Appendix B: Classifications for Intrauterine Devices

At a glance

This page includes recommendations for health care providers for the use of intrauterine devices for persons who have certain characteristics or medical conditions. This information comes from the 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC).

Overview

Classifications for intrauterine devices (IUDs) are for the copper (380 mm2) and levonorgestrel (13.5 mg, 19.5 mg, or 52 mg) IUDs (Box B1) (Table B1). IUDs do not protect against sexually transmitted infections (STIs), including HIV infection, and patients using IUDs should be counseled that consistent and correct use of external (male) latex condoms reduces the risk for STIs, including HIV infection.[1] Use of internal (female) condoms can provide protection from transmission of STIs, although data are limited.[1] Patients also should be counseled that pre-exposure prophylaxis, when taken as prescribed, is highly effective for preventing HIV infection.[2]

Box B1. Categories for classifying intrauterine devices

U.S. MEC 1
A condition for which there is no restriction for the use of the contraceptive method
U.S. MEC 2
A condition for which the advantages of using the method generally outweigh the theoretical or proven risks
U.S. MEC 3
A condition for which the theoretical or proven risks usually outweigh the advantages of using the method
U.S. MEC 4
A condition that represents an unacceptable health risk if the contraceptive method is used

Abbreviation: U.S. MEC = U.S. Medical Eligibility Criteria for Contraceptive Use.

Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device

TABLE B1 CONDITIONS

Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
Personal Characteristics and Reproductive History
Pregnancy 4 4 Clarification: The IUD is not indicated during pregnancy and should not be used because of the risk for serious pelvic infection and septic spontaneous abortion.
Age
a. Menarche to <20 years 2 2 Comment: Concern exists both about the risk for expulsion from nulliparity and for STIs from sexual behavior in younger age groups (see U.S. SPR for recommendations on STI screening before IUD placement (https://www.cdc.gov/contraception/hcp/usspr).[3]
b. ≥20 years 1 1 —
Parity
a. Nulliparous 2 2 Evidence: Data conflict about whether IUD use is associated with infertility among nulliparous women, although well-conducted studies suggest no increased risk.[4–12]
b. Parous 1 1 —
Postpartum (including
cesarean delivery,
breastfeeding, or
nonbreastfeeding)
a. <10 minutes after delivery of the placenta 2 2 Clarification: Postpartum placement of IUDs is safe and does not appear to increase health risks associated with IUD use such as infection. Higher rates of expulsion during the postpartum period should be considered as they relate to effectiveness, along with patient access to interval placement (i.e., not related to pregnancy) when expulsion rates are lower.
Clarification (breastfeeding): Breastfeeding provides important health benefits for breastfeeding parent and infant. The U.S. Dietary Guidelines for Americans and American Academy of Pediatrics recommend that infants be exclusively breastfed for about the first 6 months with continued breastfeeding while introducing appropriate complementary foods for 1 year or longer[13] or up to age 2 years or longer.[14]
Evidence: Studies suggest that immediate postplacental (<10 minutes) and early postpartum (10 minutes up until 72 hours) placement of Cu-IUDs and LNG-IUDs is associated with increased risk for expulsion compared with interval placement (i.e., not related to pregnancy). A meta-analysis found an increased risk for expulsion with immediate postplacental placement (8.6%; range = 0%–31.9%) and early postpartum placement (25.1%; range = 3.5%–46.7%) compared with interval placement (1.6%; range = 0%–4.8%) (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). Although immediate postplacental placement at the time of cesarean delivery might have increased risk for expulsion compared with interval placement, risk appears lower than that for placement at the time of vaginal delivery. Evidence for infection, perforation, and removals for pain or bleeding are limited; however, these events are rare.[15–67]
Evidence (breastfeeding): Two RCTs found conflicting results on breastfeeding outcomes when LNG-IUDs were initiated immediately postpartum compared with 6–8 weeks postpartum. Initiation of LNG-IUDs immediately postpartum had no other harmful effect on infant health, growth, or development.[19],[68] Breastfeeding women using IUDs do not have an increased risk for certain IUD-related adverse events including expulsion, infection, pain, or bleeding compared with nonbreastfeeding women. The risk for perforation is increased independently among breastfeeding women and among women ≤36 weeks postpartum, compared with nonpostpartum women; however, the absolute risk for perforation remains low.[15–67],[69]
Comment: Risk factors for breastfeeding difficulties include previous breastfeeding difficulties, certain medical conditions, certain perinatal complications, and preterm birth. For all breastfeeding persons, with or without risk factors for breastfeeding difficulties, discussions about contraception should include information about risks, benefits, and alternatives.
b. 10 minutes after delivery of the placenta to <4 weeks 2 2 Clarification: Postpartum placement of IUDs is safe and does not appear to increase health risks associated with IUD use such as infection. Higher rates of expulsion during the postpartum period should be considered as they relate to effectiveness, along with patient access to interval placement (i.e., not related to pregnancy) when expulsion rates are lower.
Clarification (breastfeeding): Breastfeeding provides important health benefits for breastfeeding parent and infant. The U.S. Dietary Guidelines for Americans and American Academy of Pediatrics recommend that infants be exclusively breastfed for about the first 6 months with continued breastfeeding while introducing appropriate complementary foods for 1 year or longer[13] or up to age 2 years or longer.[14]
Evidence: Studies suggest that immediate postplacental (<10 minutes) and early postpartum (10 minutes up until 72 hours) placement of Cu-IUDs and LNG-IUDs is associated with increased risk for expulsion compared with interval placement (i.e., not related to pregnancy). A meta-analysis found an increased risk for expulsion with immediate postplacental placement (8.6%; range = 0%–31.9%) and early postpartum placement (25.1%; range = 3.5%–46.7%) compared with interval placement (1.6%; range = 0%–4.8%) (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). Although immediate postplacental placement at the time of cesarean delivery might have increased risk for expulsion compared with interval placement, risk appears lower than that for placement at the time of vaginal delivery. Evidence for infection, perforation, and removals for pain or bleeding are limited; however, these events are rare.[15–67]
Evidence (breastfeeding): Two RCTs found conflicting results on breastfeeding outcomes when LNG-IUDs were initiated immediately postpartum compared with 6–8 weeks postpartum. Initiation of LNG-IUDs immediately postpartum had no other harmful effect on infant health, growth, or development. [19],[68] Breastfeeding women using IUDs do not have an increased risk for certain IUD-related adverse events including expulsion, infection, pain, or bleeding compared with nonbreastfeeding women. The risk for perforation is increased independently among breastfeeding women and among women ≤36 weeks postpartum, compared with nonpostpartum women; however, the absolute risk for perforation remains low.[15–67],[69]
Comment: Risk factors for breastfeeding difficulties include previous breastfeeding difficulties, certain medical conditions, certain perinatal complications, and preterm birth. For all breastfeeding persons, with or without risk factors for breastfeeding difficulties, discussions about contraception should include information about risks, benefits, and alternatives.
c. ≥4 weeks 1 1 Clarification: Postpartum placement of IUDs is safe and does not appear to increase health risks associated with IUD use such as infection. Higher rates of expulsion during the postpartum period should be considered as they relate to effectiveness, along with patient access to interval placement (i.e., not related to pregnancy) when expulsion rates are lower.
Clarification (breastfeeding): Breastfeeding provides important health benefits for breastfeeding parent and infant. The U.S. Dietary Guidelines for Americans and American Academy of Pediatrics recommend that infants be exclusively breastfed for about the first 6 months with continued breastfeeding while introducing appropriate complementary foods for 1 year or longer[13] or up to age 2 years or longer.[14]
Evidence (breastfeeding): Initiation of LNG-IUDs at 4 weeks postpartum or later demonstrated no detrimental effect on breastfeeding outcomes and no harmful effect on infant health, growth, or development.[19],[68] Breastfeeding women using IUDs do not have an increased risk for certain IUD-related adverse events including expulsion, infection, pain, or bleeding compared with nonbreastfeeding women. The risk for perforation is increased independently among breastfeeding women and among women ≤36 weeks postpartum, compared with nonpostpartum women; however, the absolute risk for perforation remains low.[15–67],[69]
Comment: Risk factors for breastfeeding difficulties include previous breastfeeding difficulties, certain medical conditions, certain perinatal complications, and preterm birth. For all breastfeeding persons, with or without risk factors for breastfeeding difficulties, discussions about contraception should include information about risks, benefits, and alternatives.
d. Postpartum sepsis 4 4 Comment: Theoretical concern exists that postpartum placement of an IUD in a person with recent chorioamnionitis or current endometritis might be associated with increased complications.
Postabortion
(spontaneous or induced)
a. First trimester abortion Clarification: IUDs may be placed immediately after abortion completion.
Evidence: Risk for complications from immediate versus delayed placement of an IUD after abortion did not differ. Expulsion was greater when an IUD was placed after a second trimester procedural abortion than when placed after a first trimester procedural abortion. Safety or expulsion for postabortion placement of an LNG-IUD did not differ from that of a Cu-IUD.[70]
  i. Procedural (surgical) 1 1
  ii. Medication 1 1
  iii. Spontaneous abortion with no intervention 1 1
b. Second trimester abortion
  i. Procedural (surgical) 2 2
  ii. Medication 2 2
  iii. Spontaneous abortion with no intervention 2 2
c. Immediate postseptic abortion 4 4 Comment: Placement of an IUD might substantially worsen the condition.
Past ectopic pregnancy 1 1 Comment: The absolute risk for ectopic pregnancy is extremely low because of the high effectiveness of IUDs. However, when a person becomes pregnant during IUD use, the relative likelihood of ectopic pregnancy increases substantially.
History of pelvic surgery
(see recommendations for Postpartum [including cesarean delivery])		 1 1 —
Smoking
a. Age <35 years 1 1 —
b. Age ≥35 years
  i. <15 cigarettes per day 1 1 —
  ii. ≥15 cigarettes per day 1 1 —
Obesity
a. BMI ≥30 kg/m2 1 1 —
b. Menarche to <18 years and BMI ≥30 kg/m2 1 1 —
History of bariatric surgery
This condition is associated with
increased risk for adverse health
events as a result
of pregnancy (Box 3).
a. Restrictive procedures: decrease storage capacity of the stomach (vertical banded gastroplasty, laparoscopic adjustable gastric band, or laparoscopic sleeve gastrectomy) 1 1 —
b. Malabsorptive procedures: decrease absorption of nutrients and calories by shortening the functional length of the small intestine (Roux-en-Y gastric bypass or biliopancreatic diversion) 1 1 —
Surgery
a. Minor surgery without immobilization 1 1 —
b. Major surgery
  i. Without prolonged immobilization 1 1 —
  ii. With prolonged immobilization 1 1 Evidence: No direct evidence was identified on risk for thrombosis with POC use among those undergoing major surgery (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).

