The inclusion of progestins in intrauterine devices (IUDs) has given rise to the terms “intrauterine system” (IUS) and “intrauterine contraception” (IUC). Currently, both progestin- and copper-containing IUS products are available in the United States: ParaGard (Cu T 380A), Mirena (LNg 20-IUD), Skyla (LNg 13.5), and Liletta (LNg 52). Of these, ParaGard is the only true IUD; the others systems release a progestin (levonorgestrel, LNg) into the uterus at a constant rate. ParaGard, Mirena, Skyla, and Liletta can provide long-term contraception. For clarity, the term IUD will be used most often throughout this book as patients may not fully understand the differences. In circumstances where the systemic effect of a IUS is most prominent, the term IUS will be used. Triage personnel should discuss what term or terms their providers prefer and under which circumstances IUD or IUS is most appropriately used in their facility.

Intrauterine contraception definitely is underused in this country for several reasons. Probably the most prominent cause is misunderstanding about the potential risks. Severe pelvic infections can be a result of IUD use. However, proper selection of candidates for this method greatly reduces the potential for problems. Risk factors for pelvic infection directly parallel a woman’s risk for sexually transmitted infection (STI) exposure. Women at low STI risk, who have borne children, and who may be looking for a method with the potential for long-term contraception may find this a convenient, and over time, cost-effective method. Under extenuating circumstances, these devices can be inserted in primiparous women who have been properly screened and counseled, for whom other good options do not exist, and who are fully informed of potential risks. This is an issue that should be discussed between a woman and her provider and is generally a discussion beyond a typical triage call.

These methods have other advantages. Copper IUDs have been inserted postcoitally for emergency contraception. The progesterone-releasing IUDs decrease menstrual symptoms, and they may have other beneficial uses, such as decreasing symptoms of fibroids and adenomyosis and providing progestin support during hormone therapy (HT).

Even if your office or clinic does not insert intrauterine contraception, you need to be familiar with triaging patient complaints. Because of the long-term approval for some of these methods (10 years for ParaGard, 5 years for Mirena, and 3 years for Skyla and Liletta). It is not uncommon for a patient to present herself at a facility other than the facility where it initially was inserted.

The following acronym often is used to educate patients to early warning signs of problems with these devices and systems:

P, Unexpected period (pregnancy), abnormal spotting or bleeding;

A, Abdominal pain, pain with intercourse;

I, Infection exposure (STIs), abnormal discharge;

N, Not feeling well, fever, chills;

S, String missing, shorter or longer.

Copper IUDs are contraindicated in women who are experiencing unexplained vaginal bleeding, gestational trophoblastic disease, pregnancy, current endometrial cancer, cervical cancer (until treated), current pelvic inflammatory disease (PID), active purulent cervicitis, anatomic abnormality of the uterus (if it will interfere with IUD insertion), pelvic tuberculosis (TB), lupus with accompanying thrombocytopenia, solid organ transplantation with complications, AIDS and not on antiretroviral therapy, puerperal sepsis, copper allergy, history of ectopic pregnancy or endometritis, or an autoimmune condition that predisposes the patient to an infection (leukemia, autoimmune disorder).

The LNg IUSs have the same contraindications as the copper IUD, with the exception of a history of copper allergy. Additionally, they may have more potential interactions with other medications. There is an excellent website where providers can go to determine if a medication may affect women who have an LNg IUS: https://www.drugs.com/cdi/levonorgestrel-iud.html.