• 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 contraindications for IUC are the same for transgender and gender-diverse individuals assigned female at birth (TGD-AFB) and cis-gender women. The Cu-IUD may appeal to TGD-AFB individuals who wish to avoid hormones. The LNG-IUD may help individuals who wish menstrual suppression. Pelvic cramping and bleeding can exacerbate gender dysphoria so clinicians should give adequate pre-procedure counselling about expected side effects and their duration, to improve tolerability. TGD individuals experience varying levels of dysphoria with their anatomy, and genital examination during IUC procedures may cause additional physical or emotional discomfort. Testosterone is teratogenic so TGD-AFB individuals using testosterone therapy and engaging in sex where there is a risk of pregnancy should use effective contraception. Testosterone treatment is not contraceptive, even if the individual is amenorrhoeic. Testosterone 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 IUC insertion

• After Pregnancy

Immediate postpartum IUC (within 48 hours of childbirth) is safe, effective, convenient and associated with high continuation rates. When inserted within 48 hours of childbirth, the insertion technique is different to that of standard IUC insertion and clinicians need to be appropriately trained in this technique

If >48 hours have passed since childbirth, insertion should be delayed until 28 days after childbirth. The risks of insertion from 48 hours until 28 days after childbirth generally outweigh the benefits (UKMEC3).

IUC insertion after abortion is convenient and acceptable and has been associated with high continuation rates and reduced likelihood of another abortion within the next 2 years.

After medical abortion, or medical or expectant management of miscarriage, IUC 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 addition when there has been early medical discharge (products passed at home) ensure there is no ongoing pregnancy prior to insertion with low sensitivity pregnancy testing done no sooner than 2 to 3 weeks post abortion.  

An IUC 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)

IUC should not be inserted after gestational trophoblastic disease (GTD) until human chorionic gonadotropin (hCG) levels are normal.

• Peri-menopause

An LNG-IUD may help perimenopausal irregular cycles, HMB (heavy menstrual bleeding) and dysmenorrhoea.. Examination and endometrial assessment/investigation should be considered prior to IUC insertion for perimenopausal individuals who have heavy and/or erratic bleeding or a recent change in bleeding pattern, taking into account any risk factors for gynaecological disease. Requirement for investigation should follow local guidelines.

• 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

Assessment of uterine position and gaining access to the uterus IUC insertion can be more challenging in individuals with raised BMI. Some practicalities may need to be considered in order to maximise the chances of insertion success (e.g. having a range of speculum sizes and an examination couch with an appropriate weight limit). In addition, availability of a large blood pressure cuff for measuring blood pressure is essential.

• Individuals at Risk of Infection 

Current pelvic inflammatory disease (PID), postpartum or post-abortion sepsis, known gonorrhoea infection, symptomatic Chlamydia infection, and purulent cervicitis are all contraindications to IUC insertion (UKMEC4). The risks associated with IUC insertion in the presence of known asymptomatic chlamydia infection are generally considered to outweigh benefits (UKMEC3). Individuals who have symptoms of possible bacterial STI and/or PID should ideally delay IUC insertion until test results are available, until PID or confirmed STI have been treated, and until symptoms have resolved. Offer a bridging contraceptive method if required.

If an individual is considered to be at increased risk for sexually transmitted infections (STIs) but has none of the aforementioned specific conditions and is not a recent contact of gonorrhoea or Chlamydia, benefits of IUC insertion are generally considered to outweigh risks.

Routine STI screening of asymptomatic individuals requesting IUC is not necessary; however, a sexual history should be taken prior to IUC insertion and screening offered, to individuals at risk of sexually transmitted infections. Providing the individual is asymptomatic and the individual is not a current or recent contact of gonorrhoea or Chlamydia, screening can be performed at the time of IUC insertion and the IUC can be inserted without awaiting results and without prophylactic antibiotic treatment so long as the user can be contacted and treated promptly, if indicated, when the results are known.

Asymptomatic individuals who are a current or recent contact of gonorrhoea or Chlamydia should delay IUC insertion until infection excluded (based on tests done outwith the window period). 

Following a positive chlamydia or gonorrhoea result, an intrauterine method can be inserted if the individual has completed antibiotic treatment (and, if applicable, completed any test of cure requirements and / or additional recommended follow-up or imaging, for example, in the case of complicated pelvic infection such as a tubo-ovarian abscess) and is asymptomatic.

Any treatment for confirmed or suspected chlamydia, gonorrhoea or PID should be in line with British Association for Sexual Health and HIV (BASHH) guidance.

Other infections (and bacterial vaginosis)

There is no indication to screen for other lower genital tract organisms in asymptomatic individuals considering IUC. If bacterial vaginosis, Trichomonas vaginalis or candida infection is diagnosed or suspected, these should be treated but the IUC can be inserted without delay.

There is no need to delay IUC insertion or treat asymptomatic individuals who have been identified as having Group B Streptococcus.

Group A streptococcus (GAS) is a rare but serious infection that can cause life-threatening septicaemia, invasive GAS (e.g. necrotising fasciitis) and streptococcal toxic shock syndrome. Therefore, if GAS is incidentally detected it is important that it is treated urgently. IUC insertion should be delayed until treatment is complete.

Refer to a senior clinician if

• Uterine cavity distortion
• Previous endometrial ablation
• After large loop excision of the transformation zone (LLETZ) procedure
• 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

The 52 mg LNG-IUD can be used in the management of  gynaecological conditions, including polycystic ovary syndrome, endometrial hyperplasia, HMB  and dysmenorrhoea. They can also be used for endometrial protection as part of HRT. Although Mirena® is the only LNG-IUD licensed for endometrial protection, the FSRH supports the use of any 52 mg LNG-IUD for up to 5 years as endometrial protection as part of HRT. This recommendation is supported by the Royal College of Obstetricians and Gynaecologists and the British Menopause Society.