#186 Long-Acting Reversible Contraception: Implants and Intrauterine Devices

Question 1

What two types of LARC are available in the United States?

Answer 1

Intrauterine devices and etonogestrel single-rod contraceptive implant

Question 2

What % of US women rely on LARCin 2011? What % are IUD and what % are implant?

Answer 2

11.6% rely on LARC. 10.3% use IUDs and 1.3% use the implant

Question 3

What % of pregnancies were unintended in 2011?

Answer 3

45%, decrease from 51% in 2008

Question 4

What was the Contraceptive CHOICE research project?

Answer 4

Prospective cohort of 9,256 women aged 14-45yo, offered choice of contraceptive method without charge.

Question 5

What % of participants in the CHOICE project chose LARC?

Answer 5

75%

Question 6

What did the CHOICE project find in regards to rate on unintended pregnancies and abortion rate of study participants?

Answer 6

Decreased compared to similar population from same geographic area

Question 7

From the public-payer perspective, after how much time does a LARC become cost neutral compared to short acting methods?

Answer 7

Within 3 years of initiation compared with use of short-acting methods

Question 8

What % of women experience an unintended pregnancy in first year of copper IUD use (typical use and perfