Side effects and complications

Providing counseling about the side effects of IUDs correlates with satisfaction and continuation rates.19 In her 2013 review, Hillard17 shows that adolescents, early adolescents in particular, tend to disregard warnings unless they are overstated. She suggests counseling adolescents to expect side effects rather than warning them that they may experience side effects. It is important that adolescents are informed that bleeding will decrease with LNG IUDs and that cramping from the copper IUD will most likely decrease over time and can be subdued with nonsteroidal anti-inflammatory drugs.18

Providers should explain the side effects of each type of IUD, paying close attention to common concerns among all patient groups and with a particular focus on clarifying those concerns. Providers should note that the LNG IUDs have been shown to reduce bleeding and pain from dysmenorrhea17; however, the copper IUD will likely increase bleeding and cramping, especially in the first few months after insertion. Patients with a history of menorrhagia or dysmenorrhea may be better served by one of the LNG IUDs.6 If patients are informed of side effects ahead of time, they will be less likely to react strongly to them if they occur.

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Providers are less concerned about IUD expulsion and uterine perforation.12-14 However, IUD expulsions and uterine perforations can develop into severe complications and are consequences for which providers should be vigilant. Of the two complications, expulsion is more common, occurring in approximately 5% of IUD users.19 Providers should be aware that IUD expulsion rates may be slightly higher in adolescent women, women with severe dysmenorrhea, most women with a history of expulsions, women who have had an immediate insertion after an abortion or miscarriage in the first trimester (when compared with an abortion or miscarriage in the second trimester), and women who have an immediate postpartum insertion (when compared with delayed insertion). Immediate insertion of an IUD after vaginal delivery also has a higher rate of expulsion than after cesarean deliveries; however, the ACOG states that the benefits of immediate postpartum insertion may outweigh the risks because delayed insertion requires another office visit that patients may not attend.6,9,22 It is also important to note that a previous expulsion is not a contraindication for the use or insertion of an IUD.9

The risk of uterine perforation is rare. Recent studies estimate that as few as 0.4 to 1 perforation occurs in every 1000 insertions. When they do occur, the perforations are rarely dangerous.16,17,22,23 Perforation in an asymptomatic patient is not an emergency.19 A recent study showed that breastfeeding at the time of insertion created a 6-fold increase in the risk of perforation.24 Other risk factors include clinician inexperience in IUD insertion, myometrial defects, an immobile uterus, or a retroverted uterus.25 A previous perforation is not a contraindication for IUD use or insertion.


Surveys and studies have shown that many common provider misconceptions are unfounded. Common misconceptions include the belief that nulliparous women, adolescent women, women who are postpartum or postabortion/miscarriage, women who have a recent history of PID or STIs, and women who have a history of ectopic pregnancy are not appropriate candidates for IUDs. In the United States, providers are often hesitant to offer IUDs to nulliparous and adolescent women because they have concerns about difficult insertions, pelvic pain, infertility, and PID. The data above illustrate that most of these concerns are unsubstantiated.

In addition to a gap in provider knowledge regarding IUDs, there is also an educational gap among patients. In one survey, only 50% of adolescents had heard of LARC.26 Patients frequently fear infertility and an increased risk of ectopic pregnancy, as well as increased pelvic pain and pain upon insertion. However, many of these concerns are unsupported, or can be ameliorated, if providers explain the potential side effects in advance. Providers also note that patients are more satisfied with LARC methods than any nonLARC method.

In order to potentially increase the use of this efficacious and well-tolerated form of contraception, it is important to clarify the facts for both patients and providers alike and to address the most common concerns. In spite of the ACOG and MEC recommendations and numerous studies, many continue to hold on to misinformation. Among NPs, PAs, and doctors, it should be reinforced that (1) IUD insertions in nulliparous and adolescent women are not more difficult than in any other group; (2) IUDs do not increase a patient’s risk of PID or infertility; (3) women who are nulliparous, adolescent, postpartum, or postabortion/miscarriage can safely use IUDs; and (4) a history of ectopic pregnancy, PID, or STIs does not preclude IUD use. Disseminating accurate information that addresses the specific concerns many providers and patients have about IUDs will empower women to make informed decisions and may increase use of IUDs to a rate that is closer to the rest of the world.

Libby Levine, MS, AGNP-BC, received her Masters in Nursing from Columbia University in February 2015. She can be reached at [email protected]


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