Skip to textbook content
Doctor’s PassportTextbook
QuestionsFlashcardsBriefsDashboardAccount
TopicsAll topics

Loading topic navigation…

Textbook navigation
TopicsAll topics

Loading topic navigation…
Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Copper and levonorgestrel intrauterine contraception

Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
!
Do not miss IUC pregnancy complications

A positive pregnancy test with pelvic pain, bleeding, collapse, shoulder-tip pain or an intrauterine device in situ requires urgent pregnancy-location assessment because ectopic pregnancy must be excluded.

Action: Arrange same-day early-pregnancy or emergency assessment with quantitative hCG and transvaginal ultrasound as indicated; do not remove the device before pregnancy location and management have been considered.

Synopsis

Counsel, insert and follow copper and levonorgestrel intrauterine contraception safely, distinguishing emergency use, product duration, bleeding effects, infection, perforation, expulsion and pregnancy pathways.

  • Copper IUD and levonorgestrel IUD are over 99% effective, rapidly reversible and unaffected by hepatic enzyme-inducing medicines; neither protects against sexually transmitted infections.
  • The copper IUD is the most effective emergency contraception: insert within five days after the first unprotected intercourse in the cycle or within five days of the earliest estimated ovulation, whichever rule permits later insertion.
  • Copper devices act immediately and commonly make periods heavier, longer or more painful; LNG-IUDs usually cause early irregular bleeding followed by lighter bleeding or amenorrhoea.
  • Duration is product-specific. Current 52 mg levonorgestrel systems used for contraception may have an eight-year licence, while duration for heavy menstrual bleeding or HRT endometrial protection is shorter and indication-specific.
  • Before insertion, reasonably exclude pregnancy, assess infection risk and unexplained bleeding, consider uterine cavity distortion and obtain specific consent for pain, perforation, expulsion, infection and failure.
  • Offer analgesia and discuss the full range of pain-control options before insertion; use an assistant or chaperone and stop whenever the patient asks.
  • Routine prophylactic antibiotics are not indicated. If asymptomatic STI risk is identified, testing can usually occur at insertion, with prompt treatment and follow-up of a positive result.
  • Missing threads do not prove expulsion. Advise condoms or abstinence, assess emergency contraception and pregnancy, then locate the device by ultrasound before instrumenting the uterine cavity.

    • Key red flags

    Severe or worsening pain, heavy bleeding, fever, offensive discharge or systemic illness after insertion may indicate perforation, infection, expulsion or an unrelated acute pelvic condition.

    Threads that suddenly lengthen, shorten or disappear, or a patient who can feel the stem, requires pregnancy-risk assessment and device localisation before unprotected intercourse continues.

    New pain or bleeding with a positive pregnancy test demands urgent ectopic exclusion even though intrauterine methods greatly reduce absolute pregnancy risk.

    Unexplained persistent intermenstrual, postcoital or postmenopausal bleeding needs its own diagnostic pathway and should not be attributed automatically to a hormonal device.

    Investigation priorities

    01
    Pregnancy assessmentFirst step

    Reasonably exclude established or very early pregnancy before insertion and assess risk after device failure.

    Management branches

    First-line emergency optionOffer the copper IUD first

    Unprotected intercourse falls within a recognised intrauterine emergency-contraception window.

    1. Establish every intercourse date, cycle timing, current contraception, pregnancy possibility, infection symptoms and patient preference without delaying access.
    2. Offer a copper IUD as the most effective emergency method, using the five-day intercourse or earliest-ovulation rule and explaining immediate ongoing protection.
    3. If it is declined or unsuitable, provide the best oral emergency option promptly and arrange an ongoing method, backup and pregnancy test at 21 days.
    Routine insertionPrepare, consent and place safely

    A patient chooses an intrauterine method and pregnancy can be reasonably excluded.

    1. Confirm brand, indication, bleeding preference, uterine and infection history, STI testing need, analgesia plan, chaperone and voluntary procedural consent.
    2. Perform bimanual and speculum assessment, use aseptic trained technique, sound and insert according to product instructions, stopping if pain or anatomy makes continuation unsafe.
    3. Record device, batch, cavity length, thread length, insertion and replacement dates and give written advice for pain, bleeding, infection, expulsion, pregnancy and removal.

    Key medicines

    Copper intrauterine deviceInsert one appropriately licensed copper-bearing device using trained aseptic technique; for emergency contraception insert within five days of first unprotected intercourse in the cycle or within five days of earliest estimated ovulation.Avoid when pregnancy cannot be excluded outside EC criteria, with current pelvic infection or incompatible cavity anatomy; discuss heavier bleeding, pain, perforation, expulsion and copper-specific contraindications.
    Levonorgestrel 52 mg intrauterine deviceInsert one 52 mg device after pregnancy exclusion and suitability assessment; use the exact brand’s current duration, with Mirena, Levosert and Benilexa licensed for up to eight years for contraception.Contraceptive, heavy-bleeding and HRT replacement intervals differ; assess breast cancer, liver disease, unexplained bleeding, infection and cavity distortion and discuss irregular bleeding, perforation and expulsion.
    Open full textbook →Answer 2 questions
    Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

    • CoSRH intrauterine contraception guidelineDevice choice, insertion, duration and complication pathways.
    • CoSRH emergency contraception guidelineCopper-IUD emergency timing and priority.
    • NHS copper IUDPatient-facing use, risks and access.
    • NHS hormonal IUDBleeding effects, effectiveness and practical advice.

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom