Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Intrauterine contraception: Management of side effects and complications

Katherine D Pocius, MD, MPH
Deborah A Bartz, MD, MPH
Section Editor
Courtney A Schreiber, MD, MPH
Deputy Editor
Kristen Eckler, MD, FACOG


Intrauterine contraception is highly effective, very safe, and generally well tolerated by most women. As such, it has become an increasingly popular method of contraception. Despite the overall excellent safety profile, side effects and complications can occur at the time of insertion and at different time points following insertion.

This topic will address diagnosis and management of side effects and complications related to intrauterine contraception in a temporal fashion broken down by typical onset of presentation in relation to timing from intrauterine device (IUD) insertion. Issues related to intrauterine contraception types, patient candidates and device selection, as well as the non-complicated insertion and removal procedure, are reviewed separately.

(See "Intrauterine contraception: Devices, candidates, and selection".)

(See "Intrauterine contraceptive device: Insertion and removal".)


Alternate terms for intrauterine contraception include the intrauterine device (IUD), intrauterine contraceptive (IUC), or intrauterine system (IUS, used in reference to the progestin-containing devices). In this topic, we use the term IUD for all types of intrauterine contraception. As of 2017, five types of IUDs are available in the United States (US); one contains copper and four release the progestin levonorgestrel (LNg). A discussion of the various IUD types is presented elsewhere. (See "Intrauterine contraception: Devices, candidates, and selection" and "Intrauterine contraception: Devices, candidates, and selection", section on 'Types of IUDs'.)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Aug 21, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Braaten KP, Benson CB, Maurer R, Goldberg AB. Malpositioned intrauterine contraceptive devices: risk factors, outcomes, and future pregnancies. Obstet Gynecol 2011; 118:1014.
  2. Aoun J, Dines VA, Stovall DW, et al. Effects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol 2014; 123:585.
  3. Madden T, McNicholas C, Zhao Q, et al. Association of age and parity with intrauterine device expulsion. Obstet Gynecol 2014; 124:718.
  4. Sufrin CB, Postlethwaite D, Armstrong MA, et al. Neisseria gonorrhea and Chlamydia trachomatis screening at intrauterine device insertion and pelvic inflammatory disease. Obstet Gynecol 2012; 120:1314.
  5. Birgisson NE, Zhao Q, Secura GM, et al. Positive testing for Neisseria gonorrhoeae and Chlamydia trachomatis and the risk of pelvic inflammatory disease in IUD users. J Womens Health (Larchmt) 2015; 24:354.
  6. Farley TM, Rosenberg MJ, Rowe PJ, et al. Intrauterine devices and pelvic inflammatory disease: An international perspective. Lancet 1992; 339:785.
  7. Trussell J. Contraceptive failure in the United States. Contraception 2011; 83:397.
  8. Heinemann K, Reed S, Moehner S, Minh TD. Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the European Active Surveillance Study on Intrauterine Devices. Contraception 2015; 91:274.
  9. Grunloh DS, Casner T, Secura GM, et al. Characteristics associated with discontinuation of long-acting reversible contraception within the first 6 months of use. Obstet Gynecol 2013; 122:1214.
  10. Dragoman MV, Simmons KB, Paulen ME, Curtis KM. Combined hormonal contraceptive (CHC) use among obese women and contraceptive effectiveness: a systematic review. Contraception 2017; 95:117.
  11. Berenson AB, Tan A, Hirth JM, Wilkinson GS. Complications and continuation of intrauterine device use among commercially insured teenagers. Obstet Gynecol 2013; 121:951.
  12. Simonatto P, Bahamondes MV, Fernandes A, et al. Comparison of two cohorts of women who expulsed either a copper-intrauterine device or a levonorgestrel-releasing intrauterine system. J Obstet Gynaecol Res 2016; 42:554.
  13. Teal SB, Romer SE, Goldthwaite LM, et al. Insertion characteristics of intrauterine devices in adolescents and young women: success, ancillary measures, and complications. Am J Obstet Gynecol 2015; 213:515.e1.
  14. Teal SB, Sheeder J. IUD use in adolescent mothers: retention, failure and reasons for discontinuation. Contraception 2012; 85:270.
  15. Jatlaoui TC, Riley HE, Curtis KM. The safety of intrauterine devices among young women: a systematic review. Contraception 2017; 95:17.
  16. Rivera R, Chen-Mok M, McMullen S. Analysis of client characteristics that may affect early discontinuation of the TCu-380A IUD. Contraception 1999; 60:155.
