Ask the client the questions below about known medical conditions. If she answers “no” to all of the questions, then she can have an IUD inserted if she wants. If she answers “yes” to a question, follow the instructions. In some cases she can still have an IUD inserted. These questions also apply to the levonorgestrel IUD.
1. Did you give birth more than 48 hours ago but less than 4 weeks ago?
No
Yes - delay inserting an IUD until 4 or more weeks afterchildbirth (see Soon after childbirth).
2. Do you have an infection following childbirth or abortion?
No
Yes - if she currently has infection of the reproductive organs during the first 6 weeks after childbirth (puerperal sepsis) or she just had an abortion-related infection in the uterus (septic abortion), do not insert the IUD. Treat or refer if she is not already receiving care. Help her choose another method or offer a backup method. Backup methods include abstinence, male and female condoms, spermicides, and withdrawal. Tell her that spermicides and withdrawal are the least effective contraceptive methods. If possible, give her condoms.
After treatment, re-evaluate for IUD use.
3. Do you have vaginal bleeding that is unusual for you?
No
Yes - if she has unexplained vaginal bleeding that suggests pregnancy or an underlying medical condition, use of an IUD could make diagnosis and monitoring of any treatment more difficult. Help her choose a method to use while being evaluated and treated (but not a hormonal IUD, progestin only injectables, or implants). After treatment, re-evaluate for IUD use.
4. Do you have any female conditions or problems (gynecologic or obstetric conditions or problems), such as genital cancer or pelvic tuberculosis? If so, what problems?
No
Yes - known current cervical, endometrial, or ovarian cancer; gestational trophoblast disease; pelvic tuberculosis: Do not insert an IUD. Treat or refer for care if she is not already receiving care. Help her choose another method. In case of pelvic tuberculosis, re-evaluate for IUD use after treatment.
5. Do you have AIDS?
No
Yes - do not insert an IUD if she has AIDS unless she is clinically well on antiretroviral therapy. If she is infected with HIV but does not have AIDS, she can use an IUD. If a woman who has an IUD in place develops AIDS, she can keep the IUD (see IUDs for Women With HIV, below).
6. Assess whether she is at very high individual risk for gonorrhea or chlamydia.
No
Yes - women who have a very high individual likelihood of exposure to gonorrhea or chlamydia should not have an IUD inserted (see Assessing Women for Risk of Sexually Transmitted Infections, below).
7. Assess whether the client might be pregnant.
No
Yes - ask the client the questions in the pregnancy checklist (see p. 372). If she answers “yes” to any question, she can have an IUD inserted (see also When to start).
For complete classifications, see Medical Eligibility Criteria for Contraceptive Use. Be sure to explain the health benefits and risks and the side effects of the method that the client will use. Also, point out any conditions that would make the method inadvisable, when relevant to the client.
Using Clinical Judgment in Special Cases
Usually, a woman with any of the conditions listed below should not have an IUD inserted. In special circumstances, however, when other, more appropriate methods are not available or acceptable to her, a qualified provider who can carefully assess a specific woman’s condition and situation may decide that she can use an IUD. The provider needs to consider the severity of her condition and, for most conditions, whether she will have access to follow-up.
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Between 48 hours and 4 weeks since giving birth
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Noncancerous (benign) gestational trophoblast disease
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Current ovarian cancer
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Is at very high individual risk for gonorrhea or chlamydia at the time of insertion
-
Has
AIDS and is not on
antiretroviral therapy and clinically well
Screening questions for pelvic examination before IUD insertion
When performing the pelvic examination, asking yourself the questions below helps you check for signs of conditions that would rule out IUD insertion. If the answer to all of the questions is “no,” then the client can have an IUD inserted. If the answer to any question is “yes,” do not insert an IUD.
For questions 1 through 5, if the answer is “yes,” refer for diagnosis and treatment as appropriate. Help her choose another method and counsel her about condom use if she faces any risk of sexually transmitted infections (STIs). Give her condoms, if possible. If STI or pelvic inflammatory disease (PID) is confirmed and she still wants an IUD, it may be inserted as soon as she finishes treatment, if she is not at risk for reinfection before insertion.
1. Is there any type of ulcer on the vulva, vagina, or cervix?
No
Yes - possible STI.
2. Does the client feel pain in her lower abdomen when you move the cervix?
No
Yes - possible PID.
3. Is there tenderness in the uterus, ovaries, or fallopian tubes (adnexal tenderness)?
No
Yes - possible STI or PID.
