Key Treatment

IUDs have a failure rate less than 1% to 2% per year (SOR: A). IUDs (e.g., Mirena) can be used during lactation and are not con-traindicated in women with a history of venous thromboembolic events, those at increased risk of myocardial infarction or stroke, or those who smoke (SOR: A) (McCarthy, 2006).


The Mirena IUD is a levonorgestrel-releasing IUC system placed for up to 5 years for extremely effective contraception. The levonorgestrel is released into the uterus, with minute amounts entering systemic circulation. Variable to no menstrual bleeding is the norm for patients after 3 to 6 months.

The Mirena device is supplied in its own delivery system aiding with placement. The patient is placed in a dorsal lithotomy position and a sterile speculum introduced into the vagina. The cervix and vaginal mucosa is cleansed with a chlorhexidine or povidone-iodine solution. A paracervical block can be placed as described earlier. The anterior or posterior cervix is grasped with a single toothed cervical tenacu-lum for stabilization of the cervix during the procedure. If normal, the uterus should be sounded to depths of 6.5 to 8.5 cm. If the uterus is sounded to a different depth, consider misplacement, cervical stenosis, or uterine perforation. The cervix can be dilated for placement, if significant stenosis is present.

Open the Mirena package, release the IUD threads, position the IUD arms, and position the flange at the proper sounded depth. Once in the same plane as the inserter system, retract the arms into the inserter by pulling on the strings at the end of the system and pushing forward on the green thumb slider. Lock the strings into the cleft at the end of the inserter. Insert the IUD system gently through the cervix into the uterus, but stop 1.5 to 2 cm before the fundus. Pull back on the thumb slider to the designated mark, and release the arms outward. Wait for 10 to 15 seconds to allow the arms to fully extend. Hold the slider with the thumb and advance the system fully forward to place the IUD arms against the uterine fundus. Now pull only the slider all the way outward to release the threads at the proximal end of the inserter, then remove the entire inserter system from the cervix, leaving behind the IUD with threads. Cut the two threads to a length of 3 to 5 cm. Remove the tenaculum and observe for any significant bleeding. Monsel's solution or pressure can be used for hemostasis. Remove the speculum, and give the patient instructions for follow-up visits and postinsertion care. (See Tuggy Video: IUD insert.)

Paragard T380A

The Paragard can be placed for up to 10 years and in a similar manner as the Mirena IUD. Patients should receive counseling and informed consent for the Paragard IUD, with specific warnings about contraindications in patients with Wilson's disease because of the copper content of the Paragard. Positioning of the patient, placement of the speculum, cleansing of the vagina and cervix, placement of the tenaculum, and uterine sounding are the same as described for the Mirena. However, the IUD arms are loaded differently into the Para-gard inserter, folded backward with the distal arms inserted into the end of the inserter tube to lie next to the IUD shaft.

The IUD system is then inserted through the cervix to the uterine fundus. The white inserter plunger is held steady and the outside clear tube retracted 1 to 2 cm to release the arms. The clear tube is then advanced back to the fundus to assist in extending the arms and placing them in the apex of the fundus. The central plunger is then removed before the outside tube to prevent inadvertent removal of the IUD (Fig. 28-18). Once the inserter is removed, the two threads can be cut to 3 to 5 cm in length and the tenaculum and speculum removed, with hemostasis as needed. The patient is instructed in postplacement care and subsequent monthly cervical thread checks. Warning signs for infection, perforation, and bleeding are given. (See Tuggy Video: IUD Insertion.)


Removal of an IUD is quite simple for the majority of devices. An oral NSAID is beneficial to assist with analgesia. The patient is placed in a dorsal lithotomy position and a speculum placed in the vagina. The two IUD strings are identified and grasped with a ring forceps. The strings are gently pulled on, and the IUD should easily follow for removal. If the strings are not present, the IUD strings are generally just inside the cervical os. One can use a Cytobrush to dislodge the strings, attempt to grasp the strings in the os with a straight hemostat, or consider cervical dilation and use of an IUD hook or extractor for removal of the IUD. In some women the IUD may be malpositioned, and an ultrasound or plain abdominal film can locate the system for removal. If the IUD does not come out easily or is disconnected from the strings with the initial traction, hysteroscopy-assisted IUD removal may be necessary in a few rare cases.

Intradermal Contraceptive Device

Implanon is a device 4 cm long and 2 mm wide containing 68 mg of etonogestrel. It is inserted on the inner side of the nondominant upper arm above the medial epicondyle in a subdermal location for up to 3 years of contraception. Insertion should occur during the first week of a patient's menstrual cycle. The site for insertion is selected, marked, and locally anesthetized. The device is placed using a subdermal insertion trochar. Complications from insertion are 1% and from removal 1.7%. Irregular bleeding is the most common side effect (11% of patients). The manufacturer requires providers to complete a 3-hour comprehensive training program, which should be completed before device placement (

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