Choosing an IUD comes down to a handful of key decisions: whether you want hormones, how long you need coverage, how you feel about period changes, and whether you’ve given birth before. There are five IUDs available in the U.S., and while they’re all over 99% effective, they differ in meaningful ways. Here’s a step-by-step way to think through your options.
Step 1: Hormonal or Hormone-Free?
This is the biggest fork in the road. Four of the five IUDs release a small amount of a progestin hormone called levonorgestrel directly into your uterus. The fifth, Paragard, uses copper instead and contains no hormones at all. Both types prevent pregnancy at rates above 99%, so effectiveness alone won’t settle the question. The real differences show up in how each one affects your periods, how long it lasts, and whether you’re comfortable with localized hormones.
If you want to avoid hormones entirely, perhaps because of personal preference, a history of hormone-sensitive conditions, or side effects you’ve experienced on hormonal birth control, Paragard is your only IUD option. It works because copper creates an environment in the uterus that’s toxic to sperm.
If you’re open to hormones (or actively want them for period management), you have four choices: Mirena, Liletta, Kyleena, and Skyla. The hormone stays mostly local to the uterus, so systemic side effects are far less common than with the pill or the shot, but some people do notice mood changes, acne, or breast tenderness.
Step 2: How Will Your Period Change?
This is where the two categories diverge sharply, and for many people it’s the deciding factor.
Hormonal IUDs: Lighter Periods or None at All
Hormonal IUDs thin the uterine lining, which typically makes periods lighter and shorter. Many users eventually stop getting a period altogether. Among first-time users of a higher-dose hormonal IUD, about 17% report no period at all after 12 months. For people who’ve used one before and are getting a replacement, that number climbs to roughly 38%. If you have heavy or painful periods and want relief, a hormonal IUD can double as treatment.
Copper IUD: Heavier Periods, Especially at First
Paragard does the opposite. Copper increases menstrual blood loss by about 50% compared to pre-insertion levels, and that increase stays fairly constant through at least the first year. In studies, about 60% of users reported heavier flow and 50% reported more bleeding days. Around 38% also experienced more menstrual pain in the first couple of months. Some of the perceived heaviness may ease over time as you adjust, but objective measurements of blood loss suggest the increase itself doesn’t shrink much. If your periods are already heavy or painful, Paragard will likely make them worse.
Step 3: How Long Do You Want Coverage?
Each IUD has a different approved lifespan, and this matters if you’re planning around a future pregnancy or simply don’t want to think about contraception for as long as possible.
- Paragard (copper): 10 years
- Mirena (hormonal, higher dose): 8 years
- Liletta (hormonal, higher dose): 8 years
- Kyleena (hormonal, mid dose): 5 years
- Skyla (hormonal, lower dose): 3 years
All IUDs can be removed early if you change your mind, and fertility returns quickly after removal. But if you want the longest “set it and forget it” option, Paragard wins at a decade. Among hormonal options, Mirena and Liletta tie at eight years.
Step 4: Choosing Between Hormonal IUDs
If you’ve decided on a hormonal IUD, the next question is which one. The four options release different daily amounts of levonorgestrel: Mirena starts at about 20 micrograms per day, Kyleena at 17.5, and Skyla at 14. Liletta is comparable to Mirena. In practical terms, this means Mirena and Liletta have the strongest effect on periods, making them the best choices if reducing menstrual bleeding is a priority. Kyleena offers a middle ground with a slightly lower hormone dose and a five-year lifespan. Skyla releases the least hormone and lasts three years.
People sometimes assume a lower hormone dose means fewer side effects, but the differences are subtle since all hormonal IUDs deliver their progestin locally. The more noticeable trade-off is in period suppression: you’re less likely to lose your period entirely on Kyleena or Skyla than on Mirena or Liletta. If the idea of no period appeals to you, lean toward the higher-dose options. If you’d rather still have a light monthly bleed as reassurance you’re not pregnant, Kyleena or Skyla may feel more comfortable.
Step 5: Does It Matter If You Haven’t Given Birth?
All five IUDs are safe for people who have never been pregnant or given birth. This is a common misconception left over from older guidelines. That said, the physical experience can differ slightly. Skyla was originally marketed toward younger, nulliparous users because of its smaller frame, though the size differences between IUDs are small enough that most providers will place any of them regardless of whether you’ve had children.
Expulsion, where the IUD partially or fully slips out of place, is the one area where birth history shows up in the data. Over three years, about 6.9% of nulliparous hormonal IUD users experienced expulsion compared to 12.2% of those who had given birth. Interestingly, the pattern reverses for copper IUDs: nulliparous copper IUD users had a 14.3% expulsion rate versus 8.2% for parous users. If you haven’t given birth and are leaning toward Paragard, it’s worth knowing the expulsion risk is somewhat higher, and you should check your strings regularly.
Emergency Contraception: A Bonus for Paragard
One unique advantage of the copper IUD is that it works as emergency contraception. If inserted within five days of unprotected sex, Paragard is the most effective emergency contraceptive available, and then it stays in place as your ongoing birth control for up to 10 years. No hormonal IUD has this capability.
What Insertion Feels Like
The insertion process is the same for all five IUDs: a provider measures your uterus, then places the device through the cervix using a thin applicator tube. The whole thing takes a few minutes. Most people feel intense cramping during placement that fades quickly, though pain levels vary widely from person to person.
The CDC’s 2024 guidelines note that lidocaine, either as a numbing injection near the cervix or as a topical gel, may reduce pain during placement. This is worth asking about ahead of time, since not all providers offer it by default. The guidelines specifically recommend that you and your provider make a pain management plan together before the appointment. Over-the-counter pain relievers taken beforehand may also help with cramping afterward, though the evidence for them reducing insertion pain itself is limited.
Cost and Insurance Coverage
Under the Affordable Care Act, Marketplace insurance plans must cover all FDA-approved contraceptive methods, including IUDs, with no copay or coinsurance when you use an in-network provider. This applies even if you haven’t met your deductible. That coverage includes the device itself and the insertion procedure. Without insurance, IUDs can cost several hundred dollars or more, but the per-year cost drops significantly the longer you keep them in. Paragard at 10 years and Mirena or Liletta at 8 years offer the best long-term value if out-of-pocket cost is a concern.
A Quick Decision Path
To pull it all together into the flowchart logic you came here for:
- Want zero hormones? Paragard is your only option. Expect heavier periods. Lasts 10 years. Also works as emergency contraception.
- Want lighter periods or no period? Choose Mirena or Liletta for the strongest effect and longest duration (8 years).
- Want hormonal but prefer a lower dose? Kyleena gives you 5 years at a slightly reduced hormone level. Skyla gives you 3 years at the lowest dose.
- Want the longest-lasting option overall? Paragard (10 years), then Mirena or Liletta (8 years).
- Never given birth and worried about fit? All IUDs are safe. Skyla is the smallest, but the size differences are minor. If choosing copper, be aware of the slightly higher expulsion rate for nulliparous users.
- Have heavy or painful periods now? Avoid Paragard. A higher-dose hormonal IUD like Mirena or Liletta can significantly reduce bleeding and cramping.