Copper Versus Hormonal IUD

Copper and levonorgestrel intrauterine devices are equally convenient, long-acting and reversible, but differ in mechanism, bleeding effect, duration and eligibility. Choice rests on the patient’s bleeding pattern, wish for a hormone-free method, need for emergency contraception, medical conditions and the length of cover wanted.

Head-to-head comparison.

Return to fertility. Immediate for all devices.

Favour a copper device. Wish to avoid hormones; emergency contraception needed; current breast cancer; acute venous thromboembolism; decompensated cirrhosis or liver tumours; lupus with antiphospholipid antibodies; need for the longest duration; perimenopausal patients at 40 or over who want cover to menopause.

Favour a levonorgestrel 52 mg device. Heavy menstrual bleeding, dysmenorrhoea, endometriosis, adenomyosis, iron deficiency anaemia, sickle cell disease and thalassaemia, and need for endometrial protection with oestrogen therapy.

Favour a 19.5 mg or 13.5 mg device. Nulliparous patients or a tight cervix where a smaller inserter helps, and patients who prefer to keep a monthly bleed.

Shared category 4 conditions. Pregnancy, unexplained vaginal bleeding before evaluation, current pelvic inflammatory disease or purulent cervicitis, puerperal sepsis, pelvic tuberculosis, cavity distortion and malignant trophoblastic disease.

Postpartum categories. Within 48 hours: copper category 1; levonorgestrel category 1 if not breastfeeding and category 2 if breastfeeding. From 48 hours to 4 weeks: category 3 for both. From 4 weeks: category 1 for both.

Interactions. Neither class loses effectiveness with enzyme inducers or antiretrovirals.

Copper T 380A regimen line. 380 mm² copper; insert within 12 days of menses start or any time if not pregnant; no backup; up to 12 years; usable as emergency contraception within 5 days.

Levonorgestrel device regimen lines. 52 mg and 19.5 mg devices replace at 5 years and the 13.5 mg device at 3 years; insert within 7 days of menses start with no backup, otherwise backup 7 days; within 48 hours or from 4 weeks postpartum; immediately after abortion.

Changing between classes. Copper to levonorgestrel within 7 days of menses start needs no backup. Later in the cycle, avoid intercourse or use condoms for 7 days before the exchange and backup for 7 days after. Levonorgestrel to copper can be exchanged at any time with immediate cover.

Follow up. All devices: review at 3 to 6 weeks, then for problems or replacement.

Bleeding. Copper: heavier menses, managed with ibuprofen 400 mg orally three times daily with food for 5 days (maximum 2.4 g daily) or tranexamic acid 1 g orally three times daily for up to 4 days. Levonorgestrel: early irregular spotting, managed with mefenamic acid 500 mg orally three times daily for 5 days or, if eligible, a 30 microgram ethinylestradiol combined pill for up to 3 months.

Hormonal effects. Only levonorgestrel devices cause acne, breast tenderness, headache, mood change and functional ovarian cysts, generally mild.

Shared device risks. Expulsion about 1 in 20 in the first year; perforation about 1 to 2 for every 1,000 insertions; pelvic infection mainly in the first 20 days; ectopic pregnancy in a higher proportion of failures, particularly with levonorgestrel devices.

Changing device for side effects. Unacceptable heavy bleeding on copper: change to a levonorgestrel 52 mg device. Unacceptable hormonal effects on a levonorgestrel device: change to copper.

Referral and escalation. Identical for both: suspected perforation, ectopic pregnancy, sepsis, or a device not located.