Previous changes

August 2024 — minor update. Length of use of LNG-IUD revised to 8 years maximum for Levosert^® in line with an update to the manufacturer's summary of product characteristics. 

January 2024 — minor update. Length of use of LNG-IUD revised to 8 years maximum for Mirena^® in line with an update to the manufacturer's summary of product characteristics. 

April 2023 — minor update. Updated in line with the Faculty of Sexual and Reproductive Healthcare (FSRH) updated guideline FSRH Intrauterine Contraception [FSRH, 2023]. 

• Levonorgestrel intrauterine systems (LNG-IUSs) are now referred to as levonorgestrel intrauterine devices (LNG-IUDs). The FSRH updated the terminology to align with other international organisations.
• The topic title has been changed from Contraception - IUS/IUD to Contraception - IUC.
• Several sections have been updated in line with the FSRH guideline, including the sections on contraceptive effectiveness, duration of use, and risks and adverse effects. Information on managing malpositioned devices and new-onset pelvic pain has been included in the topic.
• The list of available copper intrauterine contraception devices has been removed and a link provided to the British National Formulary (BNF) and the electronic Medicines Compendium (eMC).
• The recommendations on starting, switching, and removing IUDs have been tabulated to improve usability.
• The topic has undergone minor restructuring. 

September 2022 — minor update. Recommendations on switching from the progestogen-only pill drospirenone to the LNG-IUS have been added in line with the FSRH guideline Progestogen-only pills implant.

March 2021 — minor update. The recommendations on switching from a progestogen-only implant to the levonorgestrel intrauterine system (LNG-IUS) and the copper intrauterine device (Cu-IUD) have been updated in line with the Faculty of Sexual and Reproductive Healthcare (FSRH) guideline Progestogen-only implant.

February 2021 — reviewed. A literature search was conducted in January 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. 

• The topic structure has been changed.
• Recommendations have been clarified in line with the updated FSRH guideline Intrauterine contraception (April 2015, amended September 2019) [FSRH, 2019].
• The section on drug interaction of the levonorgestrel intrauterine system (LNG-IUS) with Esmya® (ulipristal acetate 5 mg) has been removed. This is because the licence for Esmya® has been suspended to protect public health while a safety review is conducted following cases of liver injury requiring transplant [MHRA, 2020].
• The Quality and Outcomes Framework (QOF) indicators listed below have been removed as they were retired in April 2019 [BMS and NHS England, 2019]:
  • CON001: The contractor establishes and maintains a register of women aged 54 or under who have been prescribed any method of contraception at least once in the last year, or other clinically appropriate interval, for example, the last 5 years for an IUS.
  • CON003: The percentage of women, on the register, prescribed emergency hormonal contraception one or more times in the preceding 12 months by the contractor who have received information from the contractor about long-acting reversible contraception at the time or within one month of the prescription.

July 2020 — minor update. Weight gain and decreased libido have been added as adverse effects of the levonorgestrel intrauterine device (LNG-IUS) in line with the updated manufacturer's Summary of Product Characteristics (SPC).

June 2020 — minor update. Dizziness has been added as an adverse effect of the LNG-IUS in line with updated manufacturer's SPC.

May 2019 — minor update. Depression has been added as an adverse effect of the LNG-IUS in line with the manufacturer's SPC [ABPI, 2019].

March 2019 — minor update. Kyleena® has been added as a type of LNG-IUS available in the UK [ABPI, 2019].

January 2019 — minor update. Levosert® 20 micrograms/24 hours IDS is now licenced for up to 5 years use [ABPI, 2019].

February 2017 — minor update. Recommendations on when to start a copper intrauterine device (Cu-IUD) or an LNG-IUS after pregnancy, miscarriage, or termination of pregnancy have been updated in line with the Faculty of Sexual and Reproductive Healthcare (FSRH) guideline Contraception after pregnancy [FSRH, 2017].

August to October 2016 — reviewed. A literature search was conducted in June 2016 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic. Minor structural changes have been made.

October 2015 — minor update. The sections on advantages, disadvantages, and risks have been updated to include additional information on uterine perforation as per the Medicines and Healthcare products Regulatory Agency (MHRA) drug safety update Intrauterine contraception: uterine perforation.

August 2013 — minor update. Text added to clarify that when used for protection from endometrial hyperplasia during oestrogen replacement therapy, the LNG-IUS should be retained for no longer than 5 years after insertion (the licence states 4 years), regardless of the age of the woman at insertion.

June 2013 — minor update. The 2013 Quality and Outcomes Framework (QOF) options for local implementation have been added to this topic.

