- Young People, individuals who have never been pregnant and individuals who have never been sexually active can use a Cu-IUD.
- Transgender and gender-diverse individuals assigned female at birth (TGD-AFB).
The medical indications and contraindication are the same as for cis-gender women. The Cu-IUD may appeal to TGD-AFB individuals who wish to avoid hormones. Genital examination pre-insertion, pelvic cramping or bleeding may exacerbate gender dysphoria. Testosterone therapy can cause vaginal atrophy and dryness, which may add to the physical discomfort of examination- consider pre-procedure treatment with local vaginal estrogen for 2 weeks prior to IUD insertion.
3. After Pregnancy
When inserted within 48 hours of childbirth, clinicians need to be appropriately trained in this technique which is different from standard.
If >48 hours have passed, insertion should be delayed until 28 days after childbirth (UKMEC3).
After medical abortion, or medical or expectant management of miscarriage, Cu-IUD can be inserted any time after expulsion of the pregnancy, providing there is no clinical suspicion of sepsis and no new risk of pregnancy. In early medical discharge (products passed at home), ensure there is no ongoing pregnancy prior to insertion with low sensitivity pregnancy testing no sooner than 3 weeks post abortion.
A Cu-IUD can be inserted immediately after surgical abortion or surgical management of miscarriage or ectopic pregnancy, providing there is no clinical suspicion of sepsis.
4. After gestational trophoblastic disease (GTD)
A Cu-IUD should not be inserted until human chorionic gonadotropin (hCG) levels are normal.
5. Peri-menopause:
Examination and endometrial assessment should be considered prior Cu-IUD insertion for perimenopausal individuals who have heavy and/or erratic bleeding or a recent change in bleeding pattern. Requirement for investigation should follow local guidelines.
6. Breast Cancer
There are no contraindications Cu-IUD use with current or previous breast cancer (UKMEC1)
7. Individuals with raised BMI
Insertion may be more challenging in terms of assessment of uterine position and gaining access to the uterus. Practical considerations include having a range of speculum sizes, appropriate weight limit examination couch and large blood pressure cuff. There is an increased risk of expulsion in those with BMI>25
8. Individuals at Risk of Infection
A sexual history should be taken prior to Cu-IUD and screening offered to those at risk of STIs.
Increased risk of STIs, no recent contact of gonorrhoea (GC) or Chlamydia (CT) and asymptomatic – IUD can be inserted without prophylactic antibiotic treatment - UKMEC 2
Current pelvic inflammatory disease (PID), postpartum or post-abortion sepsis, known GC infection, symptomatic CT infection, and purulent cervicitis are all contraindications to Cu-IUD insertion (UKMEC4).
Individuals who have symptoms of possible STI and/or PID or are asymptomatic but are a current or recent contact of GC or CT, should ideally delay IUD insertion until test results are available, and until symptoms have resolved. Offer a bridging contraceptive method.
Following a positive CT or GC result, an IUD can be inserted once antibiotic treatment is completed, any test of cure requirements performed, and they are asymptomatic.
Treatment for confirmed or suspected CT, GC or PID; please see relevant specific guidance
If emergency IUD insertion cannot be delayed:
- Known asymptomatic CT or GC infection: consider insertion on the same day that treatment is commenced – discuss with senior clinician.
- Current or recent partner is known to have GC or CT infection - consider antibiotic prophylaxis if asymptomatic.
- Symptomatic of possible CT or GC but test results not available - consider antibiotic prophylaxis
IUD insertion should be delayed until known Mycoplasma genitalium has been adequately treated and symptoms have resolved.
Other infections
There is no indication to screen for other lower genital tract organisms in asymptomatic individuals considering IUC.
Bacterial vaginosis, Trichomonas vaginalis or Candida diagnosed or suspected - these should be treated but the Cu-IUD can be inserted without delay.
Group B Streptococcus – no need to treat or delay Cu-IUD insertion.
Group A streptococcus (GAS) is a rare but serious infection that should be treated urgently. Cu-IUD insertion should be delayed until treatment is complete.
9. Discuss with a senior clinician if:
- Uterine cavity distortion
- Previous endometrial ablation
- Under follow up for gestational trophoblastic disease
- Immunosuppression/ taking immunosuppressants including patients with adrenal insufficiency and / or taking corticosteroids
- History of postural orthostatic tachycardia syndrome (PoTS)
- Known to have inherited bleeding disorders
- Anticoagulants
- Cardiac disease
- Wilson’s Disease