers a nonsurgical, reversible alternative to tubal st erilization [53]. Patient satisfaction and continuation rates are high [54,55]. As an example, a Finnish study including almost 18,000 women using the levonorge strel IUD reported continuation rates at one, two, three, four, and five years o f 93, 87, 81, 75, and 65 percent, respectively [54]. Candidates for intrauterine contraception Ideal candidates for intrauterine cont raception are women who: Desire one of the most effective methods of contraception; Are at low risk of acquiring sexually transmitted infections, since such infecti ons may require removal of the IUD; Are not planning a pregnancy for at least one year, since attempting pregnancy a lso requires removal of the IUD; Want to use a reversible contraceptive; Want or need to avoid estrogen-based methods. Use of the IUD in other populations is also reasonable, and may be indicated bec ause of noncontraceptive benefits. Nulliparous women, women in nonmonogamous relationships, adolescents, and women with a history of pelvic inflammatory disease (PID) or ectopic pregnancy can all safely use the IUD with appropriate counseling (see below). The CuT380A IUD can also be used for emergency contraception and both IUDs can be used by women pos tpartum and postabortion. (See "Emergency contraception" and "Postpartum and pos tabortion contraception".) Contraindications There are relatively few absolute, evidence-based contraindica tions to intrauterine contraception [56]. When considering any method, its contr aceptive and noncontraceptive benefits must be weighed against the risks, as wel l as the risks of unintended pregnancy with alternative methods of contraception . (See 'Coexistent chronic medical conditions and personal characteristics' belo w.). The following are the major conditions in which intrauterine contraception is co ntraindicated: Severe uterine distortion Anatomic abnormalities including bicornuate uterus, ce rvical stenosis, or fibroids severely distorting the uterine cavity are contrain dications to use because of increased difficulty with insertion and increased ri sk of expulsion when an IUD is placed in a distorted, small, or extremely large

uterine cavity [57]. Manufacturers recommend that the uterine cavity sound to be tween 6 and 9 cm for optimal performance, but this is not based on good evidence . Nondistorting fibroids are not a contraindication to intrauterine contraceptio n [3]. Active pelvic infection IUD insertion in women with active pelvic infection, inc luding PID, endometritis, mucopurulent cervicitis, and pelvic tuberculosis, is c ontraindicated because the presence of a foreign body may impede resolution of t he infection. The IUD may be inserted in women who are at least three months sta tus post-treatment for PID or puerperal or postabortion sepsis. (See "Management of problems related to intrauterine contraception", section on 'Infection'.) In women treated for gonorrhea or chlamydia who desire an IUD, the World Health Organization recommends waiting three months before IUD insertion. However, in s elected patients with no evidence of PID and who are believed to be at low risk for subsequent infection, we consider the following approach: retest after at le ast three weeks to confirm the absence of reinfection and repeat the bimanual ex amination to ensure the absence of cervical motion tenderness, uterine tendernes s or other evidence of upper genital tract infection; the IUD may be inserted at the time of the retest in asymptomatic patients. If the retest returns positive , suitability for continued IUD use should be evaluated. If the woman decides to continue the IUD, she and her partner(s) may be treated without removal of the device. In asymptomatic patients with unknown STD status, many clinicians test for gonor rhea or chlamydia at the time of IUD insertion. If the test returns positive, th e woman and her partner(s) may be treated without removal of the IUD. We recomme nd a retest after at least three weeks to confirm the absence of reinfection wit h management as described above. Women at increased risk of acquiring an STD can decrease their risk by using con doms in addition to the IUD. The LNg IUD may offer more protection against PID t han the TCu380A. (See 'Levonorgestrel-releasing IUD' above.) Known or suspected pregnancy IUD insertion during pregnancy can lead to miscarri age and increases the risk of septic abortion. Wilson's disease or copper allergy The amount of copper released daily by the TC u380A is less than that consumed in the average diet. Although no adverse event related to copper allergy or Wilson's disease has ever been reported in a woman with a copper IUD, hormone-releasing IUDs are preferred for use in women with th ese conditions [12]. Unexplained abnormal uterine bleeding Evaluation of women with abnormal uterine bleeding should precede IUD placement since, after placement, the abnormal bleed ing may be erroneously attributed to the IUD rather than the preexisting patholo gy. Other Current breast cancer is a contraindication to use of the LNg IUD. However , there is no epidemiological evidence of an increased risk of breast cancer wit h use of this IUD [58]. The LNg IUD has additional relative contraindications re lated to specific hormonally sensitive conditions, such as active liver disease (table 3). (See "Overview of contraception", section on 'World Health Organizati on tables'.) A current history of dysmenorrhea or menorrhagia is a relative contraindication to use of the TCu380A IUD. Copper or levonorgestrel? Most women can safely use either the copper or levonor gestrel (LNg) IUD. When counseling a patient about choice of IUD, it is helpful to know her menstrual history, her medical history, her desire for lighter or le ss painful menses, and her feelings about amenorrhea, unscheduled bleeding, and spotting. When to choose copper Women who may prefer the copper IUD include [59]:

Women who want or need to avoid exogenous hormones, such as women with recent br east cancer (within five years); Women who wish to avoid the potential progestin-related side effects of the LNg IUD (amenorrhea, unscheduled bleeding, spotting); Women who desire no or minimal interruption in their endogenous menstrual cycle; Women who need uninterrupted contraception for several years: the TCu380A is app roved for twice as many years of use as the LNg IUD (10 versus 5 years); Women who need emergency contraception. The TCu380A can be inserted for emergenc y contraception, and then left in place to provide ongoing contraception. Women considering the copper IUD should be advised that menses may be heavier, l onger, or more uncomfortable, particularly in the first several cycles after ins ertion; use of nonsteroidal antiinflammatory medications can reduce these sympto ms. (See "Management of problems related to intrauterine contraception", section on 'Pain'.) Heavy menses and dysmenorrhea are the most frequent reasons for copper IUD remov al in the first year [60]. The frequency of side effects was illustrated in a pr ospective study of 1962 new copper IUD users in which 38 percent reported more m enstrual pain during the first nine weeks of use compared to before IUD use and two-thirds reported increased menstrual blood loss compared to before use; howev er, the frequency of each side-effect decreased over the first year of use [61]. Average monthly menstrual blood loss is increased by up to 55 percent throughout the duration of use; however, most women do not discontinue use for this side e ffect, and the increased blood loss rarely leads to anemia [62]. In prospective trials, 2 per 100 users per year discontinued the method due to menorrhagia [25] , although as many as 9 percent discontinued use in the first year after inserti on [63]. A disadvantage of the copper TCu380A is that it does not provide protection agai nst sexually transmitted diseases (STDs) and, compared with users of the LNg IUD , there is a greater risk of PID if a TCu380A user is exposed to sexually transm itted infections [64]. The difference in risk of PID is believed to be due to a progestin-mediated reduction in upper tract infection in LNg IUD users rather th an an increased risk in copper IUD users. As with hormonal contraceptives, use of copper IUDs has been associated with a d ecreased risk of endometrial cancer; however, the mechanism for this effect from a nonhormonal contraceptive is unknown [65,66]. When to choose levonorgestrel Women may prefer the LNg IUD if they want to use a hormonal contraceptive with minimal systemic hormonal effects. Women often choo se the LNg IUD for its many noncontraceptive health benefits, listed below [67,6 8]: Reduction in dysmenorrhea and menstrual bleeding Women with heavy and painful me nses should consider the LNg IUD over the copper IUD. The LNg IUD reduces dysmen orrhea and menstrual blood loss from a variety of causes (figure 1). The reducti on in menstrual blood loss occurs both in women with normal coagulation and in t hose with bleeding diatheses, including anticoagulant therapy [69-75]. There is good evidence that the LNg IUD is an effective treatment of idiopathic menorrhag ia, whereas efficacy in treatment of menorrhagia related to uterine fibroids and adenomyosis is less clear. (See "Chronic menorrhagia or anovulatory uterine ble eding" and "Treatment of primary dysmenorrhea in adult women" and "Overview of t reatment of uterine leiomyomas (fibroids)" and "Uterine adenomyosis".) The LNg IUD is a good choice for women who desire or are not bothered by amenorr hea, as well as those able to tolerate unscheduled light bleeding or spotting, b oth of which are common side effects. At 24 months of use, 50 percent of LNg IUD users have amenorrhea, 25 percent have oligomenorrhea, and 11 percent have spot

