**5. Adverse and side effects, health benefits, and risks of IUDs**

Generally, all IUDs are well tolerated with high rates of continuation in all reversible contraception types [36]. All IUD types present potential side effects: uterus perforation and malposition, especially during the inserting technique; embedment and expulsion, as it is a foreign body, and menstrual pattern alterations (**Figure 3**). All patients should be counseled regarding the possibility of IUD expulsion as this is the most common complication following IUD insertion [37].

Regarding the *hormonal IUDs side effects*, they are similar to other progestin-based contraceptives such as headaches, nausea, hair loss, breast tenderness, depression, decreased libido, and ovarian cysts [44, 45]. Also, vulvovaginitis and abdominal or pelvic pain may be experienced by users of hormonal IUDs [44, 45]. On the contrary to copper IUDs, the hormonal IUDs

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The **contraindications/health risks** for IUD use are current pregnancy or gestational trophoblastic disease, cervico-vaginitis or acute pelvic inflammatory disease, including pelvic tuberculosis, puerperal sepsis and recent septic abortion, uterine (cervical or endometrial) cancer, unexplained vaginal bleeding, and malformed uterine cavity. Other systemic contraindications include copper allergy, immunodeficiency disorders, immunosuppressive therapy, Wilson's disease, acute liver disease or liver carcinoma and breast carcinoma—especially for

The major **health benefit** of IUD is represented by the efficacy in contraception similar or better than female sterilization. The cooper IUD failure rate is reported to be 0.8% at 1 year, while a failure rate for hormonal IUD is reported to be 0.1% at 1 year [46, 47]. Of great importance is that this efficacy is not influenced by or related to patient age, multiple medications, or medical comorbidities and does not require patient compliance [48]. IUDs can be safely placed immediately after abortion or 6 weeks postpartum with high contraceptive benefits [49]. Copper IUD is recommended as the most effective option for emergency contraception [50].

Another IUD benefit is the fact that it can be used as an adjunctive treatment modality for intrauterine adhesions. Several studies have shown that IUD can be beneficial in patients with intrauterine adhesions or Asherman's syndrome, especially when combined with other

Other noncontraceptive benefits of IUDs include the treatment of menorrhagia, anemia, dysmenorrhea and pelvic pain associated to endometriosis, and endometrial protection during hormone replacement [48]. Since 2009, when Food and Drug Administration (FDA) approved the hormonal IUD as treatment for heavy menstrual bleeding, hormonal IUDs became the most cost-effective alternative to hysterectomy/surgery for the respective patients, with improved hemoglobin concentration [52]. Studies report a decrease of the menstrual blood loss that varies between 74 and 97% at 12 months of use [53, 54]. First, an initial irregular bleeding pattern is noted by most users, but over time the menstrual blood loss is improved.

In contrast with copper IUD, the hormonal IUD can also decrease dysmenorrhea [55].

In 30% of patient with deep endometriosis or adenomyosis, an improved control of chronic pelvic pain and dyspareunia is noted after at least 6 months of hormonal IUD use [56, 57].

As the main effect of hormonal IUDs is to decrease the local endometrial response to estrogen, several studies have suggested that this may lead to primary protection from endometrial cancer [58]. Hormonal IUDs can also be used as a component of combined hormone therapy

The use of IUD contraception is considered a health benefit in special groups such as women with comorbidities, in postpartum, postabortion and lactating women, patients with prior

usually cause amenorrhea and oligomenorrhea after 2 years of use [42, 44].

hormonal IUD, multiple sexual partners for the patient or her partner.

ancillary treatments [51].

in menopausal women [52].

The *expulsion* rate is reported to be similar for copper and hormonal IUDs, as well as in nulliparous versus parous women, approximately 5% [38].

Uterine *perforation* is rare and surgical intervention is recommended if this occurs, but this is not an emergency in asymptomatic cases [39]. In these patients, a new IUD placement should be considered after at least 4–6 weeks time interval needed for uterine wall healing [40].