March 2013 — minor update. The telephone number for NHS Direct has been updated.

January 2013 — minor update. Change to the text to reflect updated advice from the FSRH regarding the interaction between Esmya® and hormonal contraceptives.

February to June 2012 — reviewed. A literature search was conducted in December 2011 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made. However, recommendations have been rewritten for clarity, and superseded references and manufacturers' SPCs have been updated accordingly.

January 2012 — minor update. Typographical errors corrected. 

March 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.

February 2010 — updated to include the revised FSRH UK Medical eligibility criteria for contraceptive use.

March 2009 — minor update. The QOF indicators for sexual health have been updated.

September 2008 — minor correction. Typographical and table heading corrections to UK medical eligibility criteria tables on CU-IUDs and LNG-IUSs.

May 2008 — update to text to reflect recommendations in the new FSRH guidance Intrauterine contraception 2007.

April to September 2007 — converted from CKS guidance to CKS topic structure. The evidence base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

January 2001 — rewritten. Validated in March 2001 and issued in June 2001. Guidance on emergency contraception is no longer included but can be found as a separate CKS topic.

December 1997 — written.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 October 2025.

HTAs (Health Technology Assessments)

No new HTAs since 1 October 2025.

Economic appraisals

No new economic appraisals relevant to England since 1 October 2025.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since1 October 2025.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 October 2025.

New policies

No new national policies or guidelines since 1 October 2025.

New safety alerts

No new safety alerts since 1 October 2025.

Changes in product availability

No changes in product availability since 1 October 2025.

What are the advantages and disadvantages of a levonorgestrel intrauterine device?

• Advantages of the levonorgestrel intrauterine device (LNG-IUD)
  • It is safe and effective within the licensed duration.
  • It can be inserted at any time in a natural menstrual cycle if it is reasonably certain that the woman is not pregnant or at risk of pregnancy. Additional contraception may be required — see Table 1 for more information. 
  • It provides long-term contraception — needs to be replaced every 3, 5, or 8 years, depending on the device. 
    •  Women who have any 52 mg LNG-IUD inserted when they are 45 years or older can use the device for contraception until age 55 years, after which time contraception is no longer required. 
  • Normal fertility returns as soon as the device is removed.
  • Sex need not be interrupted to use.
  • Periods usually become lighter and shorter, and sometimes less painful. They may stop completely after the first year of use. 
  • It may be suitable when combined oral contraceptives (COCs) are contraindicated (such as in women with migraine or venous thromboembolism).
  • The 52 mg LNG-IUD:
    • Can be used to manage menorrhagia (heavy menstrual bleeding). See the CKS topic on Menorrhagia for more information.
    • May reduce pain associated with primary dysmenorrhoea, endometriosis, or adenomyosis. See the CKS topics on Dysmenorrhoea and Endometriosis for more information.
• Disadvantages of the LNG-IUD
  • An internal pelvic examination is needed prior to insertion, to check that it is suitable.
  • A trained healthcare provider must insert and remove the device; the woman cannot do these on her own.
  • It does not protect against sexually transmitted infections (STIs). 
  • It is effective for contraception 7 days after insertion; therefore, additional contraception (such as a condom) may be needed. See Table 1 for more information. 
  • Adverse effects may occur, such as pain on insertion, acne, headaches, unscheduled bleeding, perforation of the wall of the uterus, and expulsion of the device.

[CoSRH, 2025]

What are the advantages and disadvantages of the copper intrauterine device?

• Advantages of the copper intrauterine device (Cu-IUD)
  • It is safe and effective within the licensed duration.
  • It can be inserted at any time in a natural menstrual cycle if it is reasonably certain that the woman is not pregnant or at risk of pregnancy, unless it qualifies for use as emergency contraception. See the CKS topic on Contraception - emergency for more information.
  • It is effective for contraception immediately after insertion; therefore, additional contraception is not needed. 
  • It provides long-term contraception — needs to be replaced every 5 or 10 years, depending on the device. 
    • Women who have a Cu-IUD with a copper surface area of at least 300 mm² inserted at age 40 years or older can use the device for contraception until menopause.
  • Normal fertility returns as soon as the device is removed. 
  • Sex need not be interrupted to use.
  • There are no hormonal adverse effects.
  • There are no drug interactions.
  • It may be suitable when hormonal contraceptives are contraindicated (such as in women with migraine or venous thromboembolism).
• Disadvantages of the Cu-IUD
  • An internal pelvic examination is needed prior to insertion, to check that it is suitable.
  • A trained healthcare provider must insert and remove the device; the woman cannot do these on her own.
  • It does not protect against sexually transmitted infections (STIs). 
  • Adverse effects may occur, such as pain on insertion, unscheduled bleeding, expulsion of the device, and perforation of the wall of the uterus.

[CoSRH, 2025]

What are the possible risks and adverse effects of a levonorgestrel intrauterine device?

• Breast cancer
  • The available evidence suggests that there may be an association between current or recent hormonal contraception use, including levonorgestrel-releasing intrauterine devices (LNG-IUDs), and breast cancer; however, any potential increased risk appears to be small.
• Bone mineral density (BMD)
  • Limited evidence suggests that LNG-IUD use has no significant effect on serum estradiol levels or BMD. 
• Expulsion
  • The overall risk of expulsion of an intrauterine contraception (IUC) device is approximately 1 in 20, and expulsion appears to be most common in the first year of use, particularly within 3 months after insertion.
  • Expulsion rates are higher when inserted immediately postpartum compared with interval postpartum insertion or insertion in women who have not had a recent pregnancy. 
  • Expulsion rates may be higher in adolescents, those who have the IUC inserted after late first-trimester or second-trimester surgical abortions, those with fibroids and menorrhagia, those with uterine cavity distortion, those concurrently using a menstrual cup with the IUC, those who have had a previous expulsion and those with a BMI over 25.
  • See the section on Malpositioned/expelled device for management information.
• Hormonal adverse effects
  • Acne, breast tenderness, headache, and mood changes have been reported with the 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.
• Infection
  • The risk of pelvic infection appears to increase in the first 3 weeks after IUC insertion. However, the overall risk is very low (less than 1%).
  • Evidence on the effect of IUC use on the risk of vulvovaginal candidiasis and/or bacterial vaginosis is limited and conflicting.
  • Pelvic actinomycosis is a very rare, chronic bacterial pelvic infection that is associated with long-term IUC use. 
  • See the section on Infection for management information.
• Libido
  • Decreased libido has been reported with IUC use. However, the evidence suggests that for most users, an IUC has either no impact or a positive impact on sexual experiences.
  • If a woman reports concern about their libido, other possible contributing factors should be considered. If the woman considers that the IUC is adversely affecting her libido, an alternative contraceptive method should be considered. 
• Malpositioned device 
  • The expected position of a T-shaped IUC would be that both horizontal arms are fully extended at the uterine fundus, parallel to the axis of the uterine cornua, with the vertical stem pointing directly downwards and centrally into the uterine cavity and not encroaching on the cervical canal.
  • A malpositioned IUC may be:
    • Malrotated — the IUC may be inverted (upside down), transverse or partially rotated on either the horizontal or vertical axis.
    • Displaced — downward (non-fundal –within the uterine cavity but sitting lower than expected), lateral (not central in the cavity, arms may not be deployed/only partially deployed/embedded/in the fallopian tube), cervical (stem partially or fully within the cervix).
    • Embedded — arm and/or stem partially or fully within the myometrium.
    • Incorrectly deployed — one or both arms not fully extended.
  • Correct position of an IUC at the fundus may be necessary for maximum contraceptive effectiveness, and incorrect placement may be associated with increased risk of contraceptive failure.
  • The available evidence is too limited to predict failure rates of malpositioned IUCs, and there is insufficient evidence to definitively guide whether a malpositioned IUC should be left in situ or removed and replaced.
  • See the section on Malpositioned/expelled device for management information.
• Non-visible threads
  
  • The threads of the IUC may not be visible in the vagina as a result of expulsion, perforation, or pregnancy, or the device being correctly sited but with threads within the cervical canal or uterus.
  • The prevalence of non-visible threads may be as high as 18% (standard IUC insertion), 30% (IUC insertion within 48 hours of vaginal birth), and 50% (IUC insertion at the time of caesarean section).
  • See the section on Non-visible threads for management information.
• Ovarian cysts
  • Although the incidence of ovarian cysts may be elevated during LNG-IUD use, this does not appear to be clinically significant.
  • The presence of (or history of) ovarian cysts or polycystic ovary syndrome is not a contraindication to the use of intrauterine contraception (IUC). 
• Pain on insertion
  • Most IUC insertions are associated with mild-to-moderate pain or discomfort, but that pain can range from none to severe.
  • Analgesia/anaesthetic options should be discussed and offered to all people having an IUC inserted. See the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues for prescribing information.
    • If a requested analgesic/anaesthetic option is not available locally, refer onward to an alternative provider.
• Pelvic pain
  • Pelvic pain or cramping has been reported by some women.
  • New onset pelvic pain in an IUC user should be assessed, and pregnancy should be excluded. 
    • See the section on New-onset pelvic pain for management information.
• Pregnancy
  • The risk of pregnancy (including ectopic pregnancy) is very low during the use of IUC. 
  • If pregnancy occurs with an IUC in situ, the likelihood of it being ectopic is greater than if pregnancy were to occur without an IUC in situ.
  • A previous ectopic pregnancy is not a contraindication to IUC use.
  • See the section on Pregnancy for management information.
• Unscheduled bleeding
  