ting; the remainder report either normal or heavy bleeding [76]. Treatment of endometrial hyperplasia and cancer The LNg IUD appears to be an eff ective alternative to oral progestins in the treatment of nonatypical endometria l hyperplasia [77]. It may be effective for atypical hyperplasia [77] and grade 1 stage I endometrial cancer; further study is needed [78]. (See "Classification and diagnosis of endometrial hyperplasia" and "Endometrial carcinoma: Pretreatm ent evaluation, staging and surgical treatment".) Endometrial protection The LNg IUD has been used off-label to prevent developmen t of endometrial hyperplasia in perimenopausal and postmenopausal women using es trogen therapy [79-81]. While the TCu380A is generally preferred for women with recent breast cancer, the LNg IUD is an alternative in women being treated with tamoxifen, as it appears to protect the uterus against the endometrial effects o f the drug [82,83]. (See "Managing the side effects of tamoxifen".) Treatment of endometriosis The LNg IUD may decrease pain from endometriosis and delay recurrence of endometriosis after surgical excision. (See "Overview of the treatment of endometriosis", section on 'Progestins'.) Protection from pelvic inflammatory disease The LNg IUD may decrease the risk of PID, as observed with other progestin-containing contraceptives [64,84]. Proges tin thickens cervical mucus, thereby possibly providing an enhanced barrier agai nst ascending infection. The main reasons for LNg IUD discontinuation are changes in bleeding pattern, pr imarily amenorrhea and unscheduled bleeding and spotting. Other side effects res ulting in early discontinuation include hormonal side effects, such as breast te nderness, mood changes, and acne [25,54]. These side effects are discussed in de tail separately. (See "Management of problems related to intrauterine contracept ion".) Special populations and considerations Coexistent chronic medical conditions and personal characteristics The Centers f or Disease Control (CDC) (table 4) and the World Health Organization (WHO) have published eligibility criteria tables for intrauterine contraception by maternal medical condition or personal characteristics (table 5 and table 6 and table 7 and table 8 and table 3 and table 9 and table 10 and table 11 and table 12 and t able 13 and table 14). Some of these issues, and others, are discussed in more d etail below. Previous problems with IUD Women who had problems with a previous IUD, including method failure (ie, pregnancy), expulsion, pain, abnormal bleeding, and cervica l or uterine perforation, can still use intrauterine contraception, but they sho uld be informed of the recurrence risk and given other options. Depending on the problem (eg, heavy bleeding with a copper device or intermenstrual bleeding wit h the LNg), switching from one type of IUD to another might be useful. (See "Man agement of problems related to intrauterine contraception".) Immunocompromised women Intrauterine contraception does not enhance the risk of HIV acquisition over that in users of other contraceptives (table 4 and table 13 ) [85,86]. Limited data also show no increased risk of PID in HIV-infected IUD u sers compared with HIV-negative IUD users or HIV-infected women not using an IUD ; the lack of increased risk also applies to HIV infected women with low CD4 cou nts [87,88]. There is no evidence of greater cervical shedding of HIV-1 DNA in HIV-infected I UD users and no increased risk of transmission to an HIV-negative partner [89]. In addition, there are no known drug interactions between IUDs and antiretrovira l therapy [90]. Women who are HIV-infected, like other women, need effective long-term contracep tion. In conjunction with correct and consistent condom use, the IUD may be safe ly used in women with or at risk for HIV infection (table 9) [89]. However, for