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Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
Cardiovascular Disease
Multiple risk factors for atherosclerotic cardiovascular disease (e.g., older age, smoking, diabetes, hypertension, low HDL, high LDL, or high triglyceride levels) 1 2 —
Hypertension
Systolic blood pressure
≥160 mm Hg or diastolic blood
pressure ≥100 mm Hg are
associated with increased risk
for adverse health events as a
result of pregnancy (Box 3).
a. Adequately controlled hypertension 1 1 Clarification: For all categories of hypertension, classifications are based on the assumption that no other risk factors for cardiovascular disease exist. When multiple risk factors do exist, risk for cardiovascular disease might increase substantially. A single reading of blood pressure level is not sufficient to classify a person as hypertensive.
b. Elevated blood pressure levels
(properly taken measurements)		 Clarification: For all categories of hypertension, classifications are based on the assumption that no other risk factors for cardiovascular disease exist. When multiple risk factors do exist, risk for cardiovascular disease might increase substantially. A single reading of blood pressure level is not sufficient to classify a person as hypertensive.
Comment: Theoretical concern exists about the effect of LNG on lipids. Use of Cu-IUDs has no restrictions.
  i. Systolic 140–159 mm Hg or diastolic 90–99 mm Hg 1 1
  ii. Systolic ≥160 mm Hg or diastolic ≥100 mm Hg 1 2
c. Vascular disease 1 2 Clarification: For all categories of hypertension, classifications are based on the assumption that no other risk factors for cardiovascular disease exist. When multiple risk factors do exist, risk for cardiovascular disease might increase substantially. A single reading of blood pressure level is not sufficient to classify a person as hypertensive.
Comment: Theoretical concern exists about the effect of LNG on lipids. Use of Cu-IUDs has no restrictions.
History of high blood pressure during pregnancy (when current blood pressure is measurable and normal) 1 1 —
Deep venous thrombosis/
Pulmonary embolism
This condition is associated with
increased risk for adverse health
events as a result
of pregnancy (Box 3).
a. Current or history of DVT/PE, receiving anticoagulant therapy (therapeutic dose) (e.g., acute DVT/PE or long-term therapeutic dose) 2 2 Clarification (Cu-IUD): Persons using anticoagulant therapy are at risk for gynecologic complications of therapy, such as heavy or prolonged bleeding. Cu-IUDs might worsen bleeding.
Clarification (LNG-IUD): Persons using anticoagulant therapy are at risk for gynecologic complications of therapy, such as heavy or prolonged bleeding. LNG-IUDs can be of benefit in preventing or treating this complication. When a contraceptive method is used as a therapy, rather than solely to prevent pregnancy, the risk/benefit ratio might differ and should be considered on a case-by-case basis.
Evidence: Limited evidence was identified on use of POCs or Cu-IUDs among women with acute DVT/PE receiving anticoagulant therapy (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). In one study among women with a history of acute VTE currently receiving therapeutic anticoagulant therapy (i.e., rivaroxaban or enoxaparin/vitamin K antagonist [warfarin or acenocoumarol]), the incidence of recurrent VTE was similar among estrogen users (CHC or estrogen-only pills), POC users, and women not on hormonal therapy.[71] Limited evidence suggests that placement of a Cu-IUD or LNG-IUD does not increase risk for bleeding complications in women receiving anticoagulant therapy (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
b. History of DVT/PE, receiving
anticoagulant therapy
(prophylactic dose)		 Clarification (Cu-IUD): Persons using anticoagulant therapy are at risk for gynecologic complications of therapy, such as heavy or prolonged bleeding. Cu-IUDs might worsen bleeding.
Clarification (LNG-IUD): Persons using anticoagulant therapy are at risk for gynecologic complications of therapy, such as heavy or prolonged bleeding. LNG-IUDs can be of benefit in preventing or treating this complication. When a contraceptive method is used as a therapy, rather than solely to prevent pregnancy, the risk/benefit ratio might differ and should be considered on a case-by-case basis.
Evidence: Limited evidence suggests that placement of the LNG-IUD does not increase risk for bleeding complications in women receiving anticoagulant therapy (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
  i. Higher risk for recurrent DVT/PE (one or more risk factors) 2 2
• Thrombophilia (e.g., factor V Leiden mutation; prothrombin gene mutation; protein S, protein C, and antithrombin deficiencies; or antiphospholipid syndrome)
• Active cancer (metastatic, receiving therapy, or within 6 months after clinical remission), excluding nonmelanoma skin cancer
• History of recurrent DVT/PE
  ii. Lower risk for recurrent DVT/PE (no risk factors) 2 2
c. History of DVT/PE, not
receiving anticoagulant therapy
  i. Higher risk for recurrent DVT/PE (one or more risk factors) 1 2 —
• History of estrogen-associated DVT/PE
• Pregnancy-associated DVT/PE
• Idiopathic DVT/PE
• Thrombophilia (e.g., factor V Leiden mutation; prothrombin gene mutation; protein S, protein C, and antithrombin deficiencies; or antiphospholipid syndrome)
• Active cancer (metastatic, receiving therapy, or within 6 months after clinical remission), excluding nonmelanoma skin cancer
• History of recurrent DVT/PE
  ii. Lower risk for recurrent DVT/PE (no risk factors) 1 2 —
d. Family history (first-degree relatives) 1 1 —
Thrombophilia (e.g., factor V Leiden mutation; prothrombin gene mutation; protein S, protein C, and antithrombin deficiencies; or antiphospholipid syndrome)
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).		 1 2 Clarification: Routine screening in the general population before contraceptive initiation is not recommended.
Clarification: If a person has current or history of DVT/PE, see recommendations for DVT/PE.
Clarification: Classification of antiphospholipid syndrome includes presence of a clinical feature (e.g., thrombosis or obstetric morbidity) and persistently abnormal antiphospholipid antibody test on two or more occasions at least 12 weeks apart.[72]
Evidence: Limited evidence was identified on LNG-IUD use among persons with thrombophilia. Among women with factor V Leiden mutation, one study found that women using LNG-IUD had similar risk for venous thrombosis as those not using hormonal contraception.[73] No evidence was identified on POC use among persons with prothrombin gene mutation, protein S deficiency, protein C deficiency, antithrombin deficiency, or antiphospholipid syndrome (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
Superficial venous disorders
a. Varicose veins 1 1 —
b. Superficial venous thrombosis (acute or history) 1 1 —
Current and history of ischemic heart disease
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).		 1 Initiation Continuation Comment: Theoretical concern exists about the effect of LNG on lipids. Use of Cu-IUDs has no restrictions.
2 3
Stroke (history of cerebrovascular accident)
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).		 1 2 Comment: Theoretical concern exists about the effect of LNG on lipids. Use of Cu-IUDs has no restrictions.
Valvular heart disease
Complicated valvular heart disease
is associated with increased risk for
adverse health events as a result of
pregnancy (Box 3).		 Comment: According to the American Heart Association, administration of prophylactic antibiotics solely to prevent endocarditis is not recommended for patients who undergo genitourinary tract procedures, including placement or removal of IUDs.[74]
a. Uncomplicated 1 1
b. Complicated (pulmonary hypertension, risk for atrial fibrillation, or history of subacute bacterial endocarditis) 1 1
Peripartum cardiomyopathy
This condition is associated with
increased risk for adverse health
events as a result of
pregnancy (Box 3).		 Evidence: No direct evidence exists on the safety of IUDs among women with peripartum cardiomyopathy. Limited indirect evidence from noncomparative studies did not demonstrate any cases of arrhythmia or infective endocarditis in women with cardiac disease who used IUDs.[75]
Comment: IUD placement might induce cardiac arrhythmias in healthy persons; persons with peripartum cardiomyopathy have a high incidence of cardiac arrhythmias.
a. Normal or mildly impaired
cardiac function (New York Heart
Association Functional Class I or II:
no limitation of activities or slight,
mild limitation of activity).[76]
  i. <6 months 2 2
  ii. ≥6 months 2 2
b. Moderately or severely impaired cardiac function (New York Heart Association Functional Class III or IV: marked limitation of activity or should be at complete rest).[76] 2 2

