Review article| Volume 87, ISSUE 4, P486-496, April 2013

Hemoglobin and serum ferritin levels in women using copper-releasing or levonorgestrel-releasing intrauterine devices: a systematic review

  • Richard F. Lowe
    Venture Strategies Innovations, Berkeley, CA 94704, USA
    Search for articles by this author
  • Ndola Prata
    Corresponding author. Scientific Director, Bixby Center for Population Health and Sustainability, School of Public Health, University of California, Berkeley, 229 University Hall, Berkeley, CA 94720-6390. Tel.: +1 510 643 4284.
    Bixby Center for Population, Health and Sustainability, Berkeley, CA 94720, USA
    Search for articles by this author



      The use of intrauterine devices as a contraceptive method has been steadily growing in developing countries. Anemia in reproductive-age women is a growing concern in those settings.

      Study Design

      A systematic review of studies with measured hemoglobin and serum ferritin at baseline and after 1 year of use of copper intrauterine devices (IUDs) or a levonorgestrel-releasing intrauterine system (LNG IUS) was performed.


      Fourteen studies involving copper IUDs in nonanemic women and 4 studies in anemic women and 6 involving the LNG IUS met the criteria for the systematic review. Meta-analyses for hemoglobin changes showed significant decreases for users of copper IUDs and an increase for the LNG IUS, but with limited data. In general, ferritin levels followed the same pattern.