women at risk of HIV infection who are also at risk of acquiring other sexually transmitted diseases (STDs), a progestin contraceptive, including the LNg IUD, m ay be preferable due to protection against ascending infections. Adolescents Age should not be the primary determinant of acceptable candidacy fo r intrauterine contraception. Other factors, including parity, pregnancy history , medical history, risk of STDs, and prior contraceptive history should govern t he decision to provide intrauterine contraception to a particular adolescent. Wi th adequate counseling regarding anticipated side effects and their management, the IUD can be used safely and effectively in adolescents [91,92]. In a 2007 Com mittee Opinion, ACOG concluded that the IUD does not increase an adolescents risk of PID and STDs, and does not affect the fertility of adolescents [91]. They al so noted that the LNg IUD may lower the risk of PID in adolescents. (See "Contra ception: Overview of issues specific to adolescents".) Even though pregnancies, expulsions, and removals for bleeding or pain are more frequent among IUD users under age 20 than in older women, the IUD is still more effective than other forms of reversible contraception in this age group [40,60 ,93,94]. In general, adolescents have better compliance with long-acting methods than they do with daily-use methods [92], but adolescents are more likely to di scontinue any contraceptive compared with older women. Rates of infection in ado lescent IUD users are similar to those in adults [94]. Method failure is higher in young women (under the age of 25) since fertility naturally declines with age [28]. Nulliparous women Nulliparous women at low risk of STDs can safely use either th e TCu380A or LNg IUD [95,96]. Both have equivalent efficacy in nulliparous and m ultiparous women, and infection rates are also similar [95-98]. Nulliparous wome n report high acceptability and continuation rates with both IUDs [95,99,100]. H owever, copper-based IUDs have been associated with a slightly higher frequency of pain, bleeding, and expulsion in nulliparas than in multiparas [93,95,101]. Restrictive product labeling and misinformation about the health risks of IUDs h ave limited IUD use in nulliparous women in the United States. In the past, pack age labels for both IUDs available in the US recommended their use only for wome n with at least one child. In response to research showing that the IUD is an ap propriate option for nulliparous and nulligravid women at low risk for STDs, in 2005, the manufacturers of ParaGard (TCu380A) gained approval from the FDA to cha nge its labeling to reflect these new data. Mirena continues to recommend use by women who have had at least one child; however, we do not feel that its use shou ld be restricted to parous women. Most women, including nulliparas, experience a rapid return to fertility after d iscontinuing intrauterine contraception [102,103]. However, misinformation about infection and infertility risk has limited the use of IUDs in the United States , particularly in women who have never been pregnant. IUDs are not associated wi th a clinically meaningful increase in pelvic infections. In a systematic review of 12 WHO studies including almost 23,000 insertions of modern IUDs and 81 subs equent cases of PID, the risk of pelvic infection was highest in the first 20 da ys after insertion, but this risk was transitory and small (9.7 cases per 1000 w oman-years) [104]. After 20 days, the risk returned to the background level of n on-IUD users and did not increase with prolonged use. In addition, a large welldesigned case-control study of nulligravid women with tubal infertility found th at women with infertility due to tubal occlusion were no more likely to have pre viously used a copper IUD than women with infertility due to other factors or fe rtile controls [105]. Moreover, the LNg IUD may protect against PID and subseque nt infertility in much the same way as other progestin-containing methods, by th ickening the cervical mucus and thinning the endometrium. IUD placement is well-tolerated by most nulliparous women [106], although nullip

arity has also been found to be a predictor of pain with IUD insertion. In sever al studies, the degree of pain reported by nulliparas was variable, ranging from the low end of the pain scale to moderate to severe [107-109]. (See "Insertion and removal of an intrauterine contraceptive device".) The WHO concluded that the benefits of IUD use outweigh the potential or known r isks in nulliparous women (table 5) [3]. The Society of Family Planning conclude d, based on level A evidence, that contemporary IUDs are safe for parous and nul liparous women and do not increase the risk of PID and infertility, that IUDs ha ve similarly low failure rates in parous and nulliparous women, and that IUDs ar e highly acceptable regardless of parity and are more acceptable than other meth ods of reversible contraception [98]. Prior ectopic pregnancy The IUD is protective against both intrauterine and extr auterine pregnancies and is an acceptable option for women with a history of a p rior ectopic pregnancy or risk factors for ectopic pregnancy [25,28,110-114]. (S ee "Incidence, risk factors, and