  17. Long-term reversible contraception. Twelve years of experience with the TCu380A and TCu220C. Contraception 1997; 56:341.
  18. Sivin I, Schmidt F. Effectiveness of IUDs: A review. Contraception 1987; 36:55.
  19. Mechanism of action, safety and efficacy of intrauterine devices. Report of a WHO Scientific Group. World Health Organ Tech Rep Ser 1987; 753:1.
  20. Grimes DA, Lopez LM, Schulz KF, et al. Immediate post-partum insertion of intrauterine devices. Cochrane Database Syst Rev 2010; :CD003036.
  21. Grimes DA, Lopez LM, Schulz KF, Stanwood NL. Immediate postabortal insertion of intrauterine devices. Cochrane Database Syst Rev 2010; :CD001777.
  22. Jacob NS, Mahnert N, Livingston JB, et al. Comparison of intrauterine device expulsion rates after aspiration abortion or interval insertion. Obstet Gynecol 2014; 123 Suppl 1:10S.
  23. Chi IC, Kelly E. Is lactation a risk factor of IUD- and sterilization-related uterine perforation? A hypothesis. Int J Gynaecol Obstet 1984; 22:315.
  24. Chi I, Feldblum PJ, Rogers SM. IUD--related uterine perforation: an epidemiologic analysis of a rare event using an international dataset. Contracept Deliv Syst 1984; 5:123.
  25. Chi IC, Wilkens LR, Champion CB, et al. Insertional pain and other IUD insertion-related rare events for breastfeeding and non-breastfeeding women--a decade's experience in developing countries. Adv Contracept 1989; 5:101.
  26. Heartwell SF, Schlesselman S. Risk of uterine perforation among users of intrauterine devices. Obstet Gynecol 1983; 61:31.
  27. Berry-Bibee EN, Tepper NK, Jatlaoui TC, et al. The safety of intrauterine devices in breastfeeding women: a systematic review. Contraception 2016; 94:725.
  28. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.
  29. Espey E, Ogburn T, Hall R, Byrn F. Use of intrauterine device in the setting of uterus didelphys. Obstet Gynecol 2006; 108:774.
  30. Eskew AM, Crane EK. Levonorgestrel Intrauterine Device Placement in a Premenopausal Breast Cancer Patient with a Bicornuate Uterus. J Minim Invasive Gynecol 2016; 23:133.
  31. Zapata LB, Whiteman MK, Tepper NK, et al. Intrauterine device use among women with uterine fibroids: A systematic review. Contraception 2010; 82:41.
  32. Chi IC, Farr G, Dominik R, Robinson N. Do retroverted uteri adversely affect insertions and performance of IUDs? Contraception 1990; 41:495.
  33. Avecilla-Palau A, Moreno V. Uterine factors and risk of pregnancy in IUD users: a nested case-control study. Contraception 2003; 67:235.
  34. Bahamondes MV, Monteiro I, Canteiro R, et al. Length of the endometrial cavity and intrauterine contraceptive device expulsion. Int J Gynaecol Obstet 2011; 113:50.
  35. Liang H, Li L, Yuan W, et al. Dimensions of the endometrial cavity and intrauterine device expulsion or removal for displacement: a nested case-control study. BJOG 2014; 121:997.
  36. Hatcher R, Trussell J, Stewart F, et al. Contraceptive technology, 17th ed, Ardent Media, Inc, New York 1998.
  37. Shipp TD, Bromley B, Benacerraf BR. The width of the uterine cavity is narrower in patients with an embedded intrauterine device (IUD) compared to a normally positioned IUD. J Ultrasound Med 2010; 29:1453.
  38. Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.
  39. Caliskan E, Oztürk N, Dilbaz BO, Dilbaz S. Analysis of risk factors associated with uterine perforation by intrauterine devices. Eur J Contracept Reprod Health Care 2003; 8:150.
  40. Van Houdenhoven K, van Kaam KJ, van Grootheest AC, et al. Uterine perforation in women using a levonorgestrel-releasing intrauterine system. Contraception 2006; 73:257.
  41. Kaislasuo J, Suhonen S, Gissler M, et al. Intrauterine contraception: incidence and factors associated with uterine perforation--a population-based study. Hum Reprod 2012; 27:2658.
  42. Ylikorkala O, Kauppila A, Siljander M. Anti-prostglandin therapy in prevention of side-effects of intrauterine contraceptive devices. Lancet 1978; 2:393.
