Long-Acting Reversible Contraceptive Devices

Implant

The US MEC assigns a Category 1 rating (ie, no restriction) to the use of the contraceptive implant by nulliparous women and adolescents 47. Data on implant use in adolescents and nulliparous women are limited, although the CHOICE study demonstrated high uptake of IUDs and implants by adolescents when these contraceptive methods are made readily available 51. Adolescents aged 14–17 years who chose a LARC method were more likely to use the contraceptive implant 51. Contraceptive acceptability and continuation rates were studied in a group of 137 postpartum adolescents 64. At 24 months, continuation rates were higher in contraceptive implant users compared with contraceptive injection and combined contraceptive pill users (P<.001) 64. In another study of 116 adolescents, continuation rates for the implant were high, 78% at 12 months and 50% at 24 months 65.

When is an appropriate time to insert an intrauterine device or contraceptive implant?

Insertion of an IUD or an implant may occur at any time during the menstrual cycle as long as pregnancy may be reasonably excluded 48.

Interval Insertion

Interval insertion refers to the placement of an IUD or contraceptive implant that occurs at any time during the menstrual cycle and is not in relationship to the end of a pregnancy. Clinicians traditionally have inserted the IUD during menses; however, a systematic review concluded that outcomes of continuation, effectiveness, and safety were no better when a copper IUD was inserted during menses and that requiring a woman to be menstruating is an obstacle to access 66. Similarly, two-visit IUD insertion protocols are a barrier to contraceptive access and do not appear to improve quality of care 67. A study of Medicaid-insured women who requested IUDs in an urban clinic that required two visits found that only 54.4% actually had an IUD inserted 68.

No backup contraceptive method is needed after inserting the copper IUD, regardless of when in the menstrual cycle it is inserted 48. In contrast, a backup method of contraception (ie, use of a condom) is recommended for 7 days after insertion of the LNG-IUD or contraceptive implant, unless these devices are inserted immediately after surgical abortion, within 21 days of childbirth, upon transition from another reliable contraceptive method, within the first 7 days since menstrual bleeding started for the LNG-IUD, or within the first 5 days since menstrual bleeding started for the implant 48.

Postabortion Insertion

Insertion of LARC immediately after an induced or spontaneous abortion is safe and effective. Women who have an abortion are at high risk of repeat unintended pregnancy; ovulation may resume as early as 10 days after abortion 69. Prompt initiation of a contraceptive method for women who desire it may reduce repeat unintended pregnancy. Women who choose to have an IUD inserted immediately after abortion have higher rates of use compared with those who choose interval insertion 70, and lower rates of repeat abortion than those who choose a non-IUD contraceptive method 71. In the CHOICE study, women who were offered immediate postabortion contraception were more than three times more likely to choose an IUD and 50% more likely to choose an implant than women presenting for a family planning visit 72. The authors concluded that women seeking abortion may be more likely to choose a LARC method because they are already undergoing a procedure and are more highly motivated to initiate contraception.

Postpartum Insertion

The American College of Obstetricians and Gynecologists supports immediate postpartum LARC insertion (ie, before hospital discharge) as a best practice, recognizing its role in preventing rapid repeat and unintended pregnancy 80 81. Optimally, women should be counseled prenatally about the option of immediate postpartum LARC. Counseling should include discussion of the advantages and disadvantages to allow for informed decision making 81. The immediate postpartum period is particularly favorable for IUD or implant insertion. Women who have recently given birth often are highly motivated to use contraception and are known not to be pregnant. The hospital setting offers convenience for the patient and the health care provider. In addition, women are at risk of an unintended pregnancy in the period immediately after delivery as resumption of ovulation may occur shortly after delivery 82. Between 40% and 57% of women report having unprotected intercourse before the routine 6-week postpartum visit 83 84 85.

Copper Intrauterine Device

Three studies have reported no pregnancies among parous women who used the copper IUD for longer than 12 years. However, very few women were followed for more than 12 years of copper IUD use 109.

Levonorgestrel-20 Intrauterine Device

Current data support the efficacy of the LNG-20 beyond its approved duration of use. Extended-use studies are ongoing for the LNG-18.6, and data are not yet available for the newer devices such as the LNG-19.5 IUD and the LNG-13.5 IUD.

In the contraceptive CHOICE study, there were two pregnancies among 496 women using the LNG-20 IUD for at least 1 year beyond its FDA-approved 5-year duration of use, for a failure rate of 0.25 per 100 women-years in the sixth year of use and 0.43 per 100 women in the seventh year of use 110. Another multicenter randomized trial also found that the LNG-20 IUD is effective for at least 7 years, with a 7-year pregnancy rate of 0.5 per 100 among women using the LNG-20 IUD 111. In that trial, there were no pregnancies in the last 2 years of use 111.

