Reproductive · Year 2 · from Reproductive
Case 1: IUD Placement and Counseling
Clinical Image
Source: Wikipedia - Intrauterine device - CC BY-SA 4.0
Case Presentation
A 22-year-old nulligravid woman presents for contraception counseling. She has been using combined oral contraceptives but reports frequently missing pills and had a pregnancy scare 3 months ago. She desires highly effective, long-acting contraception and does not plan to become pregnant for at least 5 years. She has no significant medical history. Her menstrual periods are regular but heavy, causing her to miss school or work monthly. Physical examination is unremarkable. She is counseled about long-acting reversible contraception (LARC) options. Given her heavy menstrual bleeding, she is particularly interested in the levonorgestrel IUD (Mirena), which may reduce menstrual blood loss. After counseling about the insertion procedure, potential side effects (irregular bleeding initially, possibility of expulsion), and the lack of STI protection, she opts for Mirena placement. A urine pregnancy test is negative. The IUD is inserted successfully with mild cramping. She is counseled that the IUD is effective immediately and provides contraception for up to 8 years, though heavy bleeding typically improves within 3-6 months. At her follow-up visit, the IUD strings are visualized. At 6 months, she reports minimal menstrual bleeding and is very satisfied.
Key Learning Points
- LARC methods (IUDs and implants) have the lowest failure rates (<1%) and are recommended as first-line contraception by ACOG, including for nulliparous women and adolescents
- The levonorgestrel IUD (Mirena) provides contraception for up to 8 years and has non-contraceptive benefits including reduced menstrual blood loss (20-50% of users become amenorrheic)
- Common myths should be dispelled: IUDs do not cause infertility, are safe in nulliparous women, and PID risk is limited to the first 20 days after insertion
- Effectiveness is not user-dependent, making LARC superior to methods like pills, patches, or rings that require consistent correct use