Australian and New Zealand Journal of Obstetrics and Gynaecology 2016; 56: 655661 DOI: 10.1111/ajo.

12534
COPYRIGHT NOTICE
Copyright law, Title 17, of the U.S. Code, may protect the attached information. Section 504
states that you are liable for any actual or statutory damages for copyright infringement.
Original Article THIS MATERIAL IS FOR YOUR ONE-TIME USE. IF YOU RE-DISTRIBUTE IT
ELECTRONICALLY OR IN PRINT, STORE IN PERMANENT FILES, OR ALLOW
OTHERS TO ACCESS THIS ELECTRONIC FILE, YOU MAY BE INFRINGING UPON
COPYRIGHT.

User characteristics, experiences and continuation rates of copper

intrauterine device use in a cohort of Australian women
Deborah BATESON,1,2 Caroline HARVEY,3,* Lieu TRINH,1 Mary STEWART1 and
Kirsten I. BLACK2
1
Family Planning NSW, 2Discipline of Obstetrics, Gynaecology and Neonatology, Central Clinical School, University of Sydney,
Sydney, New South Wales, 3Family Planning Queensland (now called True Relationships and Reproductive Choice), Brisbane,
Queensland, Australia

Background: Copper intrauterine device (Cu-IUD) use in Australia is low despite being a highly effective, cost effective
non-hormonal contraceptive with reported 12-month continuation rates of 85% compared to 59% for oral contraception.
Aims: To describe the characteristics of Cu-IUD users in the Australian context, their experiences of side effects,
continuation rates and reasons for discontinuation.
Methods: Between August 2009 and January 2012 we undertook a prospective cohort study of consecutive women
presenting for Cu-IUD insertion to three family planning clinics in Queensland and New South Wales. We used survival
analysis for continuation rates and univariate and multivariable analyses to characterise users, their experiences up to three
years and reasons for discontinuation.
Results: Of the 211 enrolled women, a third (36.0%) were aged under 30 and a third were nulliparous (36.5%). Efcacy
and lack of hormones were the most frequently cited reasons to choose the method. Four women were lost to follow-up.
Overall continuation rates were 79.1% at one year and 61.3% at three years. Early discontinuation was reduced in those
with two or more children (adjusted hazards ratio 0.22, 95% CI 0.090.50). Heavy menstrual bleeding was the
commonest reason for removal in 28 of 59 (47.5%) discontinuations due to complications or side effects. One uterine
perforation and one method failure resulting in an ectopic pregnancy occurred.
Conclusions: Cu-IUDs were chosen for their efcacy and lack of hormones by a range of Australian women, including
young and nulliparous women. While bleeding-related side effects were relatively common, overall continuation rates were
high. Serious complications and failures were rare.
Key words: bleeding, continuation rates, discontinuation, intrauterine devices.

Introduction regions in the types of devices used and in prevalence of

Intrauterine contraception (IUC), including the
copper intrauterine devices (Cu-IUDs) and the levonorgestrel
intrauterine system (LNG-IUS), are the most widely
utilised reversible method of contraception in the world
with around 150 million users.1 In all, 13.9% of women
married or partnered have an IUD or IUS as their main
method of contraception with notable variations across
Correspondence: Associate Professor Kirsten Black, Discipline
of Obstetrics, Gynaecology and Neonatology, Central Clinical
School, University of Sydney, Level 4, Building 63, Royal
Prince Alfred Hospital, Missenden Road, Camperdown,
NSW 2050, Australia. Email: kirsten.black@sydney.edu.au
*Present address: Aboriginal and Torres Strait Islander
Community Health Service, Brisbane, Queensland, Australia.
Received 17 February 2016; accepted 16 August 2016.
use.2 In areas of northern Africa and eastern and central
Asia Cu-IUDs are inexpensive to manufacture and are
widely used. In Australia and the US the uptake is
signicantly lower.2 In these countries misunderstandings
about the risks of IUC linger because an earlier device, the
Dalkon Shield,3 was found to promote infection, and has
tainted the perceptions of healthcare providers and the
public about the safety of this method in general.46 The
Cu-IUDs receive government subsidies in New Zealand
and are more widely used than the LNG-IUS.7 In contrast
the LNG-IUS has a higher prevalence of use in Australia
which most likely relates to its availability through the
government-funded Pharmaceutical Benets Scheme (PBS)
unlike the Cu-IUD devices which do not receive
government subsidies.8
Cu-IUDs have been available since the 1970s and a
recent longitudinal study of 61 488 IUC users, 30% of
whom were using a Cu-IUD, conrms that they are an
extremely effective method, with a failure rate of less than