  43. Ngo LL, Braaten KP, Eichen E, et al. Naproxen Sodium for Pain Control With Intrauterine Device Insertion: A Randomized Controlled Trial. Obstet Gynecol 2016; 128:1306.
  44. Ngo LL, Ward KK, Mody SK. Ketorolac for Pain Control With Intrauterine Device Placement: A Randomized Controlled Trial. Obstet Gynecol 2015; 126:29.
  45. Abbas AM, Abdellah MS, Khalaf M, et al. Effect of cervical lidocaine-prilocaine cream on pain perception during copper T380A intrauterine device insertion among parous women: A randomized double-blind controlled trial. Contraception 2017; 95:251.
  46. Rapkin RB, Achilles SL, Schwarz EB, et al. Self-Administered Lidocaine Gel for Intrauterine Device Insertion in Nulliparous Women: A Randomized Controlled Trial. Obstet Gynecol 2016; 128:621.
  47. Mohllajee AP, Curtis KM, Peterson HB. Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review. Contraception 2006; 73:145.
  48. Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet 2000; 356:1013.
  49. Walsh T, Grimes D, Frezieres R, et al. Randomised controlled trial of prophylactic antibiotics before insertion of intrauterine devices. IUD Study Group. Lancet 1998; 351:1005.
  50. Toivonen J, Luukkainen T, Allonen H. Protective effect of intrauterine release of levonorgestrel on pelvic infection: three years' comparative experience of levonorgestrel- and copper-releasing intrauterine devices. Obstet Gynecol 1991; 77:261.
  51. Tepper NK, Steenland MW, Gaffield ME, et al. Retention of intrauterine devices in women who acquire pelvic inflammatory disease: a systematic review. Contraception 2013; 87:655.
  52. Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.
  53. Westhoff C. IUDs and colonization or infection with Actinomyces. Contraception 2007; 75:S48.
  54. Diedrich JT, Desai S, Zhao Q, et al. Association of short-term bleeding and cramping patterns with long-acting reversible contraceptive method satisfaction. Am J Obstet Gynecol 2015; 212:50.e1.
  55. Friedlander E, Kaneshiro B. Therapeutic Options for Unscheduled Bleeding Associated with Long-Acting Reversible Contraception. Obstet Gynecol Clin North Am 2015; 42:593.
  56. Mäkäräinen L, Ylikorkala O. Ibuprofen prevents IUCD-induced increases in menstrual blood loss. Br J Obstet Gynaecol 1986; 93:285.
  57. Lin X, Gao ES, Li D, et al. Preventive treatment of intrauterine device-induced menstrual blood loss with tranexamic acid in Chinese women. Acta Obstet Gynecol Scand 2007; 86:1126.
  58. Ylikorkala O, Viinikka L. Comparison between antifibrinolytic and antiprostaglandin treatment in the reduction of increased menstrual blood loss in women with intrauterine contraceptive devices. Br J Obstet Gynaecol 1983; 90:78.
  59. Melo J, Tschann M, Soon R, et al. Women's willingness and ability to feel the strings of their intrauterine device. Int J Gynaecol Obstet 2017; 137:309.
  60. Suvisaari J, Lähteenmäki P. Detailed analysis of menstrual bleeding patterns after postmenstrual and postabortal insertion of a copper IUD or a levonorgestrel-releasing intrauterine system. Contraception 1996; 54:201.
  61. Hidalgo M, Bahamondes L, Perrotti M, et al. Bleeding patterns and clinical performance of the levonorgestrel-releasing intrauterine system (Mirena) up to two years. Contraception 2002; 65:129.
  62. Weisberg E, Hickey M, Palmer D, et al. A pilot study to assess the effect of three short-term treatments on frequent and/or prolonged bleeding compared to placebo in women using Implanon. Hum Reprod 2006; 21:295.
  63. Weisberg E, Hickey M, Palmer D, et al. A randomized controlled trial of treatment options for troublesome uterine bleeding in Implanon users. Hum Reprod 2009; 24:1852.
  64. Pedrón N, Lozano M, Gallegos AJ. The effect of acetylsalicylic acid on menstrual blood loss in women with IUDs. Contraception 1987; 36:295.
  65. Benacerraf BR, Shipp TD, Bromley B. Three-dimensional ultrasound detection of abnormally located intrauterine contraceptive devices which are a source of pelvic pain and abnormal bleeding. Ultrasound Obstet Gynecol 2009; 34:110.