  • Altered bleeding patterns are common after LNG-IUD insertion. 
  • However, for all LNG-IUD types, prolonged, frequent, and irregular bleeding as well as the number of bleeding/spotting days reduce over the first year of use, and the rates of amenorrhoea and infrequent bleeding increase. By the end of the licensed duration of use, studies report amenorrhoea in 11%–12% of 13.5 mg LNG-IUD users, 23% of 19.5 mg users, and 42% of 52 mg users.
  • Data are limited, but clinical experience indicates that consecutive LNG-IUD use appears to induce a small, temporary increase in bleeding/spotting in the first 90 days after the replacement device is inserted. Thereafter, bleeding/spotting returns to a very low and constant level, with higher rates of amenorrhoea than in first-time users at 4–6 weeks post insertion.
  • See the section on Unscheduled bleeding for management information.
• Uterine perforation
  • The rate of uterine perforation associated with IUC use is very low, with an overall risk of perforation in the general population of 1–2 in 1000.
  • Postpartum interval IUC insertion (from 48 hours after 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 at a later date.
  • Lower abdominal pain, non-visible threads, or changes in bleeding may indicate uterine perforation.
  • See the section on Suspected uterine perforation for management information.
• Weight gain
  • There is no evidence to support a causal association between IUC use and weight gain.
  • There is no specific evidence relating to weight gain with IUC use by women with raised body mass index (BMI).
  • In the general population, there are no significant differences in weight gain when LNG-IUDs are compared with copper IUDs. 

[CoSRH, 2021; Costescu, 2022; CoSRH, 2025]

What are the possible risks and adverse effects of a copper intrauterine device?

• Expulsion
  • The overall risk of expulsion of an intrauterine contraception (IUC) device is approximately 1 in 20, and expulsion appears to be most common in the first year of use, particularly within 3 months after insertion.
  • Expulsion rates are higher when inserted immediately postpartum compared with interval postpartum insertion or insertion in women who have not had a recent pregnancy. 
  • Expulsion rates may be higher in adolescents, those who have the IUC inserted after late first-trimester or second-trimester surgical abortions, those with fibroids and menorrhagia, those with uterine cavity distortion, those concurrently using a menstrual cup with the IUC, those who have had a previous expulsion and those with a BMI over 25.
  • See the section on Malpositioned/expelled device for management information.
• Infection
  • The risk of pelvic infection appears to increase in the first 3 weeks after IUC insertion. However, the overall risk is very low (less than 1%).
  • Evidence on the effect of IUC use on risk of vulvovaginal candidiasis and/or bacterial vaginosis is limited and conflicting.
  • Pelvic actinomycosis is a very rare, chronic bacterial pelvic infection that is associated with long-term IUC use. 
  • See the section on Infection for management information.
• Libido
  • Decreased libido has been reported with IUC use. However, the evidence suggests that for most users, an IUC has either no impact or a positive impact on sexual experiences.
  • If a woman reports concern about their libido, other possible contributing factors should be considered. If the woman considers that the IUC is adversely affecting her libido, an alternative contraceptive method should be considered. 
• Malpositioned device 
  • The expected position of a T-shaped IUC would be that both horizontal arms are fully extended at the uterine fundus, parallel to the axis of the uterine cornua, with the vertical stem pointing directly downwards and centrally into the uterine cavity and not encroaching on the cervical canal.
  • A malpositioned IUC may be:
    • Malrotated — the IUC may be inverted (upside down), transverse or partially rotated on either the horizontal or vertical axis.
    • Displaced — downward (non-fundal –within the uterine cavity but sitting lower than expected), lateral (not central in the cavity, arms may not be deployed/only partially deployed/embedded/in the fallopian tube), cervical (stem partially or fully within the cervix).
    • Embedded — arm and/or stem partially or fully within the myometrium.
    • Incorrectly deployed — one or both arms not fully extended.
  • Correct position of an IUC at the fundus may be necessary for maximum contraceptive effectiveness and incorrect placement may be associated with increased risk of contraceptive failure.
  • The available evidence is too limited to predict failure rates of malpositioned IUCs, and there is insufficient evidence to definitively guide whether a malpositioned IUC should be left in situ or removed and replaced.
  • See the section on Malpositioned/expelled device for management information.
• Non-visible threads
  