2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 655
The Australian and
New Zealand Journal
of Obstetrics and
Gynaecology
D. Bateson et al.
one per 100 women in the rst year of use and are
associated with few adverse events.911 As with other long-
acting reversible contraceptive (LARC) methods, they are
non-user dependent and more cost-effective than the pill
even at one year of use.12 However, clinicians around the
world remain somewhat reluctant to recommend IUC for
young and nulliparous women despite the lack of evidence
of an association with fertility issues once discontinued.5
Recent studies, such as the CHOICE contraceptive
project, have demonstrated that IUC is an acceptable
method for all women and young women may particularly
benet because of greater effectiveness compared to
combined hormonal contraceptive methods.13
Copper IUDs also have the advantages of being
hormone-free, providing highly effective emergency
contraception which can be continued long term, and not
disturbing the regularity of the menstrual cycle. However,
the inammatory response in the endometrium results in a
30% or more increase in menstrual ow which has been
cited as one of the most common reasons for discontinuation
of the method.1416 Nevertheless, cumulative continuation
rates for Cu-IUDs up to three years have been reported to
be among the highest of all modern methods of
contraception.17,18 This indicates that despite these side
effects, the method is often highly acceptable.
Australian women have low rates of IUC uptake, with
data from a 2011 national survey indicating that only
3.2% of women use the method.19 In the setting of family
planning clinics, around one-fth of women using IUC
choose the Cu-IUD over the LNG-IUS but this may not
be representative of national gures where the proportion
is likely to be less.19 As previously mentioned, a nancial
incentive for women to choose a LNG-IUS exists in the
Australian context as this device is subsidised, whereas the
copper devices are not. Women and providers may also
favour the bleeding prole offered by the LNG-IUS.
The continuation rate of the LNG-IUS in family
planning clinics has been recently reported; the study
found that 77% of women were still using the LNG-IUS
after three years,20 but there is no detailed information on
Cu-IUD users in Australia, including their reasons for
choosing the method, their experiences of it, their
continuation rates and reasons for discontinuation. This
study sought to examine the prole of current Cu-IUD
users attending family planning clinics in Queensland and
New South Wales and to document their experiences and
continuation rates over a three-year period, as well as their
reasons for discontinuation.
Materials and Methods
This was a prospective cohort study of consecutive
women presenting for Cu-IUD insertion to two family
planning clinics in Queensland and one in New South
Wales from August 2009 to January 2012. Women were
excluded if they did not speak English. The proportion of
women agreeing to participate in Queensland was not
known but of the 247 women in NSW having a Cu-IUD
656 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
inserted during the study recruitment timeframe, 19 were
excluded as they required an interpreter and 109 consented
to participate (47.8% of 228 potentially eligible women were
recruited). Whether the remaining women were not
approached or were approached and refused, is unknown.
Women had either a copper TT380 (short or long) or a
Multiload device inserted, both of which have a duration
of use between ve and ten years, and the women were
asked to consent to follow-up over a three-year period as
well as to allow the researchers to access their family
planning clinic medical records. Those who agreed to
participate were asked to provide a variety of methods of
contact. Women were asked about their demographic
characteristics, sexual and reproductive history, and
reasons for choosing a Cu-IUD. Our questions were based
on the Ortho Birth Control Satisfaction assessment tool
which has previously been adapted for use in our
setting.20
Follow-up was conducted at six weeks, six months,
one-year, two-year and three-year waves by research
nurses using telephone interviews, online questionnaires
(SurveyMonkey),21 email or post. Women were asked
whether the Cu-IUD was still in situ and if yes,
information on womens satisfaction with the device and
experience with side effects was collected. If the Cu-IUD
had been discontinued, women were asked to complete a
separate questionnaire and indicate reasons for
discontinuation and whether they would use a Cu-IUD in
the future or recommend it to others.
Data analyses
We summarised the characteristics of participants, reasons
for choosing the Cu-IUD and reasons for early removal
with frequencies and proportions. Participant
characteristics examined were age, relationship status,
number of new sexual partners in the last 12 months,
desire for children in the future, number of live births,
education, employment status, country of birth, language
spoken at home, Indigenous status, residence in a major
city or regional area, current breastfeeding, regularity of
menstrual cycle and perception of menstrual ow. Major
cities/regional classication was based on the University of
Sydney Remoteness Lookup Tool.22 We assessed the
association between participant characteristics and
discontinuation of the Cu-IUD with interval-censored
survival analyses, as the actual date of discontinuation was
not known. For women who could not be contacted for a
particular wave, paper or electronic medical records at
Medical Family Planning NSW and Family Planning
Queensland were checked to determine if their IUD was
still in situ at their last clinic visit. We made an assumption
that women recording the presence of an IUD at a later
wave had the IUD at all previous waves (eg if a woman
still had Cu-IUD at the one-year interview, then she was
considered to have had the IUD at six months and six
weeks). Removal of the copper IUD due to a desire for
pregnancy, or no ongoing need for the method (eg partner
 Copper IUD use in Australian women

