Contraception – Methods – IUD

Intrauterine Contraception

Main two available are:

  1. Levonorgesterel Interuterine System (Mirena) (LNG-IUS)
  2. Copper Interuterine deivce (Cu-IUD)

Both are very effective methods of contraception

Insertion and duration of use

  • medical / sexual history and assess need for STI screening
  • If they are low risk of STI/assymptomatic they don’t need screening – you can crack on
  • The LNG-IUS (52mg) has been used for up to five years to provide endometrial protection in conjunction with oestrogen therapy

Advantages

  • Cu-ICD reduces risk of endometrial cancer
  • Cu-ICD reduces risk of cervical cancer
  • 52mg LNG-IUS can reduce pain of dysmenorrhoea/endometriosis/adenomyosis
  • 52mg LNG-IUS can reduce blood loss in heavy menstrual bleeding
  • There is systemic absorption of progesterone from the LNG-IUS – which can lead to acne/breast tenderness/pain / headache – but these do tend to settle with time
  • No evidence that they effect labido
  • Some weight gain is reported with both Cu-ICD and LNG-IUS – it’s not significantly different between them, and there’s acutally very little evidence that it’s cause and effect

Bleeding

  • at 3-6 month women tend to experience irregular/prolonged/frequent bleeding with both types of ICD but this tends to improve with time
  • With the LNG-IUS bleeding is back to normal by 1 year and some women experience ammenorrhoea

Pain

  • Pain is much the same for all types of Copper IUD

Other things

  • Theres no link between breast cancer and IUDs
  • If the woman has had breast cancer then best to be on a non-hormonal (Cu-IUD) contraceptive
  • If you’re going to give her the merina then you need to talk with her cancer specialists
  • Theres no evidence suggesting theres and increase risk of venusthormboembolism or MI with the use of LNG-IUs

 

Ectopic Pregnancy

  • The overall risk of ectopic pregnancy is reduced when using an IUD compared to not using any contraception
  • If pregnancy does occur while using a IUC then it’s more likely to be ectopic – in some studies half of pregnancies were ectopic!!

Complications of IUC

  • Expulsion: 1 in 20, highest risk in first year, particularly first three months
  • Expulsion risk is slightly higher after abortion but doesn’t need to be delayed – as long as the women is aware
  • Ovarian cysts occur with the LNG-IUS but they tend to resolve spontaenously and most are assymptomatic
  • Rate of perforation is approx 2 per 1000, but it is 6 times higher in breastfeeding women
  • Similar return to fertility as after other contraceptive methods
  • Cu-IUD users who have recurrent Bacterial Vaginosis or vulval candida may wish to chose another contracetive method

 

Insertion

Do a bimanual first, valid consent, have an extra pair of hands, don’t use local or topical anaesthetic, but local can be used if you need cervical dilation/it’s gonna be difficult, don’t clean the cervix – it doesn’t help. NSAIDs are all thats needed for pain afterwards.

 

Managing Complications

  • If there’s unschedualled bleeding on LNG-IUS, you can use a CHC as atrial for three months – it can either be used continuously or in the cyclical manner with a pill free period
  • If there’s problematic bleeding with Cu-ICDs then consider NSAIDs
  • If a women has actinomyces-like-organisms you don’t need to put off the insertion/reinsertion, and you don’t need to remove it in this case.
  • If a lady develops pelvic inflammatory disease you don’t need to remove the ICD routeinly, but if she doesn’t respond to treatment in 72 hours then you need to removal
  • The women should be aware of how to check for the threads and if they’re not there then it might have perforated or been expelled, and they’ll need to use other contraception and seek advice.

 

Other Things:

  • Make sure they know it doesn’t protect against STIs
  • Make sure they know about emergency contraception
  • Can arrange a follow up after the first menses but make sure they know about signs of infection/perforation/expulsion
  • Mooncups/tampons aren’t associated with increased risk of explusion
  • Women with cardiac problems should be discussed with cardiology – there’s a risk of a vasovagal response causeing problems –