pathology of ectopic pregnancy".) Women with a past history of ectopic pregnancy can safely use either the LNg or copper IUD. Women using intrauterine contraception have a lower incidence of ect opic pregnancy than noncontracepting women because the IUD works by preventing f ertilization as well as implantation. Women using no contraception are 10 times as likely to develop an ectopic pregnancy as IUD users [28]. However, IUD users are at higher risk of having an ectopic pregnancy if pregnancy occurs (1 in 2 pr egnancies for the LNg IUD and 1 in 16 pregnancies for the copper IUD versus 1 in 50 pregnancies among noncontraceptors) [115,116]. (See "Incidence, risk factors , and pathology of ectopic pregnancy", section on 'Intrauterine devices'.) Women who are postabortion, postpartum, or breastfeeding IUD insertion can be pe rformed immediately after miscarriage, induced abortion, or delivery. Immediate postabortion insertion increases utilization and decreases the likelihood of rep eat induced abortion. (See "Postpartum and postabortion contraception".) Use for emergency contraception The TCu380A IUD placed within 120 hours of unpro tected intercourse can be used for emergency contraception. The LNg IUD has not been studied for this indication. (See "Emergency contraception", section on 'Co pper intrauterine contraception'.) Valvular heart disease Women with valvular heart disease can use intrauterine co ntraception because intrauterine contraception does not increase a woman's risk of bacteremia or pelvic inflammatory disease (table 6 and table 4). The American Heart Association does not recommend endocarditis prophylaxis for IUD insertion in the absence of a pelvic infection. (See "Insertion and removal of an intraut erine contraceptive device", section on 'SBE prophylaxis'.) A LNg IUD is an option for prevention and non-surgical treatment of menorrhagia in women receiving anticoagulant therapy after cardiac valve replacement. In a r andomized trial of women with menorrhagia receiving anticoagulant therapy after cardiac valve replacement, women who received the LNg IUD had significant improv ement in hemoglobin and less uterine blood loss [71]. Anticoagulation/bleeding diathesis As discussed above, the LNg IUD is an option for prevention and nonsurgical treatment of menorrhagia in women receiving antic oagulant therapy or who have a bleeding diathesis. (See 'When to choose levonorg estrel' above.) There are few data on the risk of procedural bleeding in these women [72]. In sm all case series of women with inherited bleeding diatheses who received hemostat ic cover before insertion, there were no bleeding complications [117]. In our ex perience, bleeding complications are minimal among women who have an IUD inserte

d while anticoagulated. We prefer to use an atraumatic tenaculum for IUD inserti on when possible in anticoagulated women, and in general we do not provide hemos tatic cover. Coexistent gynecologic conditions There is no contraindication to intrauterine c ontraception in women with anovulation, vaginitis, cervical intraepithelial neop lasia, cervical ectropion, a history of benign ovarian cysts, or prior cesarean delivery. There is no information on use in women with a history of ovarian canc er [118]. Fibroids The IUD may be used by women with fibroids that do not severely distort the uterine cavity in such a way that insertion is not safely possible (table 3 and table 4) [3,119]. Fibroid and uterine volume, as well as vaginal bleeding, often decline after insertion of the LNg IUS [120,121]. Women with fibroids may have a higher rate of expulsion than women without fibroids [120]. After treatment of fibroids by uterine artery embolization, it usually takes the uterus three to six months to reach its new reduced size. As a result, we sugge st waiting until there is no evidence of ongoing fibroid necrosis (as evidenced by passage of necrotic tissue or watery discharge), and until the uterus has com pleted its shrinking process before inserting an IUD after embolization for fibr oids. Other gynecological disorders As discussed above, the LNg IUD can reduce symptom s of dysmenorrhea, menorrhagia, and endometriosis, and reduce the risk of endome trial hyperplasia and pelvic inflammatory disease. Hemoglobin levels improve in women with iron deficiency anemia secondary to heavy menstrual bleeding [122]. ( See 'When to choose levonorgestrel' above.) Cancer risk reduction who have ever used a vical cancer compared 95% CI 0.40.7 [56]) Meta-analyses of casecontrol and cohort studies found women copper or LNg IUD had reduced risks of endometrial and cer with nonusers (endometrial cancer: pooled adjusted OR 0.6, (cervical cancer OR 0.55, 95% CI 0.42-0.70 [123]).