vasectomy), as well as complications (expulsion, ectopic Table 1 Characteristics of women enrolled in the study
pregnancy, malposition or perforation) were categorised as (N = 211)
reasons not related to patient experience of the method
and were censored in the survival analyses. Data were n %
analysed using Stata 14.0 (StataCorp, College Station, Age group (years)
TX, USA). Ethics approval was obtained from by the 1824 25 11.9
Family Planning NSW Ethics Committee (R2009/03). 2529 51 24.2
3039 91 43.1
4051 44 20.9
Results Relationship status
Married/living together 156 73.9
Characteristics of users and reasons for choice No current partner/separated/divorced/widowed 12 5.7
A total of 211 women were enrolled in the study (109 Casual partner 42 19.9
from NSW and 102 from Queensland). Other 1 0.5
The characteristics of the women at enrolment are Number of new sexual partners in past 12 months
01 192 91.0
documented in Table 1. One third of women (36%)
2 19 9.0
choosing a Cu-IUD were under 30 years of age and over
Future children desired
10% were under 25 years, while over a third of women
No 107 50.7
were nulliparous (36.5%; n = 77). Over half were born
Yes 56 26.5
outside Australia (56.9%; n = 120). Most participants Unsure 48 22.8
reported a regular menstrual cycle (80.6%; n = 170) and Number of live births
menses that were not heavy prior to insertion (92.3%; 0 77 36.5
n = 192). Women identied a number of reasons why 1 25 11.9
they chose to use the Cu-IUD (Table 2) with the most 2 109 51.7
common reason (94.7%, n = 198) being that it is Education
hormone-free. The next most frequently stated reasons High school or lower 41 19.4
related to the Cu-IUDs long duration of use (92.4%; TAFE 47 22.3
n = 194) and effectiveness (88.8%, n = 183). University degree or higher 123 58.3
Employment status
Employed 133 63.0
Experiences of the Cu-IUD at one year of use Unemployed 56 26.5
Data were gathered from 105 of the 167 (62.9%) Others 22 10.4
women who had retained their Cu-IUD at 12 months. Country of birth
Of these 94 (89.5%) reported being happy with the Australia 91 43.1
method and 57 (54.2%) reported that their sex life had Others 120 56.9
become more spontaneous, although eight (7.6%) said their Language spoken at home
English 162 76.8
partner experienced discomfort related to the IUD threads.
Others 49 23.2
In relation to bleeding patterns, 64 (60.9%) were
Regularity of menstrual cycle
happy with the frequency of their bleeding but some
Regular 170 80.6
women were bothered to some extent in the previous
Irregular 41 19.4
month by heavy bleeding (45; 42.8%), prolonged bleeding Perception of menstrual ow
of more than seven days (37; 35.2%), increased Heavy 16 7.7
dysmenorrhoea (45; 42.9%) and pain not associated with Not heavy 192 92.3
menses (34; 32.4%). Just over a third (38; 36.1%) of Indigenous status
women reported being bothered by increased vaginal No 208 98.6
discharge in the previous month. Yes 3 1.4
Of the 45 women who reported being bothered to some Major cities/regional
extent by heavy menstrual bleeding at 12 months, nine Major cities 182 86.3
discontinued use within the subsequent 12 months but Regional 29 13.7
only ve did so because of ongoing heavy bleeding issues Currently breastfeeding
(other reasons included desire for another child, expulsion, No 171 81.0
pelvic pain; data were missing on one woman). Yes 40 19.0
Pelvic pain was experienced to some extent by 34 of
107 women (from whom data were available) at
Method continuation
12 months of follow-up, but only 12 reported being
very or extremely bothered by pain. Nevertheless pelvic Of the 211 recruited women, information was available for
pain was the principal reason for device removal in six 207 across the three-year study period from questionnaires
women (Table 3). or medical records. Overall four women were lost to

2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 657
D. Bateson et al.

Table 2 Reasons to choose copper intrauterine device (women 45

were able to provide more than one reason) All discontinuations (n = 80)
40
Removals because of
n % patient related reasons (n = 40)
35

Percentage removed
I want a method that does not contain hormones 198 94.7 30
I consider it to be very effective 183 88.8
I do not have to remember or do anything 173 83.2 25
It is relatively inexpensive 163 77.6
20
I want a method which is quickly 155 74.5
reversible on removal 15
The clinician recommended it 82 59.4
10
I dont mind the possibility of heavier 120 57.4
periods that might last longer 5
A family member or friend recommended it 81 39.1
I have chosen it for other reasons 14 31.8 0
0.5 1 2 3
I want a method that cant be 61 29.8 Years since IUD insertion
detected by other people
Figure 1 Survival analysis of women who discontinued their
copper intrauterine device (Cu-IUD) by three years due to any
reason and those removed due to side effects.
Table 3 Primary reason for discontinuation in women who still
required contraception (N = 59) (as reported by the woman)
Heavy menstrual bleeding was the most common reason
n %
accounting for 28 of 59 early discontinuations in women
Side effects still requiring contraception. There was one failure of the
Heavy menstrual bleeding 28 47.5 method documented resulting in an ectopic pregnancy.
Pelvic pain 6 10.2 Figure 1 presents a survival analysis for women who
Intermenstrual bleeding 3 5.1 discontinued for any reason during the three-year period
Dysmenorrhea 1 1.7 (n = 80) and those who discontinued for patient-reported
Dyspareunia 1 1.7 side effects (n = 40). Of the 80 women who discontinued
Vaginal discharge 1 1.7
the method for any reason, 43% said they would use a
Complications
Cu-IUD again in the future and 53% would recommend it
Malposition 2 3.4
to someone else.
Expulsion 15 25.4
Perforation 1 1.7
Failures Pre-insertion factors associated with method
Ectopic pregnancy 1 1.7 discontinuation
Based on the baseline characteristics of the participants,
the only factor that predicted Cu-IUD discontinuation due
follow-up: one by six months, one by 12 months and two to patient-reported side effects (n = 40) was parity.
by 36 months. Of the 209 women who were contactable Nulliparous women were no more likely to discontinue
in the rst two years, 167 (79.9%) were still using the their Cu-IUD over the three-year time frame than women
method at one year and 145 (69.4%) were using it at two with one live birth (29.9% vs 28.0%, respectively), but
years. Of the 207 still contactable at three years, 127 compared to nulliparous women, women with two or more
(61.3%) were still using it. children were signicantly less likely to have discontinued
use at three years (hazards ratio 0.22; 95% CI 0.090.50)
(Table 4). Age was not associated with discontinuation.
Reasons for discontinuation
Over the three years 80 women discontinued the method.
Eighteen women discontinued use for reasons other than
Discussion
complications or side effects: two because there was no This study of a cohort of women attending family
need for contraception, one because of partner vasectomy planning clinics in Queensland and NSW is the rst in
and 15 because of wanting to conceive. In three women Australia to document the reasons for choice, the
the reason for removal was unknown. In 59 women the experiences and continuation rates of Cu-IUDs. We found
primary reason for discontinuation related to that a wide range of Australian women are choosing to use
complications (19 women) or side effects (40 women) the Cu-IUD, including young and nulliparous women for
which are documented in Table 3. Expulsion occurred in whom this method may previously have been considered
15 women (three nulliparous and 12 parous women; 7.2% unsuitable. The women in our study chose a Cu-IUD
of 209) with 12 expulsions occurring within the rst year. based on a desire for a non-hormonal method of high