  66. Inal MM, Ertopçu K, Ozelmas I. The evaluation of 318 intrauterine pregnancy cases with an intrauterine device. Eur J Contracept Reprod Health Care 2005; 10:266.
  67. Pakarinen P, Luukkainen T. Treatment of menorrhagia with an LNG-IUS. Contraception 2007; 75:S118.
  68. Tangtongpet O, Choktanasiri W, Patrachai S, Israngura Na Ayudhya N. Intrauterine location and expulsion of intrauterine device. Thai Journal of Obstetrics and Gynaecology 2003; 15:45.
  69. Morales-Roselló J. Spontaneous upward movement of lowly placed T-shaped IUDs. Contraception 2005; 72:430.
  70. Faundes D, Perdigao A, Faundes A, et al. T-shaped IUDs accomodate to their position during the first three months after insertion. Contraception 2000; 62:165.
  71. Anteby E, Revel A, Ben-Chetrit A, et al. Intrauterine device failure: relation to its location within the uterine cavity. Obstet Gynecol 1993; 81:112.
  72. Okusanya BO, Oduwole O, Effa EE. Immediate postabortal insertion of intrauterine devices. Cochrane Database Syst Rev 2014; :CD001777.
  73. Steenland MW, Tepper NK, Curtis KM, Kapp N. Intrauterine contraceptive insertion postabortion: a systematic review. Contraception 2011; 84:447.
  74. Zhang J, Feldblum PJ, Chi IC, Farr MG. Risk factors for copper T IUD expulsion: an epidemiologic analysis. Contraception 1992; 46:427.
  75. Steenland MW, Zapata LB, Brahmi D, et al. Appropriate follow up to detect potential adverse events after initiation of select contraceptive methods: a systematic review. Contraception 2013; 87:611.
  76. Bednarek PH, Creinin MD, Reeves MF, et al. Immediate versus delayed IUD insertion after uterine aspiration. N Engl J Med 2011; 364:2208.
  77. Bahamondes L, Díaz J, Marchi NM, et al. Performance of copper intrauterine devices when inserted after an expulsion. Hum Reprod 1995; 10:2917.
  78. Thonneau P, Almont T, de La Rochebrochard E, Maria B. Risk factors for IUD failure: results of a large multicentre case-control study. Hum Reprod 2006; 21:2612.
  79. Xiong X, Buekens P, Wollast E. IUD use and the risk of ectopic pregnancy: a meta-analysis of case-control studies. Contraception 1995; 52:23.
  80. Sivin I, Stern J. Health during prolonged use of levonorgestrel 20 micrograms/d and the copper TCu 380Ag intrauterine contraceptive devices: A multicenter study. International Committee for Contraception Research (ICCR). Fertil Steril 1994; 61:70.
  81. Sivin I, Stern J, Diaz J, et al. Two years of intrauterine contraception with levonorgestrel and with copper: a randomized comparison of the TCu 380Ag and levonorgestrel 20 mcg/day devices. Contraception 1987; 35:245.
  82. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2011; 118:184.
  83. Kim SK, Romero R, Kusanovic JP, et al. The prognosis of pregnancy conceived despite the presence of an intrauterine device (IUD). J Perinat Med 2010; 38:45.
  84. Ganer H, Levy A, Ohel I, Heiner E. Pregnancy outcome in women with an intrauterine contraceptive device. Am J Obstet Gynecol 2009; 4:38.
  85. Shine RM, Thompson JF. The in situ IUD and pregnancy outcome. Am J Obstet Gynecol 1974; 119:124.
  86. Koetsawang S, Rachawat D, Piya-Anant M. Outcome of pregnancy in the presence of intrauterine device. Acta Obstet Gynecol Scand 1977; 56:479.
  87. Tatum HJ, Schmidt FH, Jain AK. Management and outcome of pregnancies associated with the Copper T intrauterine contraceptive device. Am J Obstet Gynecol 1976; 126:869.
  88. Assaf A, el Tagy A, el Kady A, el Agezy H. Hysteroscopic removal of copper-containing intrauterine devices with missing tails during pregnancy. Adv Contracept 1988; 4:131.
  89. Lin JC, Chen YO, Lin BL, Valle RF. Outcome of removal of intrauterine devices with flexible hysteroscopy in early pregnancy. J Gynecol Surg 1993; 9:195.
