Levonorgestrel IUD Insertion

Levonorgestrel IUD insertion places a T-shaped device that releases levonorgestrel into the uterine cavity. It provides highly effective contraception, markedly reduces menstrual bleeding and does not contain oestrogen. It is not used as emergency contraception.

Devices.

• Levonorgestrel 52 mg: 5 years of use in the usual schedule; some labels allow longer.

• Levonorgestrel 19.5 mg: 5 years.

• Levonorgestrel 13.5 mg: 3 years.

Availability of the 19.5 mg and 13.5 mg devices varies; confirm what is stocked.

Indications. Contraception in patients who want a long-acting method, heavy menstrual bleeding, dysmenorrhoea, adenomyosis, endometrial protection during tamoxifen or oestrogen therapy, and patients who cannot use oestrogen.

Contraindications (category 4 at initiation). Pregnancy; puerperal sepsis; current pelvic inflammatory disease or purulent cervicitis; unexplained vaginal bleeding before evaluation; cervical or endometrial cancer awaiting treatment; uterine distortion; gestational trophoblastic disease with persistently raised hCG; pelvic tuberculosis; current breast cancer.

Timing.

• Within 7 days of the start of menses: no backup. At any other time when reasonably certain not pregnant: backup for 7 days.

• Postpartum: within 10 minutes of the placenta, trans-caesarean, within 48 hours of birth, or from 4 weeks.

• Postabortion: immediately, or within 12 days when there is no infection.

• Switching from a hormonal method used correctly: immediately; from an injectable, when the next injection is due.

Preparation. Consent; pregnancy exclusion; bimanual examination; ibuprofen 400 to 800 mg 30 to 60 minutes before; local anaesthetic as needed.

Equipment. The same sterile instruments that are used for a copper IUD, with the specific levonorgestrel device and its inserter. Smaller inserters (narrower tube) suit nulliparous patients.

General steps. The steps from positioning to sounding match those for a copper IUD: lithotomy position, bimanual examination, speculum, antiseptic, tenaculum on the anterior lip with gentle traction, and uterine sounding (usually 6 to 9 cm). The device is then loaded, released and positioned by the method its design requires; follow the steps for the specific device.

Typical release sequence for the 52 mg device.

• Keep the device in its package, slide the slider to the top to fold the arms into the inserter, and set the flange at the sounded depth.

• Introduce the inserter through the cervix until the flange is about 1.5 to 2 cm from the cervix.

• Hold the inserter still and pull the slider back to the mark to release the arms; wait 5 to 10 seconds for them to open.

• Advance the inserter gently until the flange touches the cervix, so that the device reaches the fundus.

• Release the device by pulling the slider fully down, then withdraw the inserter.

• Cut the strings 2 to 3 cm from the cervix.

Smaller devices. The 19.5 mg and 13.5 mg devices use a single-handed inserter with a thinner tube; the principles are the same.

Completion. Remove the tenaculum, check for bleeding, remove the speculum, let the patient rest 15 to 30 minutes and check vital signs.

Postpartum placement. Use long forceps after vaginal delivery, or place the device at caesarean section, putting it at the fundus and leaving the strings toward the cervix.

At insertion.

• Pain or vasovagal reaction: pause, lay flat with legs raised, monitor.

• Difficult insertion: stop and reassess; never force.

• Suspected perforation: stop immediately, remove the device and instruments, rest, monitor vital signs and abdominal tenderness, start an intravenous line, give a prophylactic antibiotic, and refer urgently if there is severe pain, changing vital signs or peritoneal signs.

Delayed problems.

• Irregular bleeding or spotting in the first 3 to 6 months, followed by light periods or amenorrhoea: reassure; exclude pregnancy, infection and pathology if bleeding persists; ibuprofen 400 mg orally three times daily for 5 days.

• Expulsion: reinsert after excluding pregnancy.

• Pelvic infection in the first 20 days: treat and review.

• Functional ovarian cysts: usually asymptomatic and resolve in weeks.

• Pregnancy with the device in place: exclude ectopic pregnancy.

• Hormonal effects (acne, breast tenderness, headache): usually mild; reassure.

Instructions. Spotting and cramping are common for days to weeks. Bleeding is often irregular for 3 to 6 months. Return urgently for fever, chills, severe lower abdominal pain, pain during sex, unusual discharge, missed period, or if the strings cannot be felt or the device has come out.

Backup. None within 7 days of menses; otherwise 7 days.

Follow up. Review at 3 to 6 weeks to check the strings and bleeding. If the strings cannot be felt on bimanual examination, give backup contraception and arrange ultrasound.

Card. Give a card with device type and dose, date of insertion and the date for removal or replacement.

Special groups. For heavy menstrual bleeding the 52 mg device is first choice and reduces blood loss by about 70 to 90 percent. Breastfeeding patients may use the device from 4 weeks. Patients on tamoxifen or on oestrogen therapy gain endometrial protection with the 52 mg device.

Referral and escalation. Refer suspected perforation, device not found, failed insertion after one attempt, and persistent heavy bleeding or pain.