Please see full method insertion and removal training materials for comprehensive information on the insertion and removal processes.

Risks include uterine perforation, incorrect placement leading to expulsion, or the introduction of infection if aseptic conditions are not maintained. All patient screening and insertion and removal steps must be followed to ensure that these risks are minimized. Should a provider not feel confident in their ability to safely insert or remove the hormonal IUD, they should refer the client to a colleague or another clinic for hormonal IUD services.

Insertion pain is extremely individual, but clinical evidence suggests that moderate to severe pain during insertion is common, and is more frequent in nulliparous clients, younger clients, or clients who experience painful periods. Providers should offer their clients pain management assistance if available, including NSAIDs, topical lidocaine placed on the cervix, or lidocaine injection in the cervix if trained to do so. However, if these resources are not available, clients should not be denied hormonal IUD insertion if desired. Providers should also offer comprehensive counseling on the method and insertion process to each client, as some evidence suggests higher quality counseling can lead to lower reported pain during and after insertion. Medications to induce cervical dilation are not generally recommended. While evidence is limited, non-pharmacological interventions may be beneficial, such as ensuring the environment is as quiet and calm as possible or lowering the lighting in the examination room.

Clients can get their hormonal IUD removed from any provider trained to offer the hormonal IUD. They do not need to return to the same provider who inserted their hormonal IUD if that provider is not available.

If a client returns to the clinic because they cannot locate their IUD strings, providers should perform a basic pelvic exam and gently attempt to locate the strings in the vagina and cervical canal. If trained and able, providers can use a cervical brush to return stings to vaginal canal. If the provider is unable to locate the strings, they should conduct an x-ray or ultrasound. If their facility does not offer these imaging services, they should refer to a health center that does, to determine hormonal IUD placement hormonal IUD or confirm complete expulsion. The provider should offer the client a backup contraceptive method to use during this time. If the hormonal IUD is located through x-ray or ultrasound, providers can consider cervical dilation to retrieve and remove the hormonal IUD or – in extreme cases of uterine perforation ‒ refer for surgical intervention. Once the hormonal IUD is removed, discuss the client’s contraceptive preferences. If they still wish to use the hormonal IUD and pregnancy has been ruled out, a new hormonal IUD can be inserted.

Two very small studies have suggested that IUD self-removal is both possible and safe, if the IUD user takes appropriate infection control measures, such as thorough hand washing. However, given the limited evidence and the challenge of ensuring clients have sufficient information to perform self-removal safely, this practice is not promoted. If a client expresses interest in self-removal or indicates their intention to self-remove, providers should recommend they return to the clinic for assistance in removing the hormonal IUD. Providers can also counsel clients that intend to self-remove to ensure their hands are fully sanitized in advance and to stop their attempt and seek medical assistance if they experience bleeding or pain.