5. Does the cervix bleed easily when touched?
No
Yes - possible STI or cervical cancer.
6. Is there an anatomical abnormality of the uterine cavity that will prevent correct IUD insertion?
No
Yes - if an anatomical abnormality distorts the uterine cavity, proper IUD placement may not be possible. Help her choose another method.
7. Were you unable to determine the size and/or position of the uterus?
Determining the size and position of the uterus before IUD insertion is essential to ensure high placement of the IUD and to minimize risk of perforation. If size and position cannot be determined, do not insert an IUD. Help her choose another method.
Intrauterine Devices for Women With HIV
-
Women who are at risk of
HIV or are infected with
HIV can safely have the IUD inserted.
-
Women who have
AIDS, are on antiretroviral (ARV) therapy, and are clinically well can safely have the IUD inserted.
-
Women who have
AIDS but who are not on ARV therapy or who are not clinically well should
not have the IUD inserted.
-
If a woman develops
AIDS while she has an IUD in place, it does not need to be removed.
-
IUD users with
AIDS should be monitored for
pelvic inflammatory disease.
-
Urge women to use condoms along with the
IUD. Used consistently and correctly, condoms help prevent transmission of
HIV and other STIs.
Assessing Women for Risk of Sexually Transmitted Infections
A woman who has gonorrhea or chlamydia now should not have an IUD inserted. Having these sexually transmitted infections (STIs) at insertion may increase the risk of pelvic inflammatory disease.
These STIs may be difficult to diagnose clinically, however, and reliable laboratory tests are time-consuming, expensive, and often unavailable.
Without clinical signs or symptoms and without laboratory testing, the only indication that a woman might already have an STI is whether her behavior or her situation places her at very high individual risk of infection. If this risk for the individual client is very high, she generally should not have an IUD inserted. In contrast, if a current IUD user’s situation changes and she finds herself at very high individual risk for gonorrhea or chlamydia, she can keep using her IUD. (Local STI prevalence rates are not a basis for judging individual risk.)
There is no universal set of questions that will determine if a woman is at very high individual risk for gonorrhea and chlamydia. Instead of asking questions, providers can discuss with the client the personal behaviors and the situations in their community that are most likely to expose women to STIs.
Steps to take:
1. Tell the client that a woman who faces a very high individual risk of some STIs usually should not have an IUD inserted.
Ask the woman to consider her own risk and to think about whether she might have an STI. A woman is often the best judge of her own risk. Any woman who thinks she might have an STI should seek care immediately.
She does not have to tell the provider about her behavior or her partner’s behavior. Providers can explain possibly risky situations that may place a woman at very high individual risk.
The client can think about whether such situations occurred recently (in the past 3 months or so). If so, she may have an STI now and may want to choose a method other than the IUD.
Possibly risky situations include:
-
A sexual partner has
STI symptoms such as pus coming from his penis, pain or burning during urination, or an open sore in the genital area
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She or a sexual partner was diagnosed with an
STI recently
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She has had more than one sexual partner recently
-
She has a sexual partner who has had other partners recently
-
Also, a provider can mention other high-risk situations that exist locally.
All of these situations pose less risk if a woman or her partner uses condoms consistently and correctly.
Ask if she thinks she is a good candidate for an IUD or would like to consider other contraceptive methods. If, after considering her individual risk, she thinks she is a good candidate, and she is eligible, provide her with an IUD. If she wants to consider other methods or if you have strong reason to believe that the client is at very high individual risk of infection, help her choose another method.
Note: If she still wants the IUD while at very high individual risk of gonorrhea and chlamydia, and reliable testing is available, a woman who tests negative can have an IUD inserted. A woman who tests positive can have an IUD inserted as soon as she finishes treatment, if she is not at risk of reinfection by the time of insertion.
In special circumstances, if other, more appropriate methods are not available or not acceptable, a health care provider who can carefully assess a specific woman’s condition and situation may decide that a woman at very high individual risk can have the IUD inserted even if STI testing is not available. (Depending on the circumstances, the provider may consider presumptively treating her with a full curative dose of antibiotics effective against both gonorrhea and chlamydia and inserting the IUD after she finishes treatment.)
Whether or not she receives presumptive treatment, the provider should be sure that the client can return for the follow-up visit, will be carefully checked for infection, and will be treated immediately if needed. She should be asked to return at once if she develops a fever and either lower abdominal pain or abnormal vaginal discharge or both.
Any woman who thinks she might have an STI should seek care immediately.
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