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Family Planning

Intrauterine Device (IUD)

Long-acting reversible contraceptive (LARC) device inserted into the uterus. Types include Copper IUDs (Cu-IUD - non-hormonal, lasts up to 10-12 years) and Levonorgestrel-releasing IUDs (LNG-IUD / Hormonal IUD - last 3-8 years depending on type).

Also known as: IUD, IUCD, Coil, Copper T, Hormonal IUD (Mirena, Kyleena etc)

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Referral and warning signs

When to refer

Referral needed for: IUD insertion/removal. Management of complications (perforation, difficult removal, PID, suspected ectopic pregnancy). Persistent unacceptable side effects.

Red flags

  • Signs/symptoms of PID (severe pelvic pain, fever, discharge)
  • Signs/symptoms of ectopic pregnancy (amenorrhoea + pain + bleeding)
  • Missing strings with suspected pregnancy or pain
  • Signs of uterine perforation (severe pain during insertion, subsequent severe pain/bleeding)

Signs and symptoms

  • Common Side Effects:
  • - Copper IUD: Heavier, longer, or more painful menstrual periods, especially initially. Spotting between periods.
  • - LNG-IUD: Irregular bleeding/spotting initially, often leading to lighter periods or amenorrhoea over time. Hormonal side effects possible (headache, acne, mood changes - less common than systemic methods).
  • - Both: Mild cramping during/after insertion.
  • Warning Signs (Complications - require prompt evaluation): Severe lower abdominal pain, Pain during intercourse, Fever/chills/unusual vaginal discharge (PID risk highest near insertion), Missed period/Symptoms of pregnancy (esp. rule out ectopic), Missing strings/Feeling hard part of IUD.

Risk factors

  • Contraindications (MEC Category 4): Pregnancy, Puerperal sepsis, Immediately post-septic abortion, Unexplained vaginal bleeding suspicious for serious condition (initiation), Current PID, Current purulent cervicitis/Chlamydia/Gonorrhoea, Cervical/Endometrial cancer, Distorted uterine cavity, Malignant gestational trophoblastic disease.
  • Relative Contraindications (MEC Category 3 - Copper IUD): AIDS (if not well on ART), High individual risk of STIs (initiation). (LNG-IUD): Past breast cancer >5yrs ago, Severe liver disease, SLE with antiphospholipid antibodies.
  • Copper IUD caution: Wilson's disease, Copper allergy.

Diagnosis

Clinical assessment

Eligibility assessment based on medical/reproductive history, pelvic exam (assess uterine size/position, rule out infection/pregnancy), and MEC guidelines.

Investigations

  • Rule out pregnancy before insertion.
  • Pelvic examination (essential).
  • Consider STI screening based on risk factors.
  • Cervical cancer screening as per guidelines.

Diagnostic criteria

Client meets medical eligibility criteria for IUD use and has suitable uterine cavity.

Management

Non-pharmacological management

  • Counseling: Explain types (Copper vs Hormonal), mechanism, high effectiveness, duration, insertion/removal procedure, expected side effects (bleeding changes specific to type), warning signs, lack of STI protection.
  • Skilled Insertion: Requires trained provider using sterile technique.
  • Skilled Removal: Requires trained provider.

Pharmacological treatment

  • Insertion: Timed during menstruation (less bleeding, cervix softer, pregnancy unlikely) or any time if reasonably sure not pregnant. Prophylactic antibiotics generally not needed.
  • Management of Side Effects:
  • - Cramping after insertion: NSAIDs.
  • - Increased bleeding/pain (Copper IUD): NSAIDs during menses. Tranexamic acid if severe. Reassure often improves. Check Hb if persistent. Remove if unacceptable.
  • - Irregular bleeding (LNG-IUD): Reassure often improves/leads to amenorrhoea. NSAIDs or short course hormones rarely needed. Rule out other causes.
  • - Missing Strings: Rule out pregnancy. Try to locate strings in vagina/cervix. Ultrasound to confirm presence/position in uterus. Refer if expulsion suspected or perforation possible.
  • - Suspected PID: Treat with appropriate antibiotics covering gonorrhea/chlamydia/anaerobes. Usually no need to remove IUD immediately unless severe or no improvement.
  • - Suspected Pregnancy: Remove IUD if strings visible and pregnancy <12 weeks (reduces miscarriage/sepsis risk). If strings not visible or >12 weeks, leave IUD in situ and monitor closely (high risk ectopic/preterm birth). Counsel patient. Rule out ectopic pregnancy urgently.

Monitoring

Follow-up visit 3-6 weeks post-insertion (check strings, assess side effects/concerns). Routine checks during other visits or if problems arise. Patient taught to check strings monthly (optional).

Complications

  • Pain/cramping after insertion.
  • Changes in menstrual bleeding (heavier - Cu-IUD; irregular/amenorrhoea - LNG-IUD).
  • Expulsion (partial or complete - ~2-10% in first year).
  • Uterine Perforation (rare, usually occurs at insertion - ~1-2 per 1000).
  • Pelvic Inflammatory Disease (PID - risk slightly increased in first few weeks after insertion, related to insertion process/pre-existing infection, not IUD itself long-term).
  • Pregnancy (rare - if occurs, higher relative risk of ectopic pregnancy).
  • Actinomyces-like organisms on Pap smear (usually asymptomatic, treatment controversial).

Prevention

  • Careful patient selection using MEC.
  • Screening/treatment for STIs before insertion if high risk.
  • Sterile insertion technique by trained provider.
  • Patient education on string checks and warning signs.

Patient education

  • How IUD works, effectiveness, duration.
  • Type chosen (Copper vs Hormonal) and expected bleeding pattern.
  • Insertion procedure.
  • How to check strings (optional).
  • Warning signs requiring medical attention.
  • Does not protect against STIs/HIV.
  • Fertility returns promptly after removal.
  • Emergency IUD option.

Uganda-specific notes

Copper IUDs are widely available and promoted as effective LARC. Hormonal IUDs less common/available. Requires trained providers for insertion/removal. Counseling on bleeding changes crucial for acceptance.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 15, Section 15.2.8

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