1. Intrauterine
contraceptives are as effective as permanent
contraception methods. (II-2) 2. The use of
levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg by patients taking
tamoxifen is not associated with recurrence of
breast cancer. (I) 3. Intrauterine
contraceptives have a number of noncontraceptive benefits. The
levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg significantly decreases menstrual blood loss (I) and
dysmenorrhea. (II-2) Both the
copper intrauterine device and the LNG-IUS significantly decrease the risk of
endometrial cancer. (II-2) 4. The risk of
uterine perforation decreases with inserter experience but is higher in postpartum and breastfeeding women. (II-2) 5. The risk of
pelvic inflammatory disease (PID) is increased slightly in the first month after intrauterine
contraceptive (IUC) insertion, but the absolute risk is low. Exposure to
sexually transmitted infections and not the IUC itself is responsible for PID occurring after the first month of use. (II-2) 6. Nulliparity is not associated with an increased risk of intrauterine
contraceptive expulsion. (II-2) 7.
Ectopic pregnancy with an intrauterine
contraceptive (IUC) is rare, but when a pregnancy occurs with an IUC in situ, it is an
ectopic pregnancy in 15% to 50% of the cases. (II-2) 8. In women who conceive with an intrauterine
contraceptive (IUC) in place, early IUC removal improves outcomes but does not entirely eliminate risks. (II-2) 9. Intrauterine
contraceptives do not increase the risk of
infertility. (II-2) 10. Immediate insertion of an intrauterine
contraceptive (10 minutes postplacental to 48 hours) postpartum or post-
Caesarean section is associated with a higher continuation rate compared with insertion at 6 weeks postpartum. (I) 11. Immediate insertion of an intrauterine
contraceptive (IUC; 10 minutes postplacental to 48 hours) postpartum or post-
Caesarean section is associated with a higher risk of expulsion. (I) The benefit of inserting an IUC immediately postpartum or post-
Caesarean section outweighs the disadvantages of increased risk of perforation and expulsion. (II-C) 12. Insertion of an intrauterine
contraceptive in breastfeeding women is associated with a higher risk of
uterine perforation in the first postpartum year. (II-2) 13. Immediate insertion of an intrauterine
contraceptive (IUC) post-abortion significantly reduces the risk of repeat abortion (II-2) and increases IUC continuation rates at 6 months. (I) 14.
Antibiotic prophylaxis for intrauterine
contraceptive insertion does not significantly reduce postinsertion
pelvic infection. (I) RECOMMENDATIONS: 1. Health care professionals should be careful not to restrict access to intrauterine
contraceptives (IUC) owing to theoretical or unproven risks. (III-A) Health care professionals should offer IUCs as a first-line method of
contraception to both nulliparous and multiparous women. (II-2A) 2. In women seeking intrauterine
contraception (IUC) and presenting with
heavy menstrual bleeding and/or
dysmenorrhea, health care professionals should consider the use of the
levonorgestrel intrauterine system 52 mg over other IUCs. (I-A) 3. Patients with
breast cancer taking
tamoxifen may consider a
levonorgestrel-releasing intrauterine system 52 mg after consultation with their oncologist. (I-A) 4. Women requesting a
levonorgestrel-releasing intrauterine system or a
copper-intrauterine device should be counseled regarding changes in
bleeding patterns,
sexually transmitted infection risk, and duration of use. (III-A) 5. A health care professional should be reasonably certain that the woman is not pregnant prior to inserting an intrauterine
contraceptive at any time during the menstrual cycle. (III-A) 6. Health care providers should consider inserting an intrauterine
contraceptive immediately after an
induced abortion rather than waiting for an interval insertion. (I-B) 7. In women who conceive with an intrauterine
contraceptive (IUC) in place, the diagnosis of
ectopic pregnancy should be excluded as arly as possible. (II-2A) Once an
ectopic pregnancy has been excluded, the IUC should be removed without an invasive procedure. The IUC may be removed at the time of a surgical termination. (II-2B) 8. In the case of
pelvic inflammatory disease, it is not necessary to remove the intrauterine
contraceptive unless there is no clinical improvement after 48 to 72 hours of appropriate
antibiotic treatment. (II-2B) 9. Routine
antibiotic prophylaxis for intrauterine
contraceptive (IUC) insertion is not indicated. (I-B) Health care providers should perform
sexually transmitted infection (
STI) testing in women at high risk of
STI at the time of IUC insertion. If the test is positive for chlamydia and/or
gonorrhea, the woman should be appropriately treated postinsertion and the IUC can remain in situ. (II-2B) 10. Unscheduled
bleeding in intrauterine
contraception users, when persistent or associated with
pelvic pain, should be investigated to rule out
infection, pregnancy, gynecological pathology, expulsion or malposition. (III-A)