Copper IUD

Copper intrauterine devices are nonhormonal long-acting reversible contraceptives consisting of a plastic frame, or a frameless chain, carrying copper wire or sleeves that release copper ions into the uterine cavity. They give immediate protection from insertion, last 3 to 12 years depending on the design, are the most effective method of emergency contraception, and are fully compatible with breastfeeding and with medicines of every class.

Classification by copper load and design. Effectiveness rises with copper surface area; devices carrying 300 mm² or more are the most effective.

Mechanism. Copper ions reduce sperm motility and viability and produce a sterile inflammatory reaction in the endometrium that is toxic to sperm and ova, preventing fertilisation. When used as emergency contraception after fertilisation, the same environment also prevents implantation.

Effectiveness. For the copper T 380A, about 6 pregnancies per 1,000 women in the first year with perfect use and 8 per 1,000 with typical use. Lower surface area devices have higher failure rates.

Onset and return to fertility. Protection is immediate. Fertility returns immediately on removal.

Ideal candidates. Patients who want long-term, nonhormonal contraception; those with contraindications to oestrogen or progestogen; breastfeeding patients; patients on enzyme-inducing medicines; and those needing emergency contraception who also want ongoing cover.

History and examination. Assess menstrual blood loss, dysmenorrhoea, anaemia symptoms and STI risk. Perform bimanual and speculum examination before insertion.

Investigations. Pregnancy exclusion; STI testing where risk is increased; haemoglobin where heavy bleeding or anaemia is suspected. No other routine tests.

Eligibility points specific to copper devices.

• Category 1: breastfeeding or not, within 48 hours of delivery of the placenta; blood pressure of 160/100 mmHg or higher; history of or current deep vein thrombosis or pulmonary embolism, including on anticoagulation; ischaemic heart disease or stroke; systemic lupus erythematosus without severe thrombocytopenia; migraine with or without aura; diabetes; liver tumours and decompensated cirrhosis; breast cancer, current or past.
• Category 2: heavy or prolonged menstrual bleeding; endometriosis or severe dysmenorrhoea; iron deficiency anaemia, sickle cell disease and thalassaemia; complicated valvular heart disease.
• Category 3: systemic lupus erythematosus with severe thrombocytopenia, initiation only.
• Product contraindications: copper allergy and Wilson disease.

Counselling points. The device will not protect against STIs or HIV, so advise condoms where risk exists. Expect heavier, longer and more painful menses for the first 3 to 6 months, often settling. The patient may ask for removal at any time.

Regimen line. Copper T 380A intrauterine device, 380 mm² copper; inserted transcervically by a trained clinician; start within 12 days of menses start or at any time if reasonably certain not pregnant, within 48 hours or from 4 weeks postpartum, or immediately after abortion; no backup needed; effective up to 12 years; no missed-use rule; no drug interactions; no adjustment for body weight, liver disease, kidney disease or enzyme inducers.

Switching.

• From a hormonal method used correctly: insert at any time, no backup.
• From a copper device to a hormonal method: within 7 days of menses start (5 days for combined or progestin-only pills), start the hormonal method and remove the device the same day. Later in the cycle, if sexually active since the last menses, start the hormonal method and keep the device until the next menses.
• To a partner’s vasectomy: keep the device for 3 months after the vasectomy.

Follow up. Review at 3 to 6 weeks. Thereafter review only for problems or at replacement.

Perimenopause. A copper device inserted at 40 or over may remain until 12 months after the last menstrual period.

Bleeding and pain. Heavy or prolonged bleeding and cramping are the main reasons for removal. Management:

• Ibuprofen 400 mg orally three times daily with food for 5 days from the start of bleeding; maximum 2.4 g daily; avoid in peptic ulcer disease, severe kidney impairment and late pregnancy; compatible with breastfeeding.
• Mefenamic acid 500 mg orally three times daily for up to 5 days during bleeding; avoid in kidney impairment and inflammatory bowel disease.
• Tranexamic acid 1 g orally three times daily for up to 4 days during heavy bleeding; maximum 4 g daily; avoid with active or past thromboembolism; reduce dose in kidney impairment.

Persistent abnormal bleeding. Exclude pregnancy, infection, partial expulsion, malposition, polyps, fibroids and malignancy. If no cause is found and bleeding is unacceptable or anaemia develops, remove the device and offer another method, often a levonorgestrel device.

Anaemia. Check haemoglobin where bleeding is heavy. Give oral iron, for example ferrous sulphate 200 mg (65 mg elemental iron) once daily, continued for 3 months after haemoglobin normalises.

Other complications. Expulsion, perforation, infection in the first 20 days, and ectopic pregnancy if failure occurs. Each requires examination, ultrasound where available and urgent referral when perforation, ectopic pregnancy or sepsis is suspected.

Referral and escalation. Refer anaemia with haemoglobin under 7 g/dL or symptomatic anaemia urgently. Refer devices that cannot be removed by gentle traction on the threads.