One hypothesis for the decreased risk of cervical cancer is that the device or i ts string triggers a cellular immune response that prevents persistence of HPV i nfection [123,124]. The LNg IUD provides endometrial protection in women at increased risk. A discus sion of the LNg IUD for endometrial protection can be found above. (See 'When to choose levonorgestrel' above.) Menopausal women A copper IUD inserted for contraception should be removed one y ear after the last menstrual period (ie, menopause) [125]. The LNg IUD should also be removed one year after cessation of menses in menopau sal women not on estrogen replacement. However, because the LNg IUD causes ameno rrhea in many women, especially with prolonged use, it may be difficult to deter mine whether menopause has occurred in the absence of other menopausal symptoms. Therefore, in LNg users with a history of more than 12 months amenorrhea, we su ggest removal of the device at age 51 to 52 years since the average age of menop ause is 51.3 years. The LNg IUD system may be left in place in women who elect t o use estrogen replacement since it will provide protection from endometrial hyp erplasia. This protection extends for at least 10 years after the date of insert ion. The management of expired and difficult to remove IUDs is reviewed separately. ( See "Management of problems related to intrauterine contraception", section on ' Expired and difficult to remove IUDs'.)

Women at risk for osteoporosis Neither the LNg IUD not the TCu380A IUD have an a dverse effect on bone mineral density [126]. Women undergoing magnetic resonance imaging Women with IUDs can undergo magnetic resonance imaging (MRI) procedures safely. Although copper has slight magnetic susceptibility, the IUD does not move, produce artifacts, or significantly incre ase in temperature during MRI utilized for medical diagnosis (with equipment set to produce magnetic fields 3.0 Tesla units) [127]. COST The LNg IUD is more expensive than the TCu380A IUD. Although the initial co st of an IUD is high, the overall cost decreases with each year of use, making t his a highly cost-effective method of contraception over time (as long as 10 yea rs). By five years of use, the IUD is one of the two most cost-effective methods of reversible contraception available; the other is the etonogestrel implant [1 28]. The cost-effectiveness of the IUD is illustrated by the following studies: In an analysis from 2003, three years of use of either the copper IUD or the LNg IUD was less expensive than 39 cycles of oral contraceptives [129]. Another cost-effectiveness analysis of methods of female contraception found tha t any contraceptive method was superior to no method. The three least expensive me thods over five years of use were the TCu380A IUD (US$647), vasectomy (US$713) a nd LNg IUD (US$930). Cost effectiveness for these methods became significant aft er about two years of use [130]. Results were sensitive to the cost of the contr aceptive method, the cost of an unintended pregnancy, and plan disenrollment rat es. In a third study involving almost 1 million contraceptors, intrauterine contrace ptives and the contraceptive implant were the most cost-effective, with cost sav ings of more than $7.00 for every $1.00 spent in services and supplies [131]. Pe r $1.00 spent, injectable contraceptives yielded savings of $5.60; oral contrace ptives, $4.07; the patch, $2.99; the vaginal ring, $2.55; barrier methods, $1.34 ; and emergency contraceptives, $1.43. In 2012, the list price of Mirena is US$843.60 and the list price of ParaGard is U S$754.00 in the United States. Online purchase Public health authorities have advised against purchase and use of lower cost IUDs that can be bought online because improper storage of these i mported devices, especially during transport, may impact product efficacy [132]. Legal problems can also arise since federal and state laws in the US require th at these devices be FDA approved and purchased through US-licensed pharmaceutica l and medical device suppliers [133]. SIDE EFFECTS AND COMPLICATIONS (See "Management of problems