IUD Use in Nulliparous Women

IUD on a red background

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When the ParaGard IUD was first introduced in the United States in 1988, the product label indicated that the intrauterine device (IUD) was for women who have had at least one child. This excluded women who were nulliparous (the medical term for women who have never given birth) while allowing women who were parous to use the product.

In 2005, the U.S. Food and Drug Administration (FDA) removed the restrictions, expanding the use of the Paragard IUD to both parous and nulliparous women.

A similar situation occurred with the Mirena IUD. While the original product label recommended the device for women who have had at least one child, those restrictions have also been removed, largely without explanation.

So what gives? Are there reasons you should avoid the Paragard or Mirena IUD if you have not had children?

Early Misconceptions

One of the main reasons why nulliparous women were discouraged from using IUDs was the largely unfounded fear that they would be far too difficult to insert. Generally speaking, the cervix of a nulliparous woman has a smaller diameter which many believed could lead to difficult and uncomfortable IUD insertions.

It was assumed these women could require specialized procedures, including cervical dilation, a temporary nerve block, and ultrasound, to correctly place the device. None of these are generally needed for parous women.

The problem with the FDA restriction is that it led many in the medical community to believe that IUDs are somehow riskier in nulliparous women than in parous women, and that simply isn't true.

Unfortunately, by the time the restrictions were lifted, many of these attitudes were cemented in the minds of treaters and users alike. In fact, according to a 2012 study in Obstetrics and Gynecology, no less than 30% of medical professionals, including doctors, had misconceptions about the safety of IUDs.

Because of this, the uptake of the Paragard and Mirena IUDs among nulliparous women has been historically low, increasing from 0.5% in 2002 to just 4.8% by 2013, according to the 2011-2013 National Survey of Family Growth (NSFG).

Current Evidence

In recent years, organizations like the American College of Obstetricians and Gynecologists (ACOG) have tried to clear up the confusion by issuing committee opinions on the use of IUD in nulliparous women.

According to the ACOG, medical professionals should "encourage consideration of implants and IUDs for all appropriate candidates, including nulliparous women and adolescents." The opinion was based on clinical research that, up until 2005, was largely lacking.

Failure Rates

Intrauterine devices have a low failure rate in both parous and nulliparous women. In the first year of use, the failure rate is only around 0.2%, according to a 2011 review of studies in the journal Conception. This includes both the copper-based Paragard IUD and the hormonal Mirena IUD.

User Satisfaction

Despite all of the fear about risks and complications, nulliparous women have expressed high levels of acceptance and satisfaction with both the Paragard and Mirena IUDs.

Among women enrolled in the Contraceptive CHOICE Project conducted in 2011, 85% of Mirena users and 80% of Paragard users were "very satisfied" or "somewhat satisfied" at 12 months. The response rate was equal whether the respondents were parous or nulliparous.

Expulsion Rates

Similarly, nulliparous women appear to have equivalent or lower rates of unintended expulsion than parous women. This is evidenced by the aforementioned Contraceptive CHOICE Project in which 4,219 women using the Mirena IUD and 1,184 using the Paraguard IUD experienced an expulsion rate of 10.2% over 36 months.

The rate was statistically unchanged whether a woman had given birth before or not.

After an adjustment for confounding factors, such as obesity and cervical abnormalities, nulliparous women actually had lower rates of expulsion using the Mirena than parous women.

Side Effects

Comparatively speaking, the Mirena IUD has more side effects than the Paragard simply because it is hormone-based. Expected side effects of the Mirena are cramps, spotting, and a tendency toward amenorrhea (absent periods).

In terms of side effects in nulliparous versus parous women, pain was more common in those who never give birth versus those who did. This was true irrespective of IUD type. However, with Mirena, the perceived pain was more severe.

According to a 2014 study from George Washington University, pain was the major cause for treatment discontinuation in roughly 5% of Mirena users, which generally occurred within three months of insertion. With that being said, the discontinuation rate was not influenced by whether a woman ever gave birth or not.

Despite suggestions to the contrary, there is little to no evidence that the Paragard or Mirena IUD increases the risk of perforation, pelvic inflammatory disease (PID), or infertility in nulliparous women any more than in parous women.

In all such cases, the risk is considered low to negligible.

A Word From Verywell

The general consensus among women's health experts is that IUDs are safe and effective birth control method for women who have had children and those who haven't. The ACOG further insists that the benefits of the ParaGard and Mirena IUDs far outweigh the risks, perceived or proven.

Additionally, the ParaGard IUD may be an excellent first-line option for women who can’t or don’t want to use hormonal contraception.

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Article Sources

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  6. Tyler CP, Whiteman MK, Zapata LB, Curtis KM, Hillis SD, Marchbanks PA. Health care provider attitudes and practices related to intrauterine devices for nulliparous women. Obstet Gynecol. 2012;119(4):762-71.

  7. Daniels K, Daugherty J, Jones J, Mosher W. Current Contraceptive Use and Variation by Selected Characteristics Among Women Aged 15-44: United States, 2011-2013. Natl Health Stat Report. 2015;(86):1-14.

  8. Committee Opinion No. 642: Increasing Access to Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy. Obstet Gynecol. 2015;126(4):e44-8.

  9. Trussell J. Contraceptive failure in the United States. Contraception. 2011;83(5):397-404.

  10. Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117(5):1105-13.

  11. Mejia M, McNicholas C, Madden T, Peipert JF. Association of baseline bleeding pattern on amenorrhea with levonorgestrel intrauterine system useContraception. 2016;94(5):556–560. doi:10.1016/j.contraception.2016.06.013

  12. Yoost J. Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United StatesPatient Prefer Adherence. 2014;8:947–957. Published 2014 Jul 3. doi:10.2147/PPA.S45710

  13. Aoun J, Dines VA, Stovall DW, Mete M, Nelson CB, Gomez-lobo V. Effects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol. 2014;123(3):585-92.

  14. Jatlaoui TC, Riley HEM, Curtis KM. The safety of intrauterine devices among young women: a systematic review. Contraception. 2017;95(1):17-39.

  15. Sanders JN, Adkins DE, Kaur S, Storck K, Gawron LM, Turok DK. Bleeding, cramping, and satisfaction among new copper IUD users: A prospective studyPLoS One. 2018;13(11):e0199724. Published 2018 Nov 7. doi:10.1371/journal.pone.0199724

Additional Reading

  • American College of Obstetrics and Gynecology. Committee Opinion No. 642: Increasing Access to Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy. Obstet Gynecol. 2015;126:e44–8. DOI: 10.1097/AOG.0000000000001106.

  •  Aoun, J., Dines, V.; Stovall, D. et al. Effects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol. 2014;123(3):585-92. DOI: 10.1097/AOG.0000000000000144.

  • Daniels, K.; Daugherty, J.; Jones, J. et al. Current contraceptive use and variation by selected characteristics among women aged 15–44: United States, 2011–2013. Natl Health Stat Report. 2015(86):1-4.

  • Peipert, J.; Zhao, Q., Allsworth, J. et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117(5):1105-13. DOI: 10.1097/AOG.0b013e31821188ad.

  • Trussell, J. Contraceptive failure in the United States. Contraception. 2011;83(5):397-404. DOI: 10.1016/j.contraception.2011.01.021.

  • Tyler, C.; Whiteman, M.; Zapata, L. et al. Health care provider attitudes and practices related to intrauterine devices for nulliparous women. Obstet Gynecol. 2012;119(4):762-71. DOI: 10.1097/AOG.0b013e31824aca39.