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Intrauterine device

What's new

The American College of Obstetricians and Gynecologists (ACOG) has released a new guideline on pain management for in-office uterine and cervical procedures, suggesting the use of local anesthetic agents to reduce pain associated with intrauterine device (IUD) insertion, aligning with CDC recommendations to use lidocaine (paracervical block or topical) during IUD placement. The guideline also recommends topical anesthetics and NSAIDs for endometrial biopsy; injected local anesthesia for diagnostic and operative hysteroscopy and endometrial ablation, with misoprostol as an option for intraprocedural pain; lidocaine-prilocaine cream applied to the cervix for instrumentation with a tenaculum and cannula during hysterosalpingography; paracervical block and NSAIDs for uterine aspiration; and local anesthetics for loop electrosurgical excision procedures. .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of intrauterine device are prepared by our editorial team based on guidelines from the American College of Obstetricians and Gynecologists (ACOG 2025,2018,2017), the Center for Disease Control (CDC 2024), the American Academy of Family Physicians (AAFP 2022), the Society for Maternal-Fetal Medicine (SMFM 2019), and the Society of Obstetricians and Gynaecologists ...
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Diagnostic investigations

Exclusion of pregnancy: as per SOGC 2016 guidelines, consider ensuring that the patient is not pregnant before inserting an IUD at any time during the menstrual cycle.
B
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Medical management

Antibiotic prophylaxis: as per CDC 2024 guidelines, avoid administering prophylactic antibiotics for copper or levonorgestrel IUD placement.
D
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  • Pain management

  • Management of bleeding irregulaties

Therapeutic procedures

Considerations for intrauterine contraception
As per AAFP 2022 guidelines:
Recognize that the copper IUD is the most effective form of emergency contraception, with the levonorgestrel-releasing intrauterine system found to be similarly effective, followed by oral ulipristal, oral levonorgestrel, and the Yuzpe method.
A
Recognize that pregnancy prevention persists with extended use of the levonorgestrel-releasing intrauterine system for 8 years, the copper IUD for 12 years, and the etonogestrel subdermal contraceptive implant for 5 years.
B
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  • Timing for placement (general principles)

  • Timing for placement (postabortion)

  • Timing for placement (postpartum)

  • Indications for removal (pregnancy)

  • Indications for removal (procedures)

  • Indications for removal (infection)

  • Indications for removal (expiration date)

Specific circumstances

Patients with breast cancer: as per SOGC 2016 guidelines, consider offering a levonorgestrel-releasing intrauterine system in patients with breast cancer taking tamoxifen after consultation with their oncologist.
B
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Follow-up and surveillance

Follow-up: as per CDC 2024 guidelines, assess the following at routine visits:
patient satisfaction with their contraceptive method and address any concerns regarding its use
any changes in health status, including medications, that may affect the appropriateness of the IUD for safe and effective continued use
weight changes and discussing concerns about any changes in weight and whether these changes might be related to the use of the contraceptive method
perform an examination to check for the presence of the IUD strings.
E
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