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Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
Renal Disease
Chronic kidney disease
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).		 Initiation Continuation Initiation Continuation
a. Current nephrotic syndrome 1 1 2 2 Comment: A person might have CKD without current nephrotic syndrome, but might have other conditions often associated with CKD (e.g., diabetes, hypertension, SLE). See recommendations for other conditions if they apply.
b. Hemodialysis 1 1 2 2 Evidence: No comparative studies were identified on the safety of IUD use among persons with CKD on hemodialysis (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). One case report of LNG-IUD use in a person with CKD on hemodialysis reported improved abnormal uterine bleeding and anemia.[77]
Comment: A person might have CKD without hemodialysis, but might have other conditions often associated with CKD (e.g., diabetes, hypertension, and SLE). See recommendations for other conditions if they apply.
c. Peritoneal dialysis 2 1 2 2 Evidence: No comparative studies were identified on IUD use among persons with CKD on peritoneal dialysis (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516). Four case reports of IUD use among women with CKD on peritoneal dialysis identified one case of peritoneal allergic reaction,[78] three cases of peritonitis[78-80] and one case of TOA.[78]
Comment: A person might have CKD without peritoneal dialysis, but might have other conditions often associated with CKD (e.g., diabetes, hypertension, and SLE). See recommendations for other conditions if they apply.

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Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
Rheumatic Diseases
Systemic lupus erythematosus
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).		 Initiation Continuation —
a. Positive (or unknown) antiphospholipid antibodies 1 1 2 Clarification: Persons with SLE are at increased risk for ischemic heart disease, stroke, and VTE. Categories assigned to such conditions in U.S. MEC should be the same for persons with SLE who have these conditions. For all subconditions of SLE, classifications are based on the assumption that no other risk factors for cardiovascular disease are present; these classifications must be modified in the presence of such risk factors.[81–99]
Evidence: No direct evidence was identified on POC use among persons with SLE with antiphospholipid antibodies[100] (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
b. Severe thrombocytopenia 3 2 2 Clarification: Persons with SLE are at increased risk for ischemic heart disease, stroke, and VTE. Categories assigned to such conditions in U.S. MEC should be the same for persons with SLE who have these conditions. For all subconditions of SLE, classifications are based on the assumption that no other risk factors for cardiovascular disease are present; these classifications must be modified in the presence of such risk factors.[81-99]
Clarification: Severe thrombocytopenia increases the risk for bleeding. The category should be assessed according to the severity of thrombocytopenia and its clinical manifestations. In persons with very severe thrombocytopenia who are at risk for spontaneous bleeding, consultation with a specialist and certain pretreatments might be warranted.
Evidence: The LNG-IUD might be a useful treatment for menorrhagia in women with severe thrombocytopenia.[94]
c. Immunosuppressive therapy 2 1 2 Clarification: Persons with SLE are at increased risk for ischemic heart disease, stroke, and VTE. Categories assigned to such conditions in U.S. MEC should be the same for persons with SLE who have these conditions. For all subconditions of SLE, classifications are based on the assumption that no other risk factors for cardiovascular disease are present; these classifications must be modified in the presence of such risk factors.[81-99]
d. None of the above 1 1 2 Clarification: Persons with SLE are at increased risk for ischemic heart disease, stroke, and VTE. Categories assigned to such conditions in U.S. MEC should be the same for persons with SLE who have these conditions. For all subconditions of SLE, classifications are based on the assumption that no other risk factors for cardiovascular disease are present; these classifications must be modified in the presence of such risk factors.[81-99]
Rheumatoid arthritis Initiation Continuation Initiation Continuation —
a. Not receiving immunosuppressive therapy 1 1 1 1 —
b. Receiving immunosuppressive therapy 2 1 2 1 —

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Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
Neurologic Conditions
Headaches
a. Nonmigraine (mild or severe) 1 1 —
b. Migraine
  i. Without aura (includes menstrual migraine) 1 1 Evidence: No studies directly examined the risk for stroke among women with migraine using LNG-IUDs.[101] Limited evidence demonstrated that women using LNG-IUDs do not have an increased risk for ischemic stroke compared with women not using hormonal contraceptives.[102]
Comment: Menstrual migraine is a subtype of migraine without aura. For more information see the International Headache Society’s International Classification of Headache Disorders, 3rd ed. (https://ichd-3.org)[103]
  ii. With aura 1 1
Epilepsy
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).		 1 1 —
Multiple sclerosis
a. Without prolonged immobility 1 1 —
b. With prolonged immobility 1 1 —

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Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
Depressive Disorders
Depressive disorders 1 1 Clarification: If a person is receiving psychotropic medications or St. John’s wort, see recommendations for Drug Interactions.
Evidence: The frequency of psychiatric hospitalizations for women with bipolar disorder or depression did not significantly differ among women using DMPA, LNG-IUD, Cu-IUD, or sterilization.[104]

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Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
Reproductive Tract Infections and Disorders
Vaginal bleeding patterns Initiation Continuation —
a. Irregular pattern without heavy bleeding 1 1 1
b. Heavy or prolonged bleeding (includes regular and irregular patterns) 2 1 2 Clarification: Unusually heavy bleeding should raise suspicion of a serious underlying condition.
Evidence: Evidence from studies examining the treatment effects of the LNG-IUD among women with heavy or prolonged bleeding reported no increase in adverse effects and found the LNG-IUD to be beneficial in treating menorrhagia.[105-112]
Unexplained vaginal bleeding (suspicious for serious condition) before evaluation Initiation Continuation Initiation Continuation Clarification: If pregnancy or an underlying pathological condition (e.g., pelvic malignancy) is suspected, it must be evaluated and the category adjusted after evaluation. The IUD does not need to be removed before evaluation.
4 2 4 2
Endometriosis 2 1 Evidence: LNG-IUD use among women with endometriosis decreased dysmenorrhea, pelvic pain, and dyspareunia.[113-117]
Benign ovarian tumors (including cysts) 1 1 —
Severe dysmenorrhea 2 1 Comment: Dysmenorrhea might intensify with Cu-IUD use. LNG-IUD use has been associated with reduction of dysmenorrhea.
Gestational trophoblastic disease
This condition is associated with
increased risk for adverse health
events as a result
of pregnancy (Box 3).
a. Suspected gestational trophoblastic
disease (immediate postevacuation)		 Clarification: For all subconditions of gestational trophoblastic disease, classifications are based on the assumption that persons are under close medical supervision because of the need for monitoring of β-hCG levels for appropriate disease surveillance.
Evidence: Limited evidence suggests that women using an IUD after uterine evacuation for a molar pregnancy are not at greater risk for postmolar trophoblastic disease than are women using other methods of contraception.[118]
Comment: The risk for expulsion immediately postevacuation for gestational trophoblastic disease is unknown. Expulsion is greater after IUD placement immediately postevacuation for a spontaneous or induced abortion in the second trimester compared with IUD placement after a first trimester abortion.
  i. Uterine size first trimester 1 1
  ii. Uterine size second trimester 2 2
b. Confirmed gestational trophoblastic disease (after initial evacuation and during monitoring) Initiation Continuation Initiation Continuation —
  i. Undetectable or nonpregnant β-hCG levels 1 1 1 1 Clarification: For all subconditions of gestational trophoblastic disease, classifications are based on the assumption that persons are under close medical supervision because of the need for monitoring of β-hCG levels for appropriate disease surveillance.
Evidence: Limited evidence suggests that women using an IUD after uterine evacuation for a molar pregnancy are not at greater risk for postmolar trophoblastic disease than are women using other methods of contraception.[118]
Comment: Once β-hCG levels have decreased to nonpregnant levels, the risk for disease progression is likely to be very low.
  ii. Decreasing β-hCG levels 2 1 2 1 Clarification: For all subconditions of gestational trophoblastic disease, classifications are based on the assumption that persons are under close medical supervision because of the need for monitoring of β-hCG levels for appropriate disease surveillance.
Clarification: For persons at higher risk for disease progression, the benefits of effective contraception must be weighed against the potential need for early IUD removal.
Evidence: Limited evidence suggests that women using an IUD after uterine evacuation for a molar pregnancy are not at greater risk for postmolar trophoblastic disease than are women using other methods of contraception.[118]
  iii. Persistently elevated β-hCG levels or malignant disease, with no evidence or suspicion of intrauterine disease 2 1 2 1 Clarification: For all subconditions of gestational trophoblastic disease, classifications are based on the assumption that persons are under close medical supervision because of the need for monitoring of β-hCG levels for appropriate disease surveillance.
Evidence: Limited evidence suggests that women using an IUD after uterine evacuation for a molar pregnancy are not at greater risk for postmolar trophoblastic disease than are women using other methods of contraception.[118]
  iv. Persistently elevated β-hCG levels or malignant disease, with evidence or suspicion of intrauterine disease 4 2 4 2 Clarification: For all subconditions of gestational trophoblastic disease, classifications are based on the assumption that persons are under close medical supervision because of the need for monitoring of β-hCG levels for appropriate disease surveillance.
Evidence: Limited evidence suggests that women using an IUD after uterine evacuation for a molar pregnancy are not at greater risk for postmolar trophoblastic disease than are women using other methods of contraception.[118]
Comment: For persons with suspected or confirmed intrauterine disease, an IUD should not be placed because of theoretical risk for perforation, infection, and hemorrhage. For persons who already have an IUD in place, individual circumstance along with the benefits of effective contraception must be weighed against theoretical risks of either removal or continuation of the IUD.