  90. Moreau C, Cleland K, Trussell J. Contraceptive discontinuation attributed to method dissatisfaction in the United States. Contraception 2007; 76:267.
  91. Gemzell-Danielsson K, Schellschmidt I, Apter D. A randomized, phase II study describing the efficacy, bleeding profile, and safety of two low-dose levonorgestrel-releasing intrauterine contraceptive systems and Mirena. Fertil Steril 2012; 97:616.
  92. Trussell J, Vaughan B. Contraceptive failure, method-related discontinuation and resumption of use: results from the 1995 National Survey of Family Growth. Fam Plann Perspect 1999; 31:64.
  93. Nilsson CG, Lahteenmaki PL, Luukkainen T, Robertson DN. Sustained intrauterine release of levonorgestrel over five years. Fertil Steril 1986; 45:805.
  94. Lähteenmäki P, Nilsson CG. Plasma concentrations of ethinylestradiol and D-norgestrel during two immediate postabortal oral contraceptive cycles. Contraception 1978; 17:9.
  95. Jensen JT. Contraceptive and therapeutic effects of the levonorgestrel intrauterine system: an overview. Obstet Gynecol Surv 2005; 60:604.
  96. Vickery Z, Madden T, Zhao Q, et al. Weight change at 12 months in users of three progestin-only contraceptive methods. Contraception 2013; 88:503.
  97. Skovlund CW, Mørch LS, Kessing LV, Lidegaard Ø. Association of Hormonal Contraception With Depression. JAMA Psychiatry 2016; 73:1154.
  98. Higgins JA, Sanders JN, Palta M, Turok DK. Women's Sexual Function, Satisfaction, and Perceptions After Starting Long-Acting Reversible Contraceptives. Obstet Gynecol 2016; 128:1143.
  99. Boozalis A, Tutlam NT, Chrisman Robbins C, Peipert JF. Sexual Desire and Hormonal Contraception. Obstet Gynecol 2016; 127:563.
  100. Roura E, Travier N, Waterboer T, et al. The Influence of Hormonal Factors on the Risk of Developing Cervical Cancer and Pre-Cancer: Results from the EPIC Cohort. PLoS One 2016; 11:e0147029.
  101. World Health Organization. Medical eligibility criteria for contraceptive use. Fifth Edition. World Health Organization; Geneva, 2015.
  102. Kim YJ, Youm J, Kim JH, Jee BC. Actinomyces-like organisms in cervical smears: the association with intrauterine device and pelvic inflammatory diseases. Obstet Gynecol Sci 2014; 57:393.
  103. Persson E, Holmberg K. A longitudinal study of Actinomyces israelii in the female genital tract. Acta Obstet Gynecol Scand 1984; 63:207.
  104. Lippes J. Pelvic actinomycosis: a review and preliminary look at prevalence. Am J Obstet Gynecol 1999; 180:265.
  105. Roke CM. A comparative study of the ease of removal of intrauterine contraceptive devices. Contraception 1988; 37:555.
  106. Waldron K. Intrauterine devices: insertion and removal: practical procedures. Aust Fam Physician 1982; 11:40.
  107. Bounds W, Hutt S, Kubba A, et al. Randomised comparative study in 217 women of three disposable plastic IUCD thread retrievers. Br J Obstet Gynaecol 1992; 99:915.
  108. Tugrul S, Yavuzer B, Yildirim G, Kayahan A. The duration of use, causes of discontinuation, and problems during removal in women admitted for removal of IUD. Contraception 2005; 71:149.
  109. Prabhakaran S, Chuang A. In-office retrieval of intrauterine contraceptive devices with missing strings. Contraception 2011; 83:102.
  110. Marchi NM, Castro S, Hidalgo MM, et al. Management of missing strings in users of intrauterine contraceptives. Contraception 2012; 86:354.
  111. Verma U, Astudillo-Dávalos FE, Gerkowicz SA. Safe and cost-effective ultrasound guided removal of retained intrauterine device: our experience. Contraception 2015; 92:77.
  112. Swenson C, Royer PA, Turok DK, et al. Removal of the LNG IUD when strings are not visible: a case series. Contraception 2014; 90:288.
  113. Turok DK, Gurtcheff SE, Gibson K, et al. Operative management of intrauterine device complications: a case series report. Contraception 2010; 82:354.
  114. Wilson S, Tan G, Baylson M, Schreiber C. Controversies in family planning: how to manage a fractured IUD. Contraception 2013; 88:599.