658 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
 Copper IUD use in Australian women

Table 4 Client-related factors associated with early removal of a study involving the LNG-IUS20 and suggests that women
copper intrauterine device (Cu-IUD) (n = 40) attending family planning clinics for IUC may be more
aware of their benets (and in the case of the Cu-IUD more
Hazard able to afford the associated upfront cost of the device).
N n % ratio 95% CI P-value Contraceptive side effects are an undisputed cause of
Age group (years) early method discontinuation and the discontinuations that
1824 25 4 16 1 0.168 were attributed to side effects in our study contributed to
2529 51 7 13.7 0.79 0.222.87 half of all the patient-related removals. While the main
3039 91 21 23.1 1.93 0.596.33 reason for early removal was reported as heavy menstrual
4051 44 8 18.2 1.88 0.497.13 bleeding, our study also suggests that despite the frequent
Number of live births occurrence of heavy bleeding in women using a Cu-IUD
0 77 23 29.9 1 <0.001 at one year after insertion, it is a relatively uncommon
1 25 7 28 0.95 0.362.5 reason for removal in the subsequent 12 months. Indeed,
2 109 10 9.2 0.22 0.090.5 a large study examining the menstrual side effects of
Education Cu-IUD use at 12 months found bleeding tended to
High 41 3 7.3 1 0.156
reduce over time which supports the possibility that if
school
women are provided with information about expected
or lower
improvements in bleeding patterns they may tolerate
TAFE 47 10 21.3 3.85 0.9815.05
short-term inconvenience for longer-term gain.27 The heavy
University 123 27 22 2.45 0.718.46
degree
menstrual bleeding and intermenstrual spotting experienced
or higher with Cu-IUD use15,28 are thought to be due to excessive
Regularity of menstrual cycle prostaglandin release in the endometrial cavity.16 Successful
Regular 170 35 20.6 1 0.359 management of these side effects was the subject of a
Irregular 41 5 12.2 0.61 0.231.65 Cochrane review that concluded that non-steroidal
Perception of menstrual ow anti-inammatory drugs (NSAIDs) reduce menstrual blood
Not heavy 192 36 18.5 1 0.837 loss in Cu-IUD users29 and the anti-brinolytic agent,
Heavy 16 4 25 0.8903 0.292.69 tranexamic acid, may have a useful role to play.27 More
research is needed to determine whether use of these
Proportion of women in each category who had IUD removed
medications can prolong use of the method.
per total number of women in that category.
After bleeding, pelvic pain, dysmenorrhoea or
Does not include removals for women desiring pregnancy,
partner vasectomy, malposition, ectopic pregnancy, perforation
dyspareunia were the second most common reason for
removal, a nding which aligns with other studies.30,31
When reasons including IUD malposition or pelvic
efcacy. They sought a method that was of long duration infection have been excluded, a trial of an NSAID may
that does not require action on the part of the user. also be a useful strategy for managing non-specic pain
Compared to a study in the same setting of women associated with IUD use in order to promote method
choosing an LNG-IUS,20 the Cu-IUD users in our study continuation. Enhancing awareness of management
were younger and more likely to be nulliparous. This may strategies for Cu-IUD-related side effects and letting
reect a personal preference for a non-hormonal method women know about the availability of such strategies in
by younger women who may be eschewing methods such advance is an important role of all health-care providers of
as the contraceptive pill. contraception.
Of the cohort, four out of ve women (79.9%) continued Method failure occurred in one women who presented
to use of the device over a 12-month period which is slightly with an ectopic pregnancy, giving a Pearl Index of 0.25
lower than rates reported in other studies. For example, in per 100 women years. Complications associated with
the USA, after one year, 85.1% of women enrolled in the Cu-IUD use were uncommonly reported in our cohort
contraceptive CHOICE project were still using the Cu-IUD with the exception of IUD expulsion which was
compared to 59.0% of women who chose the oral experienced by 5.7% of women in the initial 12 months.
contraceptive pill.17 Cumulative discontinuation rates of the This is in keeping with other research that has reported a
Cu-IUDs have been documented to increase to 2233% 210% range for the rst year of use.15,32,33 Factors
after three years.2325 We found that the women most likely previously documented to increase expulsion include
by baseline characteristics to continue use of the Cu-IUD at young age, pre-existing heavy menstrual bleeding and
three years were those with two or more children, being parous.20,33,34 Ensuring that women are aware of
suggesting a high degree of motivation to continue the the recommendation to check the threads of their Cu-IUD
method to prevent further pregnancies with probable family after each menstrual period, is a useful strategy to detect
completion. Of note is that the sample of women recruited expulsion and reduce the risk of unintended pregnancy.
to the study were more highly educated (58% had a Given that IUC is such a highly effective and cost-
university degree) than the general population.26 This is effective method, efforts to improve uptake in Australia
similar to the sample from the other family planning LARC are imperative through a combination of community-based