  • The threads of the IUC may not be visible in the vagina as a result of expulsion, perforation, or pregnancy, or the device being correctly sited but with threads within the cervical canal or uterus.
  • The prevalence of non-visible threads may be as high as 18% (standard IUC insertion), 30% (IUC insertion within 48 hours of vaginal birth), and 50% (IUC insertion at the time of caesarean section).
  • See the section on Non-visible threads for management information.
• Pain on insertion
  • Most IUC insertions are associated with mild-to-moderate pain or discomfort, but that pain can range from none to severe.
  • Analgesia/anaesthetic options should be discussed and offered to all people having IUC inserted. See the CKS topics on Analgesia - mild-to-moderate pain and NSAIDs - prescribing issues for prescribing information.
    • If a requested analgesic/anaesthetic option is not available locally refer onward to an alternative provider.
• Pelvic pain
  • Pelvic pain or cramping has been reported by some women.
  • New onset pelvic pain in an IUC user should be assessed and pregnancy should be excluded.
    • See the section on New-onset pelvic pain for management information.
• Pregnancy
  • The risk of pregnancy (including ectopic pregnancy) is very low during use of IUC. 
  • If a pregnancy occurs with IUC in situ, the likelihood of it being ectopic is greater than if a pregnancy was to occur without IUC in situ.
  • A previous ectopic pregnancy is not a contraindication to IUC use.
  • See the section on Pregnancy for management information.
• Unscheduled bleeding
  
  • The Cu-IUD has been associated with an increase in menstrual blood loss and intermenstrual bleeding, secondary to increased release of prostaglandin and other vasoactive agents within the endometrium as part of an inflammatory response.
  • Bleeding may be heavier, longer, or more painful than prior to Cu-IUD insertion, and users may experience intermenstrual bleeding.
  • Increased menstrual bleeding will often decrease over time; however, intermenstrual bleeding is less likely to do so. Studies do not suggest clinically significant decreases in haemoglobin and increased incidence of anaemia among Cu-IUD users in general. 
  • Bleeding patterns may differ between different Cu-IUDs; however, there is insufficient evidence to recommend one Cu-IUD device over another or predict bleeding for any specific device.
  • See the section on Unscheduled bleeding for management information.
• Uterine perforation
  • The rate of uterine perforation associated with IUC use is very low, with an overall risk of perforation in the general population of 1–2 in 1000.
  • Postpartum interval IUC insertion (from 48 hours after 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 at a later date.
  • Lower abdominal pain, non-visible threads or changes in bleeding may indicate uterine perforation.
  • See the section on Suspected uterine perforation for management information.
• Weight gain
  • There is no evidence to support a causal association between IUC use and weight gain.
  • There is no specific evidence relating to weight gain with IUC use by women with raised body mass index (BMI).
  • In the general population there are no significant differences in weight gain when Cu-IUDs are compared with levonorgestrel IUDs. 

 [CoSRH, 2021; CoSRH, 2025]

How should I assess a woman who is considering using the levonorgestrel intrauterine device?

Healthcare professionals offering intrauterine contraception (IUC) should hold the appropriate College of Sexual and Reproductive Healthcare (CoSRH) Letter of Competence in Intrauterine Techniques or have achieved equivalent recognized competencies and show evidence of recertification/reaccreditation. The CoSRH website contains information on training requirements and recertification. The CoSRH Guideline Intrauterine Contraception contains detailed recommendations on criteria that should be met prior to IUC insertion.

• If the levonorgestrel intrauterine device (LNG-IUD) is being considered:
  
  • Carry out a full medical history to assess the person's suitability for use of the LNG-IUD.
    • The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) provides evidence-based guidance on prescribing contraception safely.
    • Further guidance is given in the CKS topic on Contraception - assessment. 
    • Exclude pregnancy.
  • Take a sexual history to assess the person's risk of sexually transmitted infections (STIs). 
    • Offer STI testing and/or cervical screening as appropriate.
• Prior to inserting the LNG-IUD:
  
  • Provide detailed information on IUC to enable informed decision-making. This should include information on: 
    • Mode of action.
    • Contraceptive effectiveness.
    • Duration of use.
    • Advantages and disadvantages.
    • Potential risks, adverse effects, and associated problems, including expected changes in bleeding pattern (such as irregular bleeding and amenorrhoea).
    • The IUC insertion procedure, the associated risks (including pain and uterine perforation) and analgesic/anaesthetic options.
  • Perform a bimanual pelvic examination immediately prior to insertion, to assess the position, size, shape, and mobility of the uterus.
    • If a woman attends to discuss IUC use in advance of the procedure, a pelvic examination is not required unless indicated by the clinical history.
  • Obtain valid consent from the woman before pelvic examination and IUC insertion.

How should I start a levonorgestrel intrauterine device?

Healthcare professionals offering intrauterine contraception (IUC) should hold the appropriate College of Sexual and Reproductive Healthcare (CoSRH) Letter of Competence in Intrauterine Techniques or have achieved equivalent recognized competencies and show evidence of recertification/reaccreditation. The CoSRH website contains information on training requirements and recertification.

• See Table 1 for information on starting the levonorgestrel intrauterine device (LNG-IUD) in a woman who is not currently using a hormonal method of contraception.
  • The following situations are considered off-label use of the LNG-IUD:
    • Insertion at any time if it is reasonably certain the woman is not pregnant or at risk of pregnancy.
    • Additional precautions (such as barrier methods) for at least 7 days before replacement, even if immediate replacement is intended.
    • Insertion immediately following termination of pregnancy.
    • Postpartum insertions within 4 weeks after delivery.

Table 1: Recommendations on starting the levonorgestrel intrauterine device (no recent hormonal contraception).

How should I switch to the levonorgestrel intrauterine device from other methods of contraception?

Healthcare professionals offering intrauterine contraception (IUC) should hold the appropriate College of Sexual and Reproductive Healthcare (CoSRH) Letter of Competence in Intrauterine Techniques, or have achieved equivalent recognized competencies, and show evidence of recertification/reaccreditation. The CoSRH website contains information on training requirements and recertification.

• See Table 2 for recommendations on switching to the levonorgestrel intrauterine device (LNG-IUD) in a woman who is currently using a hormonal method of contraception.

Table 2: Recommendations on switching to the LNG-IUD from a hormonal contraceptive method.

How should I switch from the levonorgestrel intrauterine device to other methods of contraception?

Healthcare professionals offering intrauterine contraception (IUC) should hold the appropriate College of Sexual and Reproductive Healthcare (CoSRH) Letter of Competence in Intrauterine Techniques, or have achieved equivalent recognized competencies, and show evidence of recertification/reaccreditation. The CoSRH website contains information on training requirements and recertification. 

• For information on switching from the levonorgestrel intrauterine device (LNG-IUD) to the copper IUD (Cu-IUD), see the section on Switching to a Cu-IUD.
• For information on switching from the LNG-IUD to other methods of contraception, see the CKS topics on:
  • Contraception - barrier methods and spermicides.
  • Contraception - combined hormonal methods.
  • Contraception - natural family planning.
  • Contraception - progestogen-only methods.
  • Contraception - sterilization.

What aftercare and follow-up advice should I give the woman after the insertion of the levonorgestrel intrauterine device?

After insertion of the levonorgestrel intrauterine device (LNG-IUD):

• Provide information on the specific device inserted, including:
  • The name of the device.
  • Mode of action.
  • Duration of use.
  • Time to become effective.
• Routine post-insertion check-ups are not required.
  • If the device was inserted outside of the product licence, provide information on how and when a pregnancy test should be performed. See the sections on Starting an LNG-IUD and Switching to an LNG-IUD for more information.
  • If the device was inserted within 48 hours of vaginal or caesarean birth, advise the woman to attend for a review within 4–6 weeks after insertion.
•  Advise the woman:
  • To feel for the threads of the device within the first 4–6 weeks after insertion and then at regular intervals (for example, monthly or after menses).
  • That the LNG-IUD does not provide protection against sexually transmitted infections (STIs).
    • Only a barrier method of contraception (such as a condom) can reduce the risk of STIs. For more information, see the CKS topic on Contraception - barrier methods and spermicides.
  • To seek urgent review if she has:
    • New onset pelvic pain —  for more information on assessment and possible causes, see the section on new-onset pelvic pain. 
      • Pregnancy must be excluded.
    • Symptoms of pelvic infection (for example, change in vaginal discharge, pelvic pain and intermenstrual/ postcoital bleeding). 
      • For more information, see the section on pelvic infection.
    • A positive pregnancy test or thinks she might be pregnant. 
    • Symptoms suggestive of malpositioned or expelled IUC (such as change in bleeding pattern, new-onset pelvic pain or ‘lost threads’).
      • If threads cannot be felt, thread length becomes shorter or longer, or the stem of the device is felt this may mean that the IUC is incorrectly sited and effectiveness cannot be guaranteed. 
      • Advise avoidance of sexual intercourse or use of an alternative method of contraception until the IUC position is confirmed.
      • If there has been any recent unprotected intercourse, consider the need for emergency contraception. For more information, see the CKS topic on Emergency Contraception.
      • If she has lower abdominal pain or discomfort and ‘lost threads’, especially with a history of pain at the time of insertion. These may indicate uterine perforation.
    • Concerns regarding bleeding pattern.
  • To seek medical review if:
    • Menstrual abnormalities (such as unscheduled bleeding) persist beyond the initial 6 months of use.
    • The device causes discomfort to her or her partner during sexual intercourse.
    • She experiences any other adverse effects.
    • She wants to remove the IUD (or the IUD is due for removal).
• Provide additional sources of information and advice.
  • Patient information on intrauterine contraception is available online from:
    • The NHS website — IUS (intrauterine system) or hormonal coil.
    • The College of Sexual and Reproductive Health — Hormonal coil/IUS / Contraception Choices.