      Decreases in hemoglobin mean values in copper IUD users were not sufficient to induce anemia in previously nonanemic women. Women who are borderline anemic would likely benefit from using the LNG IUS.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Contraception
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • World Health Organization
        Iron deficiency anemia: assessment, prevention, and control: a guide for programme managers. WHO, Geneva2001
        • World Health Organization
        Nutritional anaemias. Report of a WHO scientific group. WHO Technical Report Series, Geneva1968
        • Hallberg L.
        • Hogdahl A.M.
        • Nilsson L.
        • Rybo G.
        Menstrual blood loss ��� a population study. Variation at different ages and attempts to define normality.
        Acta Obstet Gynecol Scand. 1966; 45: 320-351
        • Wood C.
        Menorrhagia: a management update.
        Mod Med Aust. 2000; 42: 65-75
        • Cohen B.J.
        • Gibor Y.
        Anemia and menstrual blood loss.
        Obstet Gynecol Surv. 1980; 35: 597-618
        • Mishell Jr., D.R.
        Intrauterine devices: mechanisms of action, safety, and efficacy.
        Contraception. 1998; 58 ([quiz 70S]): 45S-53S
        • Nilsson C.G.
        • Luukkainen T.
        • Diaz J.
        • Allonen H.
        Intrauterine contraception with levonorgestrel: a comparative randomised clinical performance study.
        Lancet. 1981; 1: 577-580
        • 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: 70-77
        • Sivin I.
        • Stern J.
        • Coutinho E.
        • Mattos C.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: 473-480
        • Luukkainen T.
        • Allonen H.
        • Haukkamaa M.
        • Lahteenmaki P.
        • Nilsson C.G.
        • Toivonen J.
        Five years' experience with levonorgestrel-releasing IUDs.
        Contraception. 1986; 33: 139-148
        • Andersson K.
        • Odlind V.
        • Rybo G.
        Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial.
        Contraception. 1994; 49: 56-72
        • Hubacher D.
        • Grimes D.A.
        Noncontraceptive health benefits of intrauterine devices: a systematic review.
        Obstet Gynecol Surv. 2002; 57: 120-128
        • Luukkainen T.
        • Toivonen J.
        Levonorgestrel-releasing IUD as a method of contraception with therapeutic properties.
        Contraception. 1995; 52: 269-276
        • Pakarinen P.
        • Toivonen J.
        • Luukkainen T.
        Therapeutic use of the LNG IUS, and counseling.
        Semin Reprod Med. 2001; 19: 365-372
        • Sivin I.
        Potential benefits in developing countries through use of the levonorgestrel-releasing intrauterine system.
        Gynecol Forum. 1998; 3: 23-25
        • Pakarinen P.
        • Luukkainen T.
        Treatment of menorrhagia with an LNG-IUS.
        Contraception. 2007; 75: S118-S122
        • Milsom I.
        The levonorgestrel-releasing intrauterine system as an alternative to hysterectomy in peri-menopausal women.
        Contraception. 2007; 75: S152-S154
        • Stewart A.
        • Cummins C.
        • Gold L.
        • Jordan R.
        • Phillips W.
        The effectiveness of the levonorgestrel-releasing intrauterine system in menorrhagia: a systematic review.
        BJOG. 2001; 108: 74-86
        • Clancy K.B.
        • Nenko I.
        • Jasienska G.
        Menstruation does not cause anemia: endometrial thickness correlates positively with erythrocyte count and hemoglobin concentration in premenopausal women.
        Am J Hum Biol. 2006; 18: 710-713
        • Moher D.
        • Cook D.J.
        • Eastwood S.
        • Olkin I.
        • Rennie D.
        • Struop D.F.
        Improving the quality of reports of meta-analyses of randomized controlled trials: the QUOROM statement.
        Lancet. 1999; 354: 1896-1900
        • StataCorp
        Stata survey data reference manual: release 11. StataCorp LP, College Station, TX2009
        • Goh T.H.
        • Hariharan M.
        • Tan C.H.
        A longitudinal study of serum iron indices and haemoglobin concentration following copper-IUD insertion.
        Contraception. 1980; 22: 389-395
        • Guillebaud J.
        • Barnett M.D.
        • Gordon Y.B.
        Plasma ferritin levels as an index of iron deficiency in women using intrauterine devices.
        Br J Obstet Gynaecol. 1979; 86: 51-55
        • Nehra P.C.
        • Magyar D.M.
        Hematologic characteristics in IUD users.
        Contracept Deliv Syst. 1982; 3: 149-154
        • Fernandez X.T.
        • Young B.
        • Lavin P.
        • Baeza R.
        • Seaman V.
        The IUD and anemia: a study of hematocrit.
        Contracept Deliv Syst. 1980; 1: 49-53
        • Gao J.
        The effects of four types of IUD in China on menstrual blood volume.
        Shengzhi Yu Biyun. 1986; 6: 52-53
        • Jing P.H.
        • Huang Z.L.
        • Liu Q.X.
        Measurement of menstrual blood loss following insertion of Copper-V 200 intrauterine device.
        Shengzhi Yu Biyun. 1982; 2: 19-22
        • El-sheikha Z.
        • Hamza A.
        • Mahmoud M.
        Menstrual blood loss of TCu-380 A and TCu-200 B IUDs.
        Popul Sci. 1990; : 55-62
        • Sadek S.S.
        • El Sahwi S.
        • Sadek W.
        Effect of the Cu T380 IUD on hemoglobin and iron stores in Egyptian women.
        Int J Gynaecol Obstet. 1999; 64: 69-70
        • Tchai B.S.
        • Kim S.W.
        • Han J.H.
        • Im M.W.
        Menstrual blood loss, iron nutriture, and the effects of Alza-T IPCS 52, T-Cu 220C and Lippes Loop D in Korean women.
        Seoul J Med. 1987; 28: 51-59
        • Task Force for Epidemiological Research on Reproductive Health
        • United Nations Development Programme/United Nations Population Fund/World Health Organization/World Bank Special Programme of Research
        • Development, Research Training in Human Reproduction
        • World Health Organization
        Effects of contraceptives on hemoglobin and ferritin.
        Contraception. 1998; 58: 261-273
        • Blum M.
        • Pery J.
        Prevention of iron deficiency anemia in IUD users by prostaglandin synthetase inhibitors.
        Contracept Deliv Syst. 1984; 5: 21-23
        • Heikkinen J.E.
        • Saure A.
        • Ylostalo P.
        Serum ferritin levels in pill and IUD users.
        Contracept Deliv Syst. 1983; 4: 137-141
        • Oyelola O.O.
        • Okonofua F.E.
        • Adediran T.O.
        Menstrual bleeding pattern and iron status in women fitted with copper and non-medicated intrauterine contraceptive devices.
        East Afr Med J. 1994; 71: 268-270
        • Faguer C.
        Study and significance of ferritin levels in 104 women using intrauterine devices.
