10 Important Considerations When Selecting an IUD for Younger Patients

Sexual health expert addresses common misconceptions among health professionals

This content has been independently produced by Australian Doctor Group at the request of and with funding from Bayer Australia. This article originally appeared in Australian Doctor Group on the 27th September 2021.


Being young and nulliparous is not a contraindication for using an IUD, according to a leading reproductive and sexual health expert.
Responding to a common misconception among health professionals that IUDs are not suitable for adolescents and young people, Dr Amy Moten, chair of the RACGP Specific Interests Group in Sexual Health Medicine, says “there is no lower age limit for use”.

She points out IUDs are widely recommended as first-line contraception by WHO, the UK Faculty of Sexual and Reproductive Health and the Family Planning Alliance of Australia but warns “there’s a persisting belief that IUDs are not suitable for young people who haven’t given birth or who aren’t sexually active”.

“That’s simply incorrect,” says Dr Moten, who consults from SHINE SA formerly Family Planning South Australia. “I think this is a myth that stems from the original IUDs introduced in the 70’s that were flawed devices inserted by untrained doctors.

“This sometimes resulted in painful insertions and high rates of pelvic inflammatory disease but all that’s changed now,” she says, explaining the newer devices have a “very low absolute risk of PID associated
with insertion”.

Dr Moten also addresses the myth that IUDs are technically more difficult to insert in adolescents and younger people compared to older, parous people.

“That is also not borne out by the evidence,” she says. “As GPs we should be actively encouraging our younger patients to use IUDs as they are one of the most reliable form of contraception available.”
Dr Moten says there are now four IUDs available in Australia including two levonorgestrel (LNG)-releasing intrauterine systems, the established Mirena device and the recently launched Kyleena

“Kyleena has the smallest T-frame of the four devices and has less LNG than Mirena. It is licensed for contraception only while Mirena is licensed for control of heavy menstrual bleeding, endometrial
protection in people using menopause hormone treatment, and contraception.

“The non-hormonal copper (Cu)-IUDs (commonly referred to as the copper T and the multiload) are licensed for contraception and emergency contraception and can be inserted up to five days after
unprotected sexual intercourse for emergency contraception. They are popular with people who prefer no hormones. In my clinic, around 2-4 out of 10 patients wanting an IUD are coming in for copper.”

Here, Dr Moten shares her experience in counselling young people about IUDs and provides tips for considerations for use:

When I talk about the option of an IUD I focus on the ‘set and forget’ benefit and tell patients they won’t have to think about contraception for five or possibly 10 years.

Even if you are not doing the insertion yourself, it’s useful to present the IUDs to scale in the initial consultation so the patient can make an informed decision. I use life-sized placebo models which can be supplied by pharma reps so the patient can see how small they are. I find this takes away a lot of the fear.

I avoid using terms like ‘pain’ and instead use words such as ‘discomfort’ or ‘cramping’ to help manage expectations. However, it’s important to point out that most patients tolerate insertion extremely well and this goes for nulliparous and parous people and all ages.

At the initial assessments I always advise patients to come in early, make sure they’ve had something to eat and drink so they are comfortable, and take ibuprofen 30-45 minutes beforehand. Normally, that’s all the pain relief they will need.

If a patient is very concerned about the insertion, you can reassure them that there is evidence of lower discomfort levels with Kyleena.

When explaining the differences between Mirena and Kyleena, I usually say Mirena is the most likely to lead to amenorrhea which is appealing for a lot of people while Kyleena should also result in reduced bleeding and a bit less discomfort with insertion. The Cu-IUD shouldn’t affect their regular bleeding pattern but might make periods slightly heavier.

In terms of efficacy all IUDs are around 99% effective. In comparison, the combined oral contraceptive pill is 93% effective in real life.

It’s a good idea to put the known risks associated with IUDs into perspective when counselling young patients. About 1 in 300 will get an infection up to three weeks after insertion and this can be easily treated with antibiotics. About 1 in 500 insertions results in a perforation but generally it’s quite easy to manage without any long-term complications.

Regardless of which IUD your patient opts for, if you are doing the insertion yourself, one of the best tips I can give is to have a chatty assistant in the room with you who can distract the patient. Local anaesthetic to the cervix in the form of a spray or cream reduces discomfort of placing the tenaculum. For trickier insertions sometimes I use penthrox or cervical blocks but mostly they are not required.

Current Australian recommendations state people under 30 have a chlamydia test before an insertion.

For more information refer to RANZCOG statement on intrauterine contraception.