The LNG-18.6 IUD is FDA-approved for 4 years of use, but preliminary data suggest extended efficacy of up to 5 years. It eventually may be approved for use up to 7 years because the ongoing Phase III trial for this IUD accumulates yearly effectiveness data 112.

Contraceptive Implant

The etonogestrel implant is effective for at least 4 years.One large study reported no pregnancies among 204 women using the etonogestrel implant for 5 years 113. In another study, no pregnancies were reported among 102 study participants who used the etonogestrel implant for 5 years 110. These study results may not be generalizable to obese women because only 6% of participants in the first study and 50% in the second study were obese.

Is routine screening for sexually transmitted infections required before insertion of an intrauterine device?

Women who have not undergone routine screening for sexually transmitted infections (STIs) or who are identified to be at increased risk of STIs based on patient history 114 should receive CDC-recommended STI screening at the time of a single visit for IUD insertion. Intrauterine device insertion should not be delayed while awaiting test results. Treatment for a positive test result may occur without removal of the IUD 48 115. Asymptomatic women who are at low risk of STIs and have previously undergone routine screening do not need additional screening at the time of IUD insertion 48. In a cohort of 57,728 women, the incidence of pelvic inflammatory disease was equivalent among women prescreened for STIs and those screened on the day of IUD insertion 116.

The US MEC assigns a Category 2 for IUD initiation among women with vaginitis or who are at increased risk of STIs 47. Because condom use is lower among LARC users compared with users of other contraceptive methods 117, women at risk of STIs should be counseled about the benefits of condom use for STI protection.

A positive test result for chlamydial infection or gonorrhea that was detected after IUD insertion should be treated, and the IUD may be left in place 48. The US MEC assigns a Category 2 rating for IUD continuation in a woman found to have a chlamydial infection or gonorrhea and then treated with appropriate antibiotic therapy 47. Women with an undiagnosed STI at the time of IUD insertion are more likely to develop pelvic inflammatory disease (PID) than women without an STI 118 119; however, even in women with an STI, the risk appears low 120 121.

Intrauterine device insertion is contraindicated in women with current purulent cervicitis or with known chlamydial infection or gonorrhea (US MEC Category 4) 47. Although the optimal time for IUD insertion among women treated for cervical infections is unclear, clinicians are advised to delay IUD insertion until the treatment course is complete, symptoms have resolved, the cervical examination results appear normal, and the bimanual examination is without masses or tenderness. Because of the high risk of reinfection, the CDC recommends repeat testing at 3 months for women who have been treated for gonorrhea or chlamydial infection 115.

Does antibiotic prophylaxis before intrauterine device insertion decrease the risk of subsequent pelvic infection?

Routine antibiotic prophylaxis is not recommended before IUD insertion 48 122. In a meta-analysis of all known randomized controlled trials, antibiotic prophylaxis at the time of IUD insertion did not decrease the risk of PID nor did it reduce the likelihood of IUD removal within the first 3 months 123. Most of the risk of IUD-related infection occurs within the first few weeks to months after insertion, suggesting that bacterial contamination of the endometrial cavity at the time of insertion is the cause of infection and not the IUD itself 124. Although the relative risk of PID is increased, the absolute risk of developing PID is less than 0.5% 119 125.

What are the effects of intrauterine devices and the contraceptive implant on the menstrual cycle?

Each of the LARC methods affect menstrual bleeding differently. To improve LARC method satisfaction and continuation, patient counseling should include information on expected bleeding changes and reassurance that these changes are not harmful 48 126.

New-onset abnormal uterine bleeding should be evaluated similarly to abnormal bleeding in non-LARC users; the differential diagnosis remains similar, including complications of pregnancy, infection, and gynecologic malignancy. Because LARC methods affect menstrual bleeding, some women may experience irregular, unpredictable bleeding over the entire course of LARC use. Young or low-risk women whose bleeding coincides with LARC initiation rarely require extensive evaluation.

Intrauterine Devices

A randomized trial found that long-term copper IUD users were more likely than LNG-20 IUD users to discontinue the device because of heavy menstrual bleeding and dysmenorrhea (9.7 per 100 women versus 1.3 per 100 respectively), whereas LNG-20 IUD users were more likely than copper IUD users to discontinue the device because of amenorrhea and spotting (4.3 per 100 women versus 0 per 100 women, respectively) 127.

Women should be advised that menstrual bleeding and cramping may initially increase with use of the copper IUD 48. Nonsteroidal antiinflammatory medications are effective for the treatment of dysmenorrhea or bothersome bleeding from the copper IUD 16 48 128. Reports of bleeding and dysmenorrhea decrease over time in copper IUD users 129.