When and how should I remove a levonorgestrel intrauterine device?

Healthcare professionals offering intrauterine contraception (IUC) should hold the appropriate College of Sexual and Reproductive Healthcare (CoSRH) Letter of Competence in Intrauterine Techniques, or have achieved equivalent recognized competencies, and show evidence of recertification/reaccreditation. The CoSRH website contains information on training requirements and recertification. 

• The duration of use of a levonorgestrel intrauterine device (LNG-IUD) depends on the device used.
• See Table 3 for recommendations on the timing of LNG-IUD removal or replacement.

Table 3: Recommendations on timing of LNG-IUD removal/replacement.

Managing adverse effects and associated problems

How should I assess a woman considering using a copper intrauterine device?

Healthcare professionals offering intrauterine contraception (IUC) should hold the appropriate College of Sexual and Reproductive Healthcare (CoSRH) Letter of Competence in Intrauterine Techniques or have achieved equivalent recognized competencies and show evidence of recertification/reaccreditation. The CoSRH website contains information on training requirements and recertification. The CoSRH Guideline Intrauterine Contraception contains detailed recommendations on criteria that should be met prior to IUC insertion.

• If the copper intrauterine device (Cu-IUD) is being considered:
  
  • Carry out a full medical history to assess the woman's suitability for use of the Cu-IUD.
    • The UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) provides evidence-based guidance on prescribing contraception safely.
    • Further guidance is given in the CKS topic on Contraception - assessment. 
  • Exclude pregnancy.
  • Take a sexual history to assess the woman's risk of sexually transmitted infections (STIs). 
    • Offer STI testing and/or cervical screening as appropriate.
• Prior to inserting the Cu-IUD:
  
  • Provide detailed information on IUC to enable informed decision-making. This should include information on:
    • Mode of action.
    • Contraceptive effectiveness.
    • Duration of use.
    • Advantages and disadvantages.
    • Potential risks, adverse effects, and associated problems, including expected changes in bleeding pattern (such as irregular bleeding and amenorrhoea).
    • The IUC insertion procedure, the associated risks (including pain and uterine perforation) and analgesic options.
  • Perform a bimanual pelvic examination immediately prior to insertion, to assess the position, size, shape, and mobility of the uterus.
    • If a woman attends to discuss IUC use in advance of the procedure, a pelvic examination is not required unless indicated by the clinical history.
  • Obtain valid consent from the woman before pelvic examination and IUC insertion.

How should I start a copper intrauterine device?

Healthcare professionals offering intrauterine contraception (IUC) should hold the appropriate College of Sexual and Reproductive Healthcare (CoSRH) Letter of Competence in Intrauterine Techniques or have achieved equivalent recognized competencies and show evidence of recertification/reaccreditation. The CoSRH website contains information on training requirements and recertification. 

• See Table 4 for recommendations on starting the copper intrauterine device (Cu-IUD) in a woman who is not currently using a hormonal method of contraception.

Table 4: Recommendations on starting the copper intrauterine device (no recent hormonal contraception).

How should I switch to the copper intrauterine device from other methods of contraception?

Healthcare professionals offering intrauterine contraception (IUC) should hold the appropriate College of Sexual and Reproductive Healthcare (CoSRH) Letter of Competence in Intrauterine Techniques or have achieved equivalent recognized competencies and show evidence of recertification/reaccreditation. The CoSRH website contains information on training requirements and recertification.

