Acog committee opinion, number 392, december 2007
Intrauterine Device and Adolescents
ABSTRACT: The intrauterine device (IUD) is highly effective and widely used by
women throughout the world. Data support the safety of IUDs for most women, includ-
ing adolescents. This document addresses the major benefits of IUD use in adolescents,a population at particular risk of unintended pregnancy.
The committee would like to thankNicole Zidenberg, MD,Nirupama DeSilva, MD,
gitis in IUD users, and inability to control for
the effects of sexual behavior, leading to an
exaggeration of risk estimates (8). Ongoing
pelvic inflammatory disease (PID), sexually
research continues to demonstrate the safety
transmitted diseases (STDs), infertility, and
difficult insertion have limited the use of the
IUD in adolescents. Data support the safety
line only at the time of insertion. Among
of IUDs for most women, including adoles-
22,908 IUD users, within the first 20 days of
cents. The World Health Organization sup-
ports the use of intrauterine contraception in
woman-years; from 21 days to 8 years, the
incidence of PID was 1.4 per 1,000 woman-
women from menarche to age 20 years, stat-
ing that the benefits of intrauterine contra-
years, the same as that in the general popula-
ception generally outweigh the risks (2).
controlled trials confirmed these findings (8,
10). The risk of PID with IUD placement is
0–2% when no infection is present at the
time of insertion and 0–5% when insertion
62% of 12th graders have engaged in inter-
occurred with a documented infection. The
course (3). Sexual activity and inconsistent
absolute risk of PID is very small in bothgroups (10). Case reports also have shown
contraceptive use contribute to the high rate
that women with positive chlamydia cultures
of adolescent pregnancy in the United States,
identified at the time of IUD insertion are
which exceeds that of other industrialized
unlikely to develop PID if the infection is
countries (4, 5). Intrauterine devices offer the
treated with the IUD retained (11, 12).
long-term, cost-effective, highly reliable, and
thickening cervical mucus and thinning the
endometrium (13). Studies have demonstrat-ed the reduced risk of PID using the lev-
The Intrauterine Device Does Not
onorgestrel-releasing intrauterine system as
Increase an Adolescent’s Risk of
compared with a copper IUD (14, 15).
Pelvic Inflammatory Disease and
Intrauterine Devices Do Not Affect
Sexually Transmitted Diseases
the Fertility of Adolescents
Past experiences with the Dalkon Shield have
perpetuated the myth that IUDs cause pelvic
was not higher after cessation of IUD use ver-
The American College
infections. The studies that showed a causal
sus cessation of other reversible methods of
relationship between pelvic infection and
contraception (8). In a case–control study
IUDs were fraught with methodologic errors.
examining determinants of tubal infertility,
Confounding factors included inappropriate
the presence of chlamydial antibodies was
comparison groups, overdiagnosis of salpin-
associated with infertility in both users and
nonusers of IUDs (16). Fecundity rapidly returns to nor-
In many states, adolescents have the right to receive con-
fidential contraceptive services without parental permis-sion (26). Confidential IUD insertion may be thwarted by
the cost or consent issues. Preinsertion counseling about
Adolescents are more likely than adult women to discon-
the IUD is paramount. Goals of counseling include
tinue a range of contraceptive methods, including pills
awareness of the long-term nature of the contraceptive,
and injectable contraception. In women younger than 25
side effects, risks, and benefits. Upon insertion of the
years, discontinuation of the levonorgestrel-releasing
IUD, self-examination to confirm the presence of strings
intrauterine system at 12 months was slightly higher
should be taught, and condom use for STD prevention
compared with older women (19). Among copper IUD
should be encouraged. It is important for adolescents
users, pain and bleeding led to discontinuation (20). The
using IUDs to be familiar with their anatomy and com-
rate of amenorrhea with the levonorgestrel-releasing
intrauterine system varies from 16.4% to 80% at 1 yearafter insertion and may alleviate bleeding concerns (21).
Discomfort with IUD insertion is common. In one study,86% of adolescents reported mild to severe pain with
Expulsion contributes to IUD failure with a risk of 1 in 20
insertion (13). Misoprostol may soften a nulliparous
(22). Younger age and previous IUD expulsion may con-
cervix before insertion (27). Studies of use of non-
fer the greatest risk of failure (23). Prior expulsion should
steroidal antiinflammatory drugs for analgesia yielded
not be considered a contraindication for a new IUD pro-
mixed results but they may be used (28). Less studied
vided that patients undergo appropriate counseling and
methods of analgesia include paracervical blocks or pre-
insertion narcotics. Little data suggest that IUD insertion
is technically more difficult in adolescents.