2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 659
D. Bateson et al.
education as well as increased training opportunities for
health professionals.35 While the LNG-IUS is more
commonly used in the Australian context than the Cu-
IUD, likely in part due to its subsidy through the PBS as
well as its benets in reducing menstrual blood loss, the
Cu-IUD continues to play an important role for women
who are contraindicated for the use of hormones and
those who prefer a non-hormonal, yet highly effective
method. The USA-based CHOICE study has clearly
demonstrated a benecial effect on LARC uptake when
nancial barriers are removed,12 and as the up-front cost
of a Cu-IUD in Australia may present a nancial barrier
for some women, provision of subsidy is recommended to
support its wider use across the community.
Around half of the women who discontinued their
Cu-IUD reported that they would recommend it to a
friend or use it again themselves in the future, highlighting
the importance of offering it to women during
contraceptive consultations.
Strengths and Limitations
This cohort study is the rst in Australia to follow women
using a Cu-IUD across two states and while there are
missing data in some of the reporting waves, it provides
valuable insights into womens experiences of this method.
We did not collect data on the type of Cu-IUD inserted
so we are unable to comment on whether the side effects
and complications may have differed between these groups
but it is unlikely that any signicant differences would
have been detected as the study was not powered for this
outcome. We did not document whether women were
prescribed treatment (such as non-steroidal anti-
inammatory medication or tranexamic acid for heavy
bleeding). Finally we did not collect data on all women
presenting for insertion, so the sample may not be
representative of the general family planning population,
nor may it be generalizable to women seeking Cu-IUDs
across different localities and providers. While our study
excluded non-English-speaking women for pragmatic
reasons, we acknowledge that future studies should
include translated survey instruments in order to capture
the experiences of this population group who anecdotally
have high rates of Cu-IUD use.
Conclusions
Cu-IUDs were chosen by a range of Australian women,
including young and nulliparous women. While bleeding-
related side effects were relatively common, overall
continuation rates were high. Increasing health
professionals awareness of womens experience of Cu-
IUDs, as well as understanding strategies to manage
troublesome bleeding, will help ensure that this effective
non-hormonal method is offered as a contraceptive choice.
There is a need to continue to advocate for PBS listing of
the Cu-IUDs in order to support the increased uptake of
this highly effective non-hormonal LARC method.