A rarely reported complication is the *embedment* within the endometrium. This should be suspected at the ultrasound (US) follow-up, or clinically, if no IUD strings are visualized at the cervical os or there is difficulty with removal [41].

Copper IUDs can cause *menstrual pattern alterations*, especially irregular, heavy and painful bleeding, and intermenstrual spotting or bleeding as well throughout use [42, 43].

**Figure 3.** IUDs complications. (A): complete uterine perforation; (B): partial uterine perforation; (C): partial embedment into myometrium; (D): malposition; (E): expulsion after insertion.

Regarding the *hormonal IUDs side effects*, they are similar to other progestin-based contraceptives such as headaches, nausea, hair loss, breast tenderness, depression, decreased libido, and ovarian cysts [44, 45]. Also, vulvovaginitis and abdominal or pelvic pain may be experienced by users of hormonal IUDs [44, 45]. On the contrary to copper IUDs, the hormonal IUDs usually cause amenorrhea and oligomenorrhea after 2 years of use [42, 44].

**5. Adverse and side effects, health benefits, and risks of IUDs**

liparous versus parous women, approximately 5% [38].

cervical os or there is difficulty with removal [41].

into myometrium; (D): malposition; (E): expulsion after insertion.

insertion [37].

262 Family Planning

Generally, all IUDs are well tolerated with high rates of continuation in all reversible contraception types [36]. All IUD types present potential side effects: uterus perforation and malposition, especially during the inserting technique; embedment and expulsion, as it is a foreign body, and menstrual pattern alterations (**Figure 3**). All patients should be counseled regarding the possibility of IUD expulsion as this is the most common complication following IUD

The *expulsion* rate is reported to be similar for copper and hormonal IUDs, as well as in nul-

Uterine *perforation* is rare and surgical intervention is recommended if this occurs, but this is not an emergency in asymptomatic cases [39]. In these patients, a new IUD placement should be considered after at least 4–6 weeks time interval needed for uterine wall healing [40].

A rarely reported complication is the *embedment* within the endometrium. This should be suspected at the ultrasound (US) follow-up, or clinically, if no IUD strings are visualized at the

Copper IUDs can cause *menstrual pattern alterations*, especially irregular, heavy and painful

**Figure 3.** IUDs complications. (A): complete uterine perforation; (B): partial uterine perforation; (C): partial embedment

bleeding, and intermenstrual spotting or bleeding as well throughout use [42, 43].

The **contraindications/health risks** for IUD use are current pregnancy or gestational trophoblastic disease, cervico-vaginitis or acute pelvic inflammatory disease, including pelvic tuberculosis, puerperal sepsis and recent septic abortion, uterine (cervical or endometrial) cancer, unexplained vaginal bleeding, and malformed uterine cavity. Other systemic contraindications include copper allergy, immunodeficiency disorders, immunosuppressive therapy, Wilson's disease, acute liver disease or liver carcinoma and breast carcinoma—especially for hormonal IUD, multiple sexual partners for the patient or her partner.

The major **health benefit** of IUD is represented by the efficacy in contraception similar or better than female sterilization. The cooper IUD failure rate is reported to be 0.8% at 1 year, while a failure rate for hormonal IUD is reported to be 0.1% at 1 year [46, 47]. Of great importance is that this efficacy is not influenced by or related to patient age, multiple medications, or medical comorbidities and does not require patient compliance [48]. IUDs can be safely placed immediately after abortion or 6 weeks postpartum with high contraceptive benefits [49]. Copper IUD is recommended as the most effective option for emergency contraception [50].

Another IUD benefit is the fact that it can be used as an adjunctive treatment modality for intrauterine adhesions. Several studies have shown that IUD can be beneficial in patients with intrauterine adhesions or Asherman's syndrome, especially when combined with other ancillary treatments [51].

