Young People, individuals who have never been pregnant and individuals who have never been sexually active can use an LNG-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 LNG-IUD may appeal to TGD-AFB individuals who wish to avoid or limit menstruation. 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.
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, LNG-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.
LNG-IUD can be inserted immediately after surgical abortion or surgical management of miscarriage or ectopic pregnancy, providing there is no clinical suspicion of sepsis.
After gestational trophoblastic disease (GTD.
LNG-IUD should not be inserted until human chorionic gonadotropin (hCG) levels are normal.
Peri-menopause:
Examination and endometrial assessment should be considered prior LNG-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.
An LNG-IUD may help perimenopausal irregular cycles, HMB (heavy menstrual bleeding) and dysmenorrhoea.
Breast Cancer
Current breast cancer is a UKMEC4 condition for use of an LNG-IUD
Past history of breast cancer is UKMEC3 : refer to specialist if such person wishes an LNG-IUD
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
Individuals at Risk of Infection
A sexual history should be taken prior to LNG-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
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 LNG-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.
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
Contraception choice for individuals with cardiac disease will often require a multidisciplinary approach and discussion with the individual’s cardiologist is recommended. See also FSRH Clinical Guideline: Contraceptive Choices for Women with Cardiac Disease (June 2014)
https://www.fsrh.org/standards-and-guidance/documents/ceuguidanceintrauterinecontraception