660 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Acknowledgements
The authors thank Jane Estoesta and Edith Weisberg for
their ongoing support of the study and Kevin McGeechan
for his expert statistical guidance. We also thank Rachel
Pearse, Lorraine Edney, Sarah Robertson and Lina Safro
from Family Planning NSW and Fiona Mack, Jodie
Mauro and Jacqui McLellan from Family Planning
Queensland without whom the study would not have
been possible.
References
1 dArcangues C. Worldwide use of intrauterine devices for
contraception. Contraception 2007; 75: S2S7.
2 United Nations Department of Economic and Social Affairs.
World Contraceptive Patterns, 2013.
3 Cox ML. The Dalkon Shield saga. J Fam Plann Reprod Health
Care 2003; 29: 8.
4 Black KI, Sakhaei T, Garland SM. A study investigating
obstetricians and gynaecologist management of women
requesting an intrauterine device. Aust N Z J Obstet Gynaecol
2010; 50: 184188.
5 Black KI, Lotke P, Lira J et al. Global survey of healthcare
practitioners beliefs and practices around intrauterine
contraceptive method use in nulliparous women. Contraception
2013; 88: 650656.
6 Philliber AE, Hirsch H, Mortillaro L et al. Impact of years of
clinical experience on perceived contraindications and barriers
to the use of LARC: a survey of family planning providers.
Womens Health Issues 2014; 24: 503509.
7 Rose SB, Lawton BA. Impact of long-acting reversible
contraception on return for repeat abortion. Am J Obstet
Gynecol 2012; 206: 37.e1-6.
8 Goldstone P, Mehta YH, McGeechan K et al. Factors
predicting uptake of long-acting reversible methods of
contraception among women presenting for abortion. Med J
Aust 2014; 201: 412416.
9 Thonneau PF, Almont T, Thonneau PF, Almont T.
Contraceptive efcacy of intrauterine devices. Am J Obstet
Gynecol 2008; 198: 248253.
10 Heinemann K, Reed S, Moehner S, Do Minh T. Risk of
uterine perforation with levonorgestrel-releasing and copper
intrauterine devices in the European Active Surveillance Study
on Intrauterine Devices. Contraception 2015; 91: 274279.
11 Heinemann K, Reed S, Moehner S, Do Minh T.
Comparative contraceptive effectiveness of levonorgestrel-
releasing and copper intrauterine devices: the European Active
Surveillance Study for Intrauterine Devices. Contraception
2015; 91: 280283.
12 Mavranezouli I. The cost-effectiveness of long-acting
reversible contraceptive methods in the UK: analysis based on
a decision-analytic model developed for a National Institute
for Health and Clinical Excellence (NICE) clinical practice
guideline. Hum Reprod 2008; 23: 13381345.
13 Winner B, Peipert JF, Zhao Q et al. Effectiveness of long-
acting reversible contraception. N Engl J Med 2012; 366:
19982007.
14 Petta CA, Amatya R, Farr G. Clinical evaluation of the TCu
380A IUD at six Latin American centers. Contraception 1994;
50: 1725.