Prophylactic antibiotics are not necessary for IUD
Contraindications to IUD use include current pregnancy;
insertion (29). Because adolescents have the highest num-
PID or puerperal or postabortion sepsis that is current or
ber of reported cases of chlamydia and coinfection with
within the past 3 months; current STDs; purulent cervici-
gonorrhea frequently occurs (30), all adolescents should
tis; undiagnosed abnormal vaginal bleeding; malignancy
be screened for gonorrhea and chlamydia before IUD
of the genital tract; known uterine anomalies or leiomy-
insertion (27, 31). Screening at the time of insertion expe-
omata distorting the uterine cavity in a way incompatible
dites contraceptive use. Patients with positive test results
with IUD insertion; or allergy to any component of the
have no adverse effects if treated promptly (10–12).
IUD or Wilson’s disease (for copper-containing IUDs)(24). An asymptomatic patient may use an IUD within
3 months of a treated pelvic infection or septic abortion
The IUD is a highly effective method of contraception
that is underused in the United States. Because adoles-
cents contribute disproportionately to the epidemic of
unintended pregnancy in this country, top tier methodsof contraception, including IUDs and implants, should be
The copper IUD may be used for emergency contracep-
considered as first-line choices for both nulliparous and
tion within 5 days of unprotected intercourse (24). The
parous adolescents. After thorough counseling regarding
IUD confers the additional benefit of serving as a long-
contraceptive options, health care providers should
term contraceptive. One study found that 86% of parous
strongly encourage young women who are appropriate
women and 80% of nulliparous women maintained the
IUD for long-term contraception after use as emergencycontraception (25).
In addition to providing contraception, the lev-
1. Mosher WD, Martinez GM, Chandra A, Abma JC, Willson
onorgestrel-releasing intrauterine system reduces men-
SJ. Use of contraception and use of family planning servic-
strual blood loss by 75% at 3 months. It offers the most
es in the United States: 1982-2002. Adv Data 2004;350:1–36.
favorable side effect profile of the progesterone-only
2. World Health Organization. Intrauterine devices. In:
methods. The levonorgestrel-releasing intrauterine system
Medical eligibility criteria for contraceptive use. 3rd ed.
offers an alternative to birth control pills for cycle control.
Geneva: WHO; 2004. p. 1–17. Available at: http://www.
Retrieved August 16, 2007.
3. Eaton DK, Kann L, Kinchen S, Ross J, Hawkins J, Harris
Practitioners must be familiar with federal, state, and
WA, et al. Youth risk behavior surveillance—United States,
institutional guidelines governing consent by adolescents.
2005. MMWR Surveill Summ 2006;55(5):1–108.
4. Zibners A, Cromer BA, Hayes J. Comparison of continua-
19. Luukkainen T, Allonen H, Haukkamaa M, Holma P, Pyorala
tion rates for hormonal contraception among adolescents.
T, Terho J, et al. Effective contraception with the lev-
J Pediatr Adolesc Gynecol 1999;12:90–4.
onorgestrel-releasing intrauterine device: 12-month report
of a European multicenter study. Contraception 1987;36:
5. Guttmacher Institute. In brief: facts on American teens’ sex-
ual and reproductive health. New York (NY): GI; 2006.
Available at: http://guttmacher.org/pubs/fb_ATSRH.html.
20. Rivera R, Chen-Mok M, McMullen S. Analysis of client
characteristics that may affect early discontinuation of theTCu-380A IUD. Contraception 1999;60:155–60.
6. Trussell J, Vaughan B. Contraceptive failure, method-relat-
ed discontinuation and resumption of use: results from the
21. Toma A, Jamieson MA. Revisiting the intrauterine contra-
1995 National Survey of Family Growth. Fam Plann
ceptive device in adolescents. J Pediatr Adolesc Gynecol
7. Chiou CF, Trussell J, Reyes E, Knight K, Wallace J, Udani J,
22. FFPRHC Guidance (April 2004). The levonorgestrel-releas-
et al. Economic analysis of contraceptives for women.
ing intrauterine system (LNG-IUS) in contraception and
reproductive health. Faculty of Family Planning andReproductive Health Care Clinical Effectiveness Unit. J Fam
8. Grimes DA. Intrauterine device and upper-genital-tract
Plann Reprod Health Care 2004;30:99–108; quiz 109.
infection. Lancet 2000;356:1013–9.
23. Thonneau P, Almont T, de La Rochebrochard E, Maria B.
9. Farley TM, Rosenberg MJ, Rowe PJ, Chen JH, Meirik O.
Risk factors for IUD failure: results of a large multicentre
Intrauterine devices and pelvic inflammatory disease: an
case-control study. Hum Reprod 2006;21:2612–6.
international perspective. Lancet 1992;339:785–8.