Cervical ectropion 1 1 —
Cervical intraepithelial neoplasia 1 2 Comment: Theoretical concern exists that LNG-IUDs might enhance progression of cervical intraepithelial neoplasia.
Cervical cancer (awaiting treatment) Initiation Continuation Initiation Continuation Comment: Concern exists about the increased risk for infection and bleeding at placement. The IUD most likely will need to be removed at the time of treatment but until then, the person is at risk for pregnancy.
4 2 4 2
Breast disease
Breast cancer is associated with
increased risk for adverse health
events as a result
of pregnancy (Box 3).
a. Undiagnosed mass 1 2 Clarification (LNG-IUD): Evaluation of mass should be pursued as early as possible.
b. Benign breast disease 1 1 —
c. Family history of cancer 1 1 —
d. Breast cancer Comment: Breast cancer is a hormonally sensitive tumor. Concerns about progression of the disease might be less with LNG-IUDs than with COCs or higher-dose POCs.
  i. Current 1 4
  ii. Past and no evidence of current disease for 5 years 1 3
Endometrial hyperplasia 1 1 Evidence: Among women with endometrial hyperplasia, no adverse health events occurred with LNG-IUD use; most women experienced disease regression.[119]
Endometrial cancer
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).		 Initiation Continuation Initiation Continuation Comment: Concern exists about the increased risk for infection, perforation, and bleeding at placement. The IUD most likely will need to be removed at the time of treatment, but until then, the person is at risk for pregnancy.
4 2 4 2
Ovarian cancer
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).		 1 1 Comment: Persons with ovarian cancer who undergo fertility-sparing treatment and need contraception can use an IUD.
Uterine fibroids 2 2 Evidence: Among women with uterine fibroids using an LNG-IUD, most experienced improvements in serum levels of hemoglobin, hematocrit, and ferritin and in menstrual blood loss.[120] Rates of LNG-IUD expulsion were higher in women with uterine fibroids (11%) than in women without fibroids (0%–3%); these findings were either not statistically significant or significance testing was not conducted.120 Rates of expulsion found in noncomparative studies ranged from 0%–20%.[120]
Comment: Persons with heavy or prolonged bleeding should be assigned the category for that condition.
Anatomical abnormalities
a. Distorted uterine cavity (any congenital or acquired uterine abnormality distorting the uterine cavity in a manner that is incompatible with IUD placement) 4 4 Comment: An anatomical abnormality that distorts the uterine cavity might preclude proper IUD placement.
b. Other abnormalities (including cervical stenosis or cervical lacerations) not distorting the uterine cavity or interfering with IUD placement 2 2 —
Pelvic inflammatory disease Initiation Continuation Initiation Continuation Clarification (continuation): Treat the PID using appropriate antibiotics. The IUD usually does not need to be removed if the person wants to continue using it. Continued use of an IUD depends on the person’s informed choice and current risk factors for STIs and PID.
Evidence: Among IUD users treated for PID, clinical course did not differ regardless of whether the IUD was removed or left in place.[121]
a. Current PID 4 2 4 2
b. Past PID Comment: IUDs do not protect against STIs, including HIV infection, or PID. In persons at low risk for STIs, IUD placement poses little risk for PID.
  i. With subsequent pregnancy 1 1 1 1
  ii. Without subsequent pregnancy 2 2 2 2
Sexually transmitted infections Initiation Continuation Initiation Continuation
a. Current purulent cervicitis or chlamydial infection or gonococcal infection 4 2 4 2 Clarification (continuation): Treat the STI using appropriate antibiotics. The IUD usually does not need to be removed if the person wants to continue using it. Continued use of an IUD depends on the person’s informed choice and current risk factors for STIs and PID.
Evidence: Among women who had an IUD placed, the absolute risk for subsequent PID was low among women with STI at the time of placement but greater than among women with no STI at the time of IUD placement.[122-128]
b. Vaginitis (including Trichomonas vaginalis and bacterial vaginosis) 2 2 2 2 —
c. Other factors related to STIs 2 2 2 2 Clarification (initiation): Most persons do not require additional STI screening at the time of IUD placement. If a person with risk factors for STIs has not been screened for gonorrhea and chlamydia according to CDC STI treatment guidelines,[1] screening may be performed at the time of IUD placement and placement should not be delayed.
Evidence: Women who undergo same-day STI screening and IUD placement have low incidence rates of PID. Algorithms for predicting PID among women with risk factors for STIs have poor predictive value. Risk for PID among women with risk factors for STIs is low.[129]

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Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
HIV
High risk for HIV infection Initiation Continuation Initiation Continuation Clarification: Many persons at high risk for HIV infection are also at risk for other STIs (see recommendations for Sexually transmitted infections in U.S. MEC and recommendations on STI screening before IUD placement in U.S. SPR (https://www.cdc.gov/contraception/hcp/usspr).[3]
Evidence: High-quality evidence from one RCT, along with low-quality evidence from two observational studies, suggested no increased risk for HIV acquisition with Cu-IUD use. No studies were identified for LNG-IUDs.[130-132]
1 1 1 1
HIV infection
For persons with HIV infection
who are not clinically well or not
receiving ARV therapy, this
condition is associated with
increased risk for adverse health
events as a result of
pregnancy (Box 3).		 Evidence: Among IUD users, limited evidence demonstrates a low risk for PID among HIV-infected women using IUDs and no higher risk for pelvic infectious complications in HIV-infected than in HIV-noninfected women or among women with varying degrees of HIV severity. IUD use did not adversely affect progression of HIV infection during 6–45 months of follow-up or when compared with hormonal contraceptive use among HIV-infected women. Furthermore, IUD use among HIV-infected women was not associated with increased risk for transmission to sex partners or with increased genital viral shedding.[133]
a. Clinically well receiving ARV therapy 1 1 1 1
b. Not clinically well or not receiving ARV therapy 2 1 2 1

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Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
Other Infections
Schistosomiasis
Schistosomiasis with fibrosis of
the liver is associated with
increased risk for adverse health
events as a result of
pregnancy (Box 3).
a. Uncomplicated 1 1 —
b. Fibrosis of the liver (if severe, see recommendations for Cirrhosis) 1 1 —
Tuberculosis
This condition is associated with
increased risk for adverse health
events as a result of pregnancy
(Box 3).		 Initiation Continuation Initiation Continuation
a. Nonpelvic 1 1 1 1 —
b. Pelvic 4 3 4 3 Comment: Placement of an IUD might substantially worsen the condition.
Malaria 1 1 —

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Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
Endocrine Conditions
Diabetes
Insulin-dependent diabetes
diabetes with nephropathy,
retinopathy, or neuropathy;
diabetes with other vascular
disease; or diabetes of >20 years’
duration are associated with
increased risk for adverse health
events as a result of pregnancy
(Box 3).
a. History of gestational disease 1 1 —
b. Nonvascular disease Evidence: Limited evidence on the use of the LNG-IUD among women with insulin-dependent or non–insulin-dependent diabetes suggests that these methods have little effect on short-term or long-term diabetes control (e.g., glycosylated hemoglobin levels), hemostatic markers, or lipid profile.[134],[135]
  i. Non-insulin dependent 1 2
  ii. Insulin dependent 1 2
c. Nephropathy, retinopathy, or neuropathy 1 2 —
d. Other vascular disease or diabetes of >20 years’ duration 1 2 —
Thyroid disorders
a. Simple goiter 1 1 —
b. Hyperthyroid 1 1 —
c. Hypothyroid 1 1 —

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Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
Gastrointestinal Conditions
Inflammatory bowel disease (ulcerative colitis or Crohn’s disease) 1 1 Evidence: Although two case reports described three women with IBD who experienced exacerbation of disease 5 days–25 months after LNG-IUD placement,[136] no comparative studies have examined the safety of IUD use among women with IBD.[136]
Gallbladder disease
a. Asymptomatic 1 2 —
b. Symptomatic
  i. Current 1 2 —
  ii. Treated by cholecystectomy 1 2 —
  iii. Medically treated 1 2 —
History of cholestasis
a. Pregnancy related 1 1 —
b. Past COC related 1 2 Comment: Concern exists that history of COC related cholestasis might predict subsequent cholestasis with LNG use. Whether risk exists with use of LNG-IUD is unclear.
Viral hepatitis
a. Acute or flare 1 1 Evidence: No direct evidence was identified on IUD use among persons with viral hepatitis (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
b. Chronic 1 1 Evidence: No direct evidence was identified on IUD use among persons with viral hepatitis (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
Cirrhosis
Decompensated cirrhosis is
associated with increased risk for
adverse health events as a result of
pregnancy (Box 3).
a. Compensated (normal liver function) 1 1 Evidence: No direct evidence was identified on IUD use among persons with cirrhosis (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
b. Decompensated (impaired liver function) 1 2 Evidence: No direct evidence was identified on IUD use among persons with cirrhosis (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
Comment: Hepatic metabolism of exogenous hormones might be impaired in persons with liver dysfunction, which could lead to increased progestin levels in circulation and progestin-related side effects and adverse events, which might vary by dose and formulation. Any progestin-related hepatotoxicity might be less tolerated in persons with existing liver dysfunction.
Liver tumors
Hepatocellular adenoma and
malignant liver tumors are
associated with increased risk for
adverse health events as a result
of pregnancy (Box 3).
a. Benign
  i. Focal nodular hyperplasia 1 2 Evidence: Limited evidence suggests that progestin use does not influence either progression or regression of focal nodular hyperplasia (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
  ii. Hepatocellular adenoma 1 2 Evidence: Limited evidence suggests that hepatocellular adenomas generally regress or remain stable during progestin use (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
b. Malignant (hepatocellular carcinoma) 1 3 Evidence: No direct evidence was identified on IUD use among persons with hepatocellular carcinoma (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).

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Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
Respiratory Conditions
Cystic fibrosis
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3).		 1 1 Clarification: Persons with cystic fibrosis are at increased risk for diabetes, liver disease, gallbladder disease, and VTE (particularly related to use of central venous catheters) and are frequently prescribed antibiotics. Categories assigned to such conditions in U.S. MEC should be the same for persons with cystic fibrosis who have these conditions. For cystic fibrosis, classifications are based on the assumption that no other conditions are present; these classifications must be modified in the presence of such conditions.

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Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
Hematologic Conditions
Thalassemia 2 1 Comment: Concern exists about an increased risk for blood loss with Cu-IUDs.
Sickle cell disease
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3) .		 2 1 Comment: Concern exists about an increased risk for blood loss with Cu-IUDs.
Iron deficiency anemia 2 1 Comment: Concern exists about an increased risk for blood loss with Cu-IUDs.