Hormone released from the LNG-IUD concentrates in the endometrium and produces a thin decidualized endometrial lining that becomes resistant to endogenous estrogen stimulation. Most women continue to ovulate while using the LNG-IUDs 21. An increase in irregular or prolonged spotting is common during the first 90 days of use; bleeding and spotting lessen over time 24 25. Decreased bleeding has been reported with insertion of the second consecutive LNG-20 IUD compared with first-time use 130. The reduction in menstrual bleeding is less pronounced with IUDs that contain lower doses of levonorgestrel; women using these lower-dose IUDs experience more bleeding or spotting days on average than women using the LNG-20 IUD with higher doses of levonorgestrel, although overall bleeding patterns are similar and well tolerated 25.

As with the copper IUD, evidence supports treating bleeding and spotting associated with LNG-IUD use with nonsteroidal antiinflammatory medications. In one randomized placebo-controlled trial, naproxen significantly reduced bleeding and spotting days in the first 12 weeks of LNG-20 IUD use, whereas transdermal estradiol significantly increased bleeding and spotting 131. However, another trial found that tranexamic acid and mefenamic acid did not alleviate nuisance bleeding during the first 90 days of LNG-20 IUD use 132.

The LNG-20 IUD is FDA-approved for the treatment of heavy bleeding in women who use the method for contraception, and it is used widely for this indication 17. A review of 18 studies of the LNG-20 IUD used for the treatment of heavy menstrual bleeding found a menstrual blood loss reduction of 79–97% 133. The number of bleeding or spotting days may be increased relative to baseline during the first year of use 134. The LNG-20 IUD is more effective than oral medications for treating heavy menstrual bleeding, including in women who do not use it for contraception 135 136. In addition, studies document an overall high rate of satisfaction and continued use in women with heavy menstrual bleeding 135.

Contraceptive Implant

A noncontraceptive benefit of the implant is a significant decrease in dysmenorrhea 44 137 138. However, uterine bleeding patterns with contraceptive implant use are unpredictable and are cited as among the most common reasons for discontinuation. In CHOICE study analysis, of 1,184 contraceptive implant users, 42% reported decreased bleeding frequency, and 35% reported increased bleeding frequency at 3 months of use; at 6 months, bleeding frequency had decreased for 48% of users and increased for 21% of users 8.

An integrated analysis of 11 international clinical trials that assessed the variable bleeding patterns (in 90-day reference periods) among 923 implant users found that women usually experienced infrequent bleeding (33.6% of the reference periods) or amenorrhea (22.2% of the reference periods) 137. Frequent bleeding was found in 6.7% of the reference periods and prolonged bleeding in 17.7% of the reference periods. Only 11.3% of patients discontinued the implant because of bleeding irregularities, mainly because of frequent and prolonged bleeding. Overall, the mean number of spotting or bleeding episodes was less than the number reported in normal menstrual cycles. Women with favorable bleeding profiles in the first 3 months of use were likely to continue with that bleeding pattern for the first 2 years, whereas those who started with an unfavorable pattern had a 50% chance of improving 41 44 137.

Timing of contraceptive implant insertion does not appear to affect discontinuation for bleeding. One analysis found similar discontinuation rates of the implant for irregular bleeding among women who underwent immediate postpartum insertion, insertion at 6–12 weeks postpartum, and interval insertion 139. Similar results were seen in women who received implants immediately after abortion versus those who received interval insertion 79.

A 5–7-day course of nonsteroidal antiinflammatory medication may be considered for contraceptive implant users who experience irregular bleeding. Women with bothersome implant-associated bleeding who are medically eligible for treatment with estrogen can receive a course of low-dose combined oral contraceptive pills 48 140. A randomized controlled trial of 32 women with bothersome bleeding found significant improvements in bleeding during a 14-day treatment with low-dose combined oral contraceptive pills when compared with placebo. However, bleeding resumed for most women within 10 days after stopping treatment 141. Another trial found similar beneficial effects with the use of mifepristone in combination with ethinyl estradiol or doxycycline in improving bleeding, but with resumption of bothersome bleeding after treatment ended 142.

What gynecologic procedures can be performed with an intrauterine device in place?

Endometrial biopsy, colposcopy, cervical ablation or excision, and endocervical sampling may all be performed with an IUD in place. As with other women who experience abnormal uterine bleeding in the perimenopausal period, unexpected bleeding should prompt evaluation in women with IUDs 143. Endometrial sampling can be performed with a small endometrial suction curette; sampling should be repeated if there is insufficient tissue for diagnosis. During cervical ablation or excision procedures, IUD strings may be tucked into the cervical canal if possible, or cut.