15 Reinprayoon D, Gilmore C, Farr G, Amatya R. Twelve-
month comparative multicenter study of the TCu 380A and
ML 250 intrauterine devices in Bangkok, Thailand.
Contraception 1998; 58: 201206.
16 Ylikorkala O. Prostaglandin synthesis inhibitors in
menorrhagia, intrauterine contraceptive device-induced side
effects and endometriosis. Pharmacol Toxicol 1994; 75: 8688.
17 ONeil-Callahan M, Peipert JF, Zhao Q et al. Twenty-four-
month continuation of reversible contraception. Obstet Gynecol
2013; 122: 10831091.
18 Diedrich JT, Zhao Q, Madden T et al. Three-year
continuation of reversible contraception. Am J Obstet Gynecol
2015; 213: 662.e1-8.
19 Gray E, McDonald P. Using a reproductive life course
approach to understand contraceptive method use in
Australia. J Biosoc Sci 2010; 42: 4357.
20 Weisberg E, Bateson D, McGeechan K, Mohapatra L. A
three-year comparative study of continuation rates, bleeding
patterns and satisfaction in Australian women using a
subdermal contraceptive implant or progestogen releasing-
intrauterine system. Eur J Contracept Reprod Health Care
2014; 19: 514.
21 Survey Monkey, 2015. [Accessed 30 November 2015].
Available from URL: https://www.surveymonkey.com/?
ut_source=header.
22 University of Sydney Remoteness Lookup Tool, 2001.
[Accessed 30 November 2015]. Available from URL: http://
sydney.edu.au/s/search.html?collection=Usyd&f.Content+type|
x=&query=remoteness+lookup+tool&num_ranks=10&sort=.
23 Sivin I, el Mahgoub S, McCarthy T et al. Long-term
contraception with the levonorgestrel 20 mcg/day (LNg 20)
and the copper T 380Ag intrauterine devices: a ve-year
randomized study. [Erratum appears in Contraception 1991
Jan;43(1):100]. Contraception 1990; 42: 361378.
24 Sivin I, Stern J. Health during prolonged use of levonorgestrel
20 micrograms/d and the copper TCu 380Ag intrauterine
contraceptive devices: a multicenter study. International
Committee for Contraception Research (ICCR). Fertil Steril
1994; 61: 7077.
2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Copper IUD use in Australian women
25 Sivin I, Stern J, Coutinho E et al. Prolonged intrauterine
contraception: a seven-year randomized study of the
levonorgestrel 20 mcg/day (LNg 20) and the Copper T380
Ag IUDS. Contraception 1991; 44: 473480.
26 Statistics ABo. Education and Work Australia May 2015
Canberra: ABS; 2015.
27 Hubacher D, Chen P-L, Park S. Side effects from the copper
IUD: do they decrease over time? Contraception 2009; 79:
356362.
28 Andrade AT, Pizarro E, Shaw ST Jr et al. Consequences of
uterine blood loss caused by various intrauterine contraceptive
devices in South American women. Contraception 1988; 38:
118.
29 Grimes DA, Hubacher D, Lopez LM, Schulz KF. Non-
steroidal anti-inammatory drugs for heavy bleeding or pain
associated with intrauterine-device use. Cochrane Database Syst
Rev 2011.
30 UNDP/UNFPA/WHO/World Bank Special Programme of
Research Development and Research Training in Human
Reproduction: IUD Research Group. A randomized
multicentre trial of the Multiload 375 and TCu380A IUDs in
parous women: three-year results. Contraception 1994; 49:
543549.
31 Champion CB, Behlilovic B, Arosemena JM et al. A three-
year evaluation of TCu 380Ag and multiload Cu 375
intrauterine devices. Contraception 1988; 38: 631639.
32 Grimes D. Intrauterine Devices (IUDs) Contraceptive
Technology. New York, NY: Ardent Medic, 2004.
33 Madden T, McNicholas C, Zhao Q et al. Association of age
and parity with intrauterine device expulsion. Obstet Gynecol
2014; 124: 718726.
34 Zhang J, Feldblum PJ, Chi IC, Farr MG. Risk factors for
copper T IUD expulsion: an epidemiologic analysis.
Contraception 1992; 46: 427433.
35 Time for a change: increasing the use of long acting reversible
contraceptive methods in Australia SH&FPA, 2013. [Accessed
06 January 2016.] Available from http://www.fpv.org.au/assets/
LARCstatementSHFPAFINAL.pdf.
661