Other noncontraceptive benefits of IUDs include the treatment of menorrhagia, anemia, dysmenorrhea and pelvic pain associated to endometriosis, and endometrial protection during hormone replacement [48]. Since 2009, when Food and Drug Administration (FDA) approved the hormonal IUD as treatment for heavy menstrual bleeding, hormonal IUDs became the most cost-effective alternative to hysterectomy/surgery for the respective patients, with improved hemoglobin concentration [52]. Studies report a decrease of the menstrual blood loss that varies between 74 and 97% at 12 months of use [53, 54]. First, an initial irregular bleeding pattern is noted by most users, but over time the menstrual blood loss is improved. In contrast with copper IUD, the hormonal IUD can also decrease dysmenorrhea [55].

In 30% of patient with deep endometriosis or adenomyosis, an improved control of chronic pelvic pain and dyspareunia is noted after at least 6 months of hormonal IUD use [56, 57].

As the main effect of hormonal IUDs is to decrease the local endometrial response to estrogen, several studies have suggested that this may lead to primary protection from endometrial cancer [58]. Hormonal IUDs can also be used as a component of combined hormone therapy in menopausal women [52].

The use of IUD contraception is considered a health benefit in special groups such as women with comorbidities, in postpartum, postabortion and lactating women, patients with prior thromboembolic events, bleeding diathesis, or under anticoagulation. Also, IUD contraception can be a preferable option in women with uterine fibroids after uterine artery embolization, endometrial ablation, or magnetic resonance-guided focused ultrasound.

of IUD contraception [68]. What is more, approximately one-third to one-half of health providers do not offer IUD contraception method to nulliparous women due to several myths and misconceptions [69]. Nowadays, there is sufficient evidence to support the use of IUDs in the nulliparous women as a suitable contraception method, regardless of all false myths and misconceptions including high risk of PID, tubal infertility, EP, gynecological neoplasia,

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There is a lack of awareness and understanding of IUD contraception by women worldwide, possibly due to lack of medical education and proper information. A frequent misconception of IUD use is that it increases the risk of genital cancer. Mandatory screening for cervical cancer is a requirement of many guidelines before IUD insertion. In fact, several epidemiological studies suggested that IUDs might protect against cervical carcinogenesis [71]. The role of hormonal IUD as a protective factor against endometrial hyperplasia is well known [58]. Accurate information regarding the

Female sexual dysfunction was thought to be determined by IUD but in fact has a multifacto-

IUD represents the choice method of contraception for many women as its effects are revers-

The insertion technique is easy and well tolerated by selected female patients after taking into consideration the contraindications, as well as the health benefits for women with anemia, menorrhagia, or dysmenorrhea [73]. First, it is advisable to have a documentation of a negative pregnancy test as a precaution. Also, exclusion of a possible Chlamydia or gonorrhea is advisable before an IUD is inserted [74]. The insertion can be performed at any time during the menstrual cycle [42]. In the past, the technique was preferred to be done during menses to exclude pregnancy, but this is associated with a higher risk of expulsion. Several studies found that the pain during the insertion is lower during the sixth and the tenth days of the menstrual cycle [26]. Regarding the insertion of a hormonal IUD, the appropriate timing is considered to be within the first 5 days of menstrual bleeding or immediately after childbirth, abortion, or switching from an alternative contraceptive method [42, 75]. Backup contraception is recommended for a period of 7 days after the hormonal IUD insertion and is not needed after the copper IUD insertion [48]. In cases of emergency contraception, the insertion of the copper IUD can be done within the 5 days of the unprotected intercourse to prevent pregnancy [25]. The use of a hormonal IUD has not been yet studied and so it is not recommended for emergency contraception. The removal of both the copper IUD and the hormonal IUD can be performed anytime preferably during the menstrual cycle. As mentioned before, antibiotic prophylaxis is not needed before IUD insertion

use of hormonal IUD must underline the risk of ovarian cysts, but not ovarian cancer.

rial etiology and studies found no difference between IUD users or non-users [72].

difficulties of the insertion technique, and IUD expulsion [70].

**7. The technique of inserting and removing IUDs**

**6.5. IUD and gynecological neoplasia**

**6.6. IUD and female sexual dysfunction**

ible after removal.

However, the IUD does not protect from sexually transmitted diseases; therefore, caution must be considered when selecting IUD users.