What treatment options are appropriate for an asymptomatic patient with an IUD who has actinomyces identified by cervical cytology screening?

Actinomyces on cytology is considered an incidental finding. In the absence of symptoms, no antimicrobial treatment is needed, and the IUD may be left in place 3 144. Although options for management have included oral antibiotics, or removal of the IUD, or both, expectant management is currently recommended for asymptomatic patients with an IUD and actinomyces found by cervical cytology screening. Both the UK Faculty of Family Planning and the Standards and Guidelines of the Planned Parenthood Federation of America recommend continued IUD use and patient education about the small risk of actinomycosis 144. Most frequently, however, IUD users whose Pap test results incidentally report a finding of actinomyces are asymptomatic and are at extremely low risk of pelvic actinomycosis. The prevalence of actinomycosis, characterized by granulomatous pelvic abscesses, has been estimated to be less than 0.001% 144.

In pregnant women, does removal of the intrauterine device affect pregnancy outcome?

Pregnancy in IUD users is uncommon. However, when an intrauterine pregnancy does occur with an IUD in place, management depends on the woman’s desire to continue or terminate the pregnancy, gestational age, IUD location, and whether IUD strings are visible 3 48. Initial guidance is to determine the location of the pregnancy because women who become pregnant with an IUD in place are more likely to have an ectopic pregnancy 48. For women who have an intrauterine pregnancy, there are risks associated with removing and retaining the IUD. However, the risks of adverse pregnancy outcome are greater in the setting of IUD retention 145. Therefore, IUD removal is recommended in pregnant women when the strings are visible or can be removed safely from the cervical canal 48. For women who choose pregnancy termination, the IUD can be removed at the time of the procedure or before medication-induced abortion.

If a woman decides to continue the pregnancy with an IUD in place, she should be counseled regarding the increased risks of spontaneous abortion, septic abortion, chorioamnionitis, and preterm delivery 145. These risks are reduced, but not eliminated, with the removal of the IUD 145. A population-based retrospective review of all pregnancies beyond 22 weeks that occurred from 1998 to 2007 in a large hospital in Israel reported that women with a retained copper IUD had significantly increased rates of placental abruption, placenta previa, preterm delivery, cesarean delivery, low-birth-weight infants, and chorioamnionitis compared with women who became pregnant without an IUD in place. Women who became pregnant with an IUD in place, but whose IUD was removed had outcomes that were intermediate between the other two groups 146.

Continuing a pregnancy with a retained LNG-IUD raises the theoretical concern about the effect of fetal exposure to the hormone. There is insufficient evidence to determine whether any negative fetal effects occur in the setting of this very small exposure to levonorgestrel during gestation. In a case series of 40 pregnancies with a retained LNG-IUD, more than one half were ectopic; of the 10 cases of continued pregnancy, 8 ended in spontaneous pregnancy loss, and the other two pregnancies resulted in healthy infants born at term 147.

For additional information on the management of pregnancy with an IUD in place, see Committee Opinion No. 672, Clinical Challenges of Long-Acting Reversible Contraceptive Methods.

Do intrauterine devices and implants cause ectopic pregnancy?

The use of an IUD or implant does not increase the absolute risk of ectopic pregnancy, thus intrauterine devices may be offered to women with a history of ectopic pregnancy. In women with a history of ectopic pregnancy, the US MEC classifies use of copper and LNG-IUDs and the contraceptive implant as Category 1 47. A meta-analysis of 16 case–control studies concluded that IUDs do not increase the risk of ectopic pregnancy because they prevent pregnancy so effectively 148. If pregnancy does occur with an IUD in place, the pregnancy is more likely to be ectopic. Case–control studies of ectopic pregnancy associated with IUD use indicate an increased relative risk; however, prospective data from randomized controlled trials describe a low absolute risk, a measure that is more useful clinically 149 150.

When should an intrauterine device or implant be removed in a menopausal woman?

There is no compelling evidence for the removal of an IUD or implant before its expiration date in menopausal women. Awaiting 1 year of amenorrhea in women using a copper IUD to ensure menopausal status is advisable before removing the device. Given that amenorrhea may be a secondary effect of the LNG-IUD and the contraceptive implant, and that no well-validated tool exists to confirm menopause, it is reasonable to continue these methods until age 50–55 years, which is when most women in North America will reach natural menopause 48.

No clinical trials have examined the risks from prolonged IUD retention in asymptomatic menopausal women. Generally, menopausal women tolerate IUDs well. The LNG-IUD has been found to be effective for noncontraceptive indications in menopausal women, such as the progestin component of hormone therapy 151.