related to intrauter ine contraception".). INSERTION AND REMOVAL (See "Insertion and removal of an intrauterine contracepti ve device".). INFORMATION FOR PATIENTS UpToDate offers two types of patient education material s, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the f our or five key questions a patient might have about a given condition. These ar ticles are best for patients who want a general overview and who prefer short, e asy-to-read materials. Beyond the Basics patient education pieces are longer, mo re sophisticated, and more detailed. These articles are written at the 10th to 1 2th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We enco

urage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) Beyond the Basics topics (see "Patient information: Long-term methods of birth c ontrol (Beyond the Basics)") SUMMARY AND RECOMMENDATIONS Modern intrauterine contraception (IUD) is highly effective, safe, cost-effectiv e, long-acting, and rapidly reversible with few side effects. It is a private an d convenient method of contraception, does not interfere with the spontaneity of sex, is very acceptable to patients, has superior continuation rates, and offer s several noncontraceptive health benefits. (See 'Overview of benefits' above.) The optimal candidates for intrauterine contraception are women who are at low r isk of sexually transmitted infections and who want an effective, low-maintenanc e, reversible contraceptive for use over an extended period of time. IUDs can be used by nulliparous, nulligravid, and adolescent women. Women who want or need to avoid exogenous estrogen can safely use both forms of intrauterine contracept ion. There are few absolute contraindications to use; the risks and benefits nee d to be assessed according to individual patient characteristics. (See 'Candidat es for intrauterine contraception' above.) The copper T380A IUD and the levonorgestrel-releasing IUD are the only IUDs appr oved by the United States Food and Drug Administration for use in the United Sta tes. (See 'Types of IUDs' above.) The LNg IUD and the TCu380A IUD are two of the three most effective forms of rev ersible contraception available (the single rod implant is the third method). Me thod failure rates are comparable to tubal sterilization, thus they should be co nsidered as first-line alternatives to surgical sterilization. (See 'Types of IU Ds' above.) Advantages of the TCu380A IUD include that it can be used in women who want or n eed to avoid hormonal contraception, it may be left in place for as long as 10 y ears (versus five years for the LNg IUD); it may be used for emergency contracep tion, and it is the only IUD currently approved for postplacental insertion. The major disadvantage of the TCu380A is that menses become heavier (approximate ly 50 percent increase in blood loss) and sometimes more painful. These symptoms can usually be managed by use of nonsteroidal antiinflammatory drugs during men ses. The TCu380A should not be used in women with a history of menorrhagia-induc ed anemia or dysmenorrhea. (See 'Copper or levonorgestrel?' above.) Advantages of the LNg IUD include a significant reduction in menstrual blood los s and dysmenorrhea. For women with heavy or painful menses, we suggest the LNg I UD rather than the TCu380A (Grade 2B). It is a good choice for women who desire or are not bothered by amenorrhea, as well as those able to tolerate unscheduled light bleeding or spotting, both of which are common side effects. The LNg IUD has several potential noncontraceptive health benefits: it is an alt ernative to surgical management of menorrhagia and it is being evaluated for tre atment of endometrial hyperplasia, for endometrial protection during estrogen th erapy and tamoxifen use, and in the management of pain related to endometriosis. In addition, the LNg IUD may decrease the risk of pelvic inflammatory disease ( PID), similar to other progestin-releasing contraceptives. (See 'Copper or levon orgestrel?' above.) IUDs decrease the frequency of both intrauterine and extrauterine pregnancy. (Se e 'Overview of benefits' above.)