• See Table 5 for recommendations on switching to the copper intrauterine device (CU-IUD) in a woman who is currently using a hormonal method of contraception.

Table 5: Recommendations on switching to the CU-IUD from a hormonal contraceptive method.

How should I switch from a copper intrauterine device to other methods of contraception?

Healthcare professionals offering intrauterine contraception (IUC) should hold the appropriate College of Sexual and Reproductive Healthcare (CoSRH) Letter of Competence in Intrauterine Techniques or have achieved equivalent recognized competencies and show evidence of recertification/reaccreditation. The CoSRH website contains information on training requirements and recertification.

• For information on switching from the copper intrauterine device (Cu-IUD) to the levonorgestrel IUD (LNG-IUD), see the section on Switching to an LNG-IUD.
• For information on switching from the Cu-IUD to other methods of contraception, see the CKS topics on:
  • Contraception - barrier methods and spermicides.
  • Contraception - combined hormonal methods.
  • Contraception - natural family planning.
  • Contraception - progestogen-only methods.
  • Contraception - sterilization.

What aftercare and follow-up advice should I give the woman after the insertion of the copper intrauterine device?

After insertion of the copper intrauterine device (Cu-IUD):

• Provide information on the specific device inserted, including:
  • The name of the device.
  • Mode of action.
  • Duration of use.
  • Time to become effective.
• Routine post-insertion check-ups are not required.
  • If the device was inserted outside of the product licence or as emergency contraception, provide information on how and when a pregnancy test should be performed. See the sections on Starting a Cu-IUD and Switching to a Cu-IUD for more information.
  • If the device was inserted within 48 hours of vaginal or caesarean birth, advise the woman to attend for a review within 4–6 weeks after insertion.
•  Advise the woman:
  • To feel for the threads of the device within the first 4–6 weeks after insertion and then at regular intervals (for example, monthly or after menses).
  • That the Cu-IUD does not provide protection against sexually transmitted infections (STIs).
    • Only a barrier method of contraception (such as a condom) can reduce the risk of STIs. For more information, see the CKS topic on Contraception - barrier methods and spermicides.
  • To seek urgent review if she has:
    • New onset pelvic pain —  for more information on assessment and possible causes, see the section on new-onset pelvic pain. 
      • Pregnancy must be excluded.
    • Symptoms of pelvic infection (for example, change in vaginal discharge, pelvic pain and intermenstrual/ postcoital bleeding). 
      • For more information, see the section on pelvic infection.
    • A positive pregnancy test or thinks she might be pregnant. 
    • Symptoms suggestive of malpositioned or expelled IUC (such as change in bleeding pattern, new-onset pelvic pain or ‘lost threads’).
      • If threads cannot be felt, thread length becomes shorter or longer, or the stem of the device is felt this may mean that the IUC is incorrectly sited and effectiveness cannot be guaranteed. 
      • Advise avoidance of sexual intercourse or use of an alternative method of contraception until the IUC position is confirmed.
      • If there has been any recent unprotected intercourse, consider the need for emergency contraception. For more information, see the CKS topic on Contraception - emergency.
      • If she has lower abdominal pain or discomfort and ‘lost threads’, especially with a history of pain at the time of insertion. These may indicate uterine perforation.
    • Concerns regarding bleeding pattern.
  • To seek medical review if:
    • Menstrual abnormalities (such as unscheduled bleeding) persist beyond the initial 6 months of use.
    • The device causes discomfort to her or her partner during sexual intercourse.
    • She experiences any other adverse effects.
    • She wants to remove the IUD (or the IUD is due for removal).
• Provide additional sources of information and advice.
  • Patient information on intrauterine contraception is available online from:
    • The NHS website — IUD (intrauterine device) or copper coil.
    • The College of Sexual and Reproductive Health — Copper Coil / IUD.

When and how should I remove a copper intrauterine device?

Healthcare professionals offering intrauterine contraception (IUC) should hold the appropriate College of Sexual and Reproductive Healthcare (CoSRH) Letter of Competence in Intrauterine Techniques or have achieved equivalent recognized competencies and show evidence of recertification/reaccreditation. The CoSRH website contains information on training requirements and recertification. 

• The duration of use of a copper intrauterine device (Cu-IUD) depends on the device used.
• See Table 6 for recommendations on the timing of Cu-IUD removal or replacement.

Table 6: Recommendations on the timing of Cu-IUD removal or replacement.

Managing adverse effects and associated problems