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Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
Solid Organ Transplantation
Solid organ transplantation
This condition is associated with increased risk for adverse health events as a result of pregnancy (Box 3) .		 Initiation Continuation Initiation Continuation Evidence: Limited evidence suggests that LNG-IUD use among solid organ transplantation recipients does not increase risk for pelvic infections or decrease contraceptive effectiveness over time or compared with persons without solid organ transplantation No evidence was identified for Cu-IUD (Supplementary Appendix, https://stacks.cdc.gov/view/cdc/156516).
a. No graft failure 1 1 1 1
b. Graft failure 2 1 2 1

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Table B1. Classifications for intrauterine devices, including the copper intrauterine device and levonorgestrel intrauterine device
Condition Category Clarification/Evidence/Comment
Cu-IUD LNG-IUD
Drug Interactions
Antiretrovirals used for prevention (PrEP) or treatment of HIV Initiation Continuation Initiation Continuation Clarification: No known interaction exists between ARV therapy and IUD use. However, for persons with HIV infection, IUD placement is classified as category 2 if the person is not clinically well or not receiving ARV therapy. Otherwise, both placement and continuation are classified as category 1 (see recommendations for HIV infection). For persons at high risk for HIV infection, IUDs are category 1 for initiation and continuation (see recommendations for High risk for HIV infection).
a. Nucleoside reverse
transcriptase inhibitors
(NRTIs)
  i. Abacavir (ABC) 1/2 1 1/2 1
  ii. Tenofovir (TDF) 1/2 1 1/2 1
  iii. Zidovudine (AZT) 1/2 1 1/2 1
  iv. Lamivudine (3TC) 1/2 1 1/2 1
  v. Didanosine (DDI) 1/2 1 1/2 1
  vi. Emtricitabine (FTC) 1/2 1 1/2 1
  vii. Stavudine (D4T) 1/2 1 1/2 1
b. Nonnucleoside reverse
transcriptase inhibitors (NNRTIs)
  i. Efavirenz (EFV) 1/2 1 1/2 1
  ii. Etravirine (ETR) 1/2 1 1/2 1
  iii. Nevirapine (NVP) 1/2 1 1/2 1
  iv. Rilpivirine (RPV) 1/2 1 1/2 1
c. Ritonavir-boosted protease
inhibitors
  i. Ritonavir-boosted atazanavir (ATV/r) 1/2 1 1/2 1
  ii. Ritonavir-boosted darunavir (DRV/r) 1/2 1 1/2 1
  iii. Ritonavir-boosted fosamprenavir (FPV/r) 1/2 1 1/2 1
  iv. Ritonavir-boosted lopinavir (LPV/r) 1/2 1 1/2 1
  v. Ritonavir-boosted saquinavir (SQV/r) 1/2 1 1/2 1
  vi. Ritonavir-boosted tipranavir (TPV/r) 1/2 1 1/2 1
d. Protease inhibitors without
ritonavir
  i. Atazanavir (ATV) 1/2 1 1/2 1
  ii. Fosamprenavir (FPV) 1/2 1 1/2 1
  iii. Indinavir (IDV) 1/2 1 1/2 1
  iv. Nelfinavir (NFV) 1/2 1 1/2 1
e. CCR5 co-receptor antagonists
  i. Maraviroc (MVC) 1/2 1 1/2 1
f. HIV integrase strand transfer
inhibitors
  i. Raltegravir (RAL) 1/2 1 1/2 1
  ii. Dolutegravir (DTG) 1/2 1 1/2 1
  iii. Elvitegravir (EVG) 1/2 1 1/2 1
g. Fusion inhibitors
  i. Enfuvirtide 1/2 1 1/2 1
Anticonvulsant therapy
a. Certain anticonvulsants (phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine) 1 1 Evidence: Limited evidence suggests use of certain anticonvulsants does not interfere with the contraceptive effectiveness of the LNG-IUD.[137],[138]
b. Lamotrigine 1 1 Evidence: No drug interactions have been reported among women with epilepsy who are receiving lamotrigine and using the LNG-IUD.[138],[139]
Antimicrobial therapy
a. Broad-spectrum antibiotics 1 1 —
b. Antifungals 1 1 —
c. Antiparasitics 1 1 —
d. Rifampin or rifabutin therapy 1 1 Evidence: One cross-sectional survey found that rifabutin had no impact on the effectiveness of the LNG-IUD.[137]
Psychotropic medications
a. Selective serotonin reuptake inhibitors (SSRIs) 1 1 Comment: For many common psychotropic agents, limited or no theoretical concern exists for clinically significant drug interactions when co-administered with hormonal contraceptives. However, either no or very limited data exist examining potential interactions for these classes of medications.
St. John’s wort 1 1 —

Abbreviations: ARV = antiretroviral; BMI = body mass index; CHC = combined hormonal contraceptive; CKD = chronic kidney disease; COC = combined oral contraceptive; Cu-IUD = copper intrauterine device; DMPA = depot medroxyprogesterone acetate; DVT = deep venous thrombosis; hCG = human chorionic gonadotropin; HDL = high-density lipoprotein; IBD = inflammatory bowel disease; IUD = intrauterine device; LDL = low-density lipoprotein; LNG = levonorgestrel; LNG-IUD = levonorgestrel intrauterine device; NA = not applicable; PE = pulmonary embolism; PID = pelvic inflammatory disease; POC = progestin-only contraceptive; PrEP = pre-exposure prophylaxis; RCT = randomized clinical trial; SLE = systemic lupus erythematous; STI = sexually transmitted infection; TOA = tubo-ovarian abscess; U.S. MEC = U.S. Medical Eligibility Criteria for Contraceptive Use; U.S. SPR = U.S. Selected Practice Recommendations for Contraceptive Use; VTE = venous thromboembolism.

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