        J Gynecol Obstet Biol Reprod (Paris). 1994; 23: 141-144
        • Faundes A.
        • Alvarez F.
        • Brache V.
        • Tejada A.S.
        The role of the levonorgestrel intrauterine device in the prevention and treatment of iron deficiency anemia during fertility regulation.
        Int J Gynaecol Obstet. 1988; 26: 429-433
        • Faundes A.
        • Alvarez F.
        • Diaz J.
        A Latin American experience with levonorgestrel IUD.
        Ann Med. 1993; 25: 149-153
        • Goh T.H.
        • Hariharan M.
        Iron-deficiency anemia and long-term use of copper-bearing IUDs.
        Contracept Deliv Syst. 1982; 3: 17-20
        • Luukkainen T.
        • Allonen H.
        • Haukkamaa M.
        • et al.
        Effective contraception with the levonorgestrel-releasing intrauterine device: 12-month report of a European multicenter study.
        Contraception. 1987; 36: 169-179
        • Sivin I.
        • Stern J.
        • Diaz J.
        • Diaz M.M.
        • et al.
        Two years of intrauterine contraception with levonorgestrel and with copper: a randomized comparison of the TCu 380Ag and levonorgestrel 20 mcg/day devices.
        Contraceptio. 1987; 35: 245-255
        • Souza J.P.
        • Andrade A.T.
        • Pizarro E.
        Menstrual blood loss and body iron stores: comparative study between a Multiload-375 IUD and a levonorgestrel vaginal ring.
        Bol Cent Biol Reprod. 1991; 10: 26-32
        • Milsom I.
        • Jonasson K.
        • Lindstedt G.
        • Rybo G.
        The long-term effects of copper surface area on menstrual blood loss and iron status in women fitted with an IUD.
        Contraception. 1993; 48: 471-480
        • Andrade A.T.
        • Pizarro E.
        • Shaw Jr., S.T.
        • Souza J.P.
        • Belsey E.M.
        • Rowe P.J.
        Consequences of uterine blood loss caused by various intrauterine contraceptive devices in South American women. World Health Organization Special Programme of Research, Development and Research Training in Human Reproduction.
        Contraception. 1988; 38: 1-18
        • Gao J.
        • Zeng S.
        • Sun B.L.
        • et al.
        Menstrual blood loss, haemoglobin and ferritin concentration of Beijing women wearing steel ring, VCu 200, and TCu 220c IUDs.
        Contraception. 1986; 34: 559-571
        • Haugan T.
        • Skjeldestad F.E.
        • Halvorsen L.E.
        • Kahn H.
        A randomized trial on the clinical performance of Nova T380 and Gyne T380 Slimline copper IUDs.
        Contraception. 2007; 75: 171-176
        • Heikkila M.
        • Nylander P.
        • Luukkainen T.
        Body iron stores and patterns of bleeding after insertion of a levonorgestrel- or a copper-releasing intrauterine contraceptive device.
        Contraception. 1982; 26: 465-474
        • Imperato F.
        • Perniola G.
        • Mossa B.
        • et al.
        The role of copper-releasing intrauterine device or levonorgestrel-releasing intrauterine system on uterine bleeding and iron status (prospective study of 8 years).
        Minerva Ginecol. 2002; 54: 271-278
        • Milsom I.
        • Andersson K.
        • Jonasson K.
        • Lindstedt G.
        • Rybo G.
        The influence of the Gyne-T 380S IUD on menstrual blood loss and iron status.
        Contraception. 1995; 52: 175-179
        • Milsom I.
        • Rybo G.
        • Lindstedt G.
        The influence of copper surface area on menstrual blood loss and iron status in women fitted with an IUD.
        Contraception. 1990; 41: 271-281
        • Pedron Nuevo N.
        • Gonzalez Diddi M.
        • Alvarado Duran A.
        • Gallegos A.
        • Aznar Ramos R.
        Changes in menstrual flow induced by copper intrauterine devices.
        Ginecol Obstet Mex. 1982; 50: 165-168
        • Piedras J.
        • Cordova M.S.
        • Perez-Toral M.C.
        • Lince E.
        • Garza-Flores J.
        Predictive value of serum ferritin in anemia development after insertion of T Cu 220 intrauterine device.
        Contraception. 1983; 27: 289-297
        • Sivin I.
        • Alvarez F.
        • Diaz J.
        • et al.
        Intrauterine contraception with copper and with levonorgestrel: a randomized study of the TCu 380Ag and levonorgestrel 20 mcg/day devices.
        Contraception. 1984; 30: 443-456
        • Wright E.A.
        • Kapu M.M.
        • Isichei U.P.
        Zinc depletion and menorrhagia in Nigerians using copper T-200 intrauterine device.
        Trace Elem Med. 1989; 6: 147-149
        • China National IUD Research Group
        A randomized, multicenter comparative study of three types of IUD.
        Shengzhi Yu Biyun. 1987; 7: 39-47
        • Kivijarvi A.
        • Timonen H.
        • Rajamaki A.
        • Gronroos M.
        Iron deficiency in women using modern copper intrauterine device.
        Obstet Gynecol. 1986; 67: 95-98
        • Cheng W.
        Relationship between IUD and menstrual blood loss.
        Tianjin Yi Yao. 1988; 16: 212-215
        • Goh T.H.
        • Hariharan M.
        Effect of laparoscopic sterilization and insertion of Multiload Cu 250 and Progestasert IUDs on serum ferritin levels.
        Contraception. 1983; 28: 329-336
        • Hassan E.O.
        • el-Husseini M.
        • el-Nahal N.
        The effect of 1-year use of the CuT 380A and oral contraceptive pills on hemoglobin and ferritin levels.
        Contraception. 1999; 60: 101-105
        • Rivera R.
        • Almonte H.
        • Arreola M.
        • et al.
        The effects of three different regimens of oral contraceptives and three different intrauterine devices on the levels of hemoglobin, serum iron and iron binding capacity in anemic women.
        Contraception. 1983; 27: 311-327
        • Dubuisson J.B.
        • Mugnier E.
        Acceptability of the levonorgestrel-releasing intrauterine system after discontinuation of previous contraception: results of a French clinical study in women aged 35 to 45 years.
        Contraception. 2002; 66: 121-128
        • Gao J.
        • Wang S.L.
        • Wu S.C.
        • Sun B.L.
        • Allonen H.
        • Luukkainen T.
        Comparison of the clinical performance, contraceptive efficacy and acceptability of levonorgestrel-releasing IUD and Norplant-2 implants in China.
        Contraception. 1990; 41: 485-494
      1. Wang SL, et al. A comparative study of norplant-2 and levonorgestrel-releasing intrauterine device. Zhong hua fu chan ke za zhi (Chinese Journal of, Obstetrics and Gynecology. 1990;25(4):232���3, 253.

        • Ratsula K.
        • Toivonen J.
        • Allonen H.
        Patterns of bleeding and body iron stores during the use of a levonorgestrel-releasing intracervical device.
        Contraception. 1988; 38: 333-340