By Melinda Young

Executive Summary

Clinicians are increasingly aware of strong evidence for using levonorgestrel (LNG) intrauterine devices (IUDs) for treating some gynecological issues and for emergency contraception.

• Until recent years, OB/GYNs offered patients the copper IUD for emergency contraception as well as for ongoing contraception. Now, evidence shows the LNG IUD also can be used for both purposes, which gives patients another option.
• Both the copper and LNG IUDs have several advantages over oral emergency contraceptives, including lower failure rates, no issue with patients’ body weight, and a longer window of efficacy after unprotected sexual intercourse.
• LNG IUDs also can help patients with abnormal or heavy menstrual bleeding by reducing or stopping their menstrual flow.

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Hormonal intrauterine devices (IUDs) provide benefits that go beyond long-term contraception. These include use as emergency contraception (EC) and in treatment of gynecological problems, such as excessive bleeding and endometriosis. Clinicians can recommend levonorgestrel (LNG) IUDs as EC and be confident these will work as well for patients as copper IUDs.^1,2

“A decade ago, or even a few years ago, we only had evidence on using oral emergency contraceptives or the copper IUD for emergency contraception,” says Lori M. Gawron, MD, MPH, FACOG, professor of obstetrics and gynecology at the University of Utah in Salt Lake City. “We didn’t really have data on any of the other hormonal contraceptive methods in the United States on use for emergency contraception,” she adds. “This limited access to these methods when patients came in and reported recent unprotected intercourse.”

Clinicians would offer oral EC and have the patient make an appointment for their desired ongoing contraception method. “Or they would be given the copper IUD because there wasn’t evidence for [using] the hormonal IUD,” Gawron says. This meant that women who want a hormonal IUD might not obtain their preferred method. The LNG IUD is popular in the United States, she adds.

Then in 2021, the New England Journal of Medicine published a research paper that compared LNG IUDs to copper IUDs for EC. Investigators, including Gawron, found the LNG IUD was noninferior to the copper IUD for EC. Pregnancy rates were one in 317 in the LNG IUD group and zero in 321 in the copper IUD group.^1,2 Since then, the LNG 52 mg IUD for EC has become a more popular option in the United States Gawron notes.

“These data were disseminated and changed practice in all Planned Parenthood affiliates across the country to allow patients to choose hormonal IUD for emergency contraception,” she says. “It was a large practice shift for Planned Parenthood patients.”² Planned Parenthood was a partner in the LNG IUD for EC research, which also found that the LNG IUD was effective when used as a quick-start method for contraception.² The research also found that half of participants in both the LNG and copper IUD groups were satisfied or very satisfied in the first month after IUD placement.

As methods of EC, both IUDs have advantages over oral emergency contraceptives. These include very low failure rates, efficacy that is not dependent on the person’s body weight, and longer window of efficacy — five days after unprotected sexual intercourse instead of just three days after intercourse as with over-the-counter oral contraception, Gawron says.

The chief obstacles to wider use of LNG IUD for EC involve logistics. “It’s a huge access issue for patients and even for non-emergency contraception patients who want an IUD, and it’s only getting harder across the U.S. as the Title X program is impacted with fewer grantees providing same day and urgent care,” Gawron explains. “And there has not been a shift across healthcare systems for urgent access to IUDs, so this option is limited to where a patient [lives and which provider] they may have access to.”

Cost is another logistical barrier: “IUDs are costly, so depending on a patient’s insurance or noninsurance, they may not be able to access them,” Gawron says. When people with limited insurance or economic means go to a Title X program, they receive care on a sliding income scale that could draw down to zero depending on their income and family size. But Planned Parenthood affiliates may be excluded from Title X, and other Title X grantees do not have the same spectrum of contraceptive options, she adds. “It’s costly to provide IUDs in same-day fashion, so costs are going to patients who don’t have insurance because of the loss of funding,” Gawron says.

These drawbacks to the use of IUDs for EC are occurring at the same time people are increasing their reliance on emergency contraceptives, according to an overview of an ongoing research study on the use of LNG 52 mg IUD for EC and same-day start.³ Globally, use of EC methods to decrease pregnancy risk have climbed. In 2002, 4% of women ever reporting sexual intercourse used EC, and it climbed to 20% in 2015 and 27% for urban women by 2017.³

IUDs are a desirable EC method because they are more effective than EC pills and can provide ongoing effective contraception for up to 10-12 years, Gawron says.³

IUDs for EC are effective for people with body mass index of 25 kg/m² or greater and also can continue to protect patients who have additional acts of unprotected intercourse later in the cycle after EC use.³

Same-day start is when women receive their method of choice on the same day in which they first meet with the clinician. This means that an IUD would be placed at one visit, even if the visit is for sexually transmitted infection (STI) testing, for instance.³ When adolescent, post-abortion, and postpartum patients are able to receive their long-acting reversible contraceptive (LARC) on their first visit, they are more likely to get their desired method and they have lower pregnancy rates.³

Clinicians can confidently promote both hormonal and copper IUDs for EC as well as for ongoing contraception because research shows these both work well. But there remain access barriers that are increasing, Gawron says.

“I think we’ll see general use of IUDs and implants falling across the United States as we have changes in funding for these devices, and we also anticipate higher uninsured rates in the next year,” she says. “Also, if the Affordable Care Act subsidies are not extended, and it does not appear it will happen by January 2026, then people will be placed out of the Marketplace plans, and more people will go without insurance, and therefore there will be fewer options in getting these methods.”

Another important reason clinicians and patients might consider use of the LNG IUD is because it may provide relief from abnormal uterine bleeding.⁴ LNG-releasing IUDs can be effective for treating benign gynecological conditions like uterine bleeding caused by uterine polyps.^4,5

LNG IUDs are safe and can provide relief for heavy or abnormal bleeding, says Whitney R. Robinson, PhD, MSPH, an associate professor in the department of obstetrics and gynecology at Duke University School of Medicine in Durham, NC. Robinson also is a core faculty member of Duke’s Margolis Center for Health Policy.

The hormonal IUD is an alternative solution for women with abnormal uterine bleeding severe enough that they may consider a hysterectomy as treatment, she adds. In past decades, hysterectomies were considered for treating abnormal uterine bleeding, but as research pointed toward less risky treatments, hysterectomy rates have fallen in the past 25 years, Robinson explains.

“OB/GYNs say they would like to avoid hysterectomy, if possible, because hysterectomy can have long-term health issues,” she adds. “Let’s do things to avoid taking out the uterus, and for bleeding problems — specifically — there are hormonal options to regulate bleeding.”

The LNG IUD is a popular option among physicians for treating uterine bleeding problems, Robinson says. “It delivers hormones locally, and the levonorgestrel IUD uses progestins, and a lot of people think the profile of progestins is good vs. sometimes giving patients estrogen, which in high doses could increase risk of embolism or blood clots,” she explains.

The LNG IUD is not a treatment that every patient will find comfortable. For some people, IUD insertion is a painful experience. Also, IUDs typically require a clinic visit for removal, which affects patients’ autonomy and control over their contraceptive method and/or treatment, she adds. “There is some evidence of racial differences in who likes IUDs for birth control,” Robinson notes.

Abnormal or heavy menstrual bleeding is a serious problem for some patients. They could become anemic, and they could withdraw from social events and public life out of fear their bleeding will leak through their clothing, she says. “That’s a quality of life issue,” Robinson says. “Some clinicians don’t ask their patients about this problem, and patients may feel like their bleeding is not being taken seriously.”

Clinicians might ask patients these questions:

• How long are your periods? If a patient’s periods are longer than a week, then it flags an investigation, Robinson says.
• How closely do your periods come? If a patient’s periods are faster than three to four weeks, then this should be investigated.
• How regular are your periods?
• Do you have spotting between periods?
• How heavy are your periods? Do you have to change pads every two hours or is there a lot of soiling if your bleeding is heavy?
• Are you uncomfortable going places because you may bleed through?

These answers can lead to further investigation and suggestions for treatment, such as a hormonal IUD, which will reduce bleeding and, in some cases, stop it. “We ideally want patients to get treatments that are satisfactory to them and to improve their symptoms,” Robinson says. Patients may ask for a hormonal IUD but then may have problems with expulsion because of their uterine fibroids. So, this solution may not work for everyone.

Other patients may have surgery to remove fibroids and then opt for an IUD after surgery as a long-term solution to control bleeding. “IUDs are not for women who are interested in childbearing, and we have good pain relief measures now for patients who are concerned about pain with IUD insertion,” Robinson adds.

Historical context also is very important when treating patients, including Black women, who come from a family or cultural background in which the medical community sterilized women without their consent, she says. “Sometimes, patients will not want to move forward with [treatment] because of a family history or knowing about the history of sterilization, and this is something to be aware of,” Robinson explains. “Patients build trust when they feel like you are presenting them with all options and you are taking them seriously.”

Clinicians can build this trust with the use of IUDs by reassuring patients that they can have it removed at any time and the clinic will not delay their appointment to have that removal happen, she adds. “Delaying that really does damage trust,” Robinson says.

Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.

References

1. The Levonorgestrel vs. Copper Intrauterine Device (IUD) for Emergency Contraception. Planned Parenthood. Last updated January 2021. https://www.plannedparenthood.org/uploads/filer_public/f5/9c/f59ce050-a851-4ab1-898a-9d2e7d73a39c/210128-fact-sheet-lng-ec-p01.pdf

2. Turok DK, Gero A, Simmons RG, et al. Levonorgestrel vs. copper intrauterine devices for emergency contraception. N Engl J Med. 2021;384:336-344.

3. Recruiting: Levonorgestrel 52 mg IUD for Emergency Contraception and Same-Day Start. Sponsor: University of Utah. ClinicalTrials.gov. https://clinicaltrials.gov/study/NCT05444582?locStr=Utah&country=US&state=Utah&cond=iud&term=turok&rank=8

4. Green MJ, Doll KM, Wood ME, et al. Ethno-racial differences in age and symptom severity among pre-menopausal women commencing treatment for benign gynecological conditions with a levonorgestrel-releasing intrauterine device. Health Equity. 2025;9(1):326-338.

5. Cason P, Cwiak C, Edelman A, et al. Contraceptive Technology. 22nd edition. Jones & Bartlett Learning;2025:53.