24. Intrauterine device. ACOG Practice Bulletin No. 59.
10. Mohllajee AP, Curtis KM, Peterson HB. Does insertion and
American College of Obstetricians and Gynecologists.
use of an intrauterine device increase the risk of pelvic
inflammatory disease among women with sexually trans-
25. Zhou L, Xiao B. Emergency contraception with Multiload
mitted infection? A systematic review. Contraception
Cu-375 SL IUD: a multicenter clinical trial. Contraception
11. Skjeldestad FE, Halvorsen LE, Kahn H, Nordbo SA, Saake K.
26. Guttmacher Institute. State policies in brief: minors’ access
IUD users in Norway are at low risk for genital C. tra-
to contraceptive services. New York (NY): GI; 2007.
chomatis infection. Contraception 1996;54:209–12.
Available at: http://www.guttmacher.org/statecenter/spibs/
12. Faundes A, Telles E, Cristofoletti ML, Faundes D, Castro S,
spib_MACS.pdf. Retrieved September 6, 2007.
Hardy E. The risk of inadvertent intrauterine device inser-
27. McNaught J. Adolescents and IUCDs—Not a contraindica-
tion in women carriers of endocervical Chlamydia tra-
tion. J Pediatr Adolesc Gynecol 2006;19:303–5.
chomatis. Contraception 1998;58:105–9.
28. Grimes DA, Hubacher D, Lopez LM, Schulz KF. Non-
13. Suhonen S, Haukkamaa M, Jakobsson T, Rauramo I. Clinical
steroidal anti-inflammatory drugs for heavy bleeding or
performance of a levonorgestrel-releasing intrauterine sys-
pain associated with intrauterine-device use. Cochrane
tem and oral contraceptives in young nulliparous women: a
Database of Systematic Reviews 2006, Issue 4. Art. No.:
comparative study. Contraception 2004;69:407–12.
CD006034. DOI: 10.1002/14651858.CD006034.pub2.
14. Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing
29. Grimes DA, Schulz FK. Antibiotic prophylaxis for intrauter-
and copper-releasing (Nova T) IUDs during five years of
ine contraceptive device insertion. Cochrane Database of
use: a randomized comparative trial. Contraception 1994;
Systematic Reviews 1999, Issue 3. Art. No.: CD001327. DOI:
15. Toivonen J, Luukkainen T, Allonen H. Protective effect of
30. Centers for Disease Control and Prevention. Sexually trans-
intrauterine release of levonorgestrel on pelvic infection:
mitted disease surveillance 2005. Atlanta (GA): CDC; 2006.
three years’ comparative experience of levonorgestrel- and
Available at: http://www.cdc.gov/std/stats/05pdf/Surv2005. pdf.
copper-releasing intrauterine devices. Obstet Gynecol
31. Lacy J. Clinic opinions regarding IUCD use in adolescents.
16. Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra-Infante F,
J Pediatr Adolesc Gynecol 2006;19:301–3.
Guzman-Rodriguez R. Use of copper intrauterine devicesand the risk of tubal infertility among nulligravid women.
N Engl J Med 2001;345:561–7.
Copyright December 2007 by the American College of Obstet-
ricians and Gynecologists, 409 12th Street, SW, PO Box 96920,
17. Hov GG, Skjeldestad FE, Hilstad T. Use of IUD and subse-
Washington, DC 20090-6920. Al rights reserved. No part of this pub-
quent fertility—follow-up after participation in a random-
lication may be reproduced, stored in a retrieval system, posted on
ized clinical trial. Contraception 2007;75:88–92.
the Internet, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without prior
18. Penney G, Brechin S, de Souza A, Bankowska U, Belfield T,
written permission from the publisher. Requests for authorization to
Gormley M, et al. FFPRHC Guidance (January 2004). The
make photocopies should be directed to: Copyright Clearance Center,
copper intrauterine device as long-term contraception.
222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400.
Faculty of Family Planning and Reproductive Health Care
Intrauterine device and adolescents. ACOG Committee Opinion No.
Clinical Effectiveness Unit [published erratum appears in J
392. American College of Obstetricians and Gynecologists. Obstet
Fam Plann Reprod Health Care 2004;30:134]. J Fam Plann
Reprod Health Care 2004;30:29–41; quiz 42.
A five day opiate withdrawal programme gives general and mental health nurses the opportunity to help people turn their lives aroundCygnet’s unique approach to detox transforms lives assessed to ensure they have appropriate time for patients to take naltrexone because support in place and that they will not be it gets them through all the good and bad returning to an environment where they
Updated Clinical Practice Guidelines for thePrevention and Treatment of MucositisConsiderable progress in research and clinical application has been made sincethe original guidelines for managing mucositis in cancer patients were publishedin 2004, and the first active drug for the prevention and treatment of this condi-tion has been approved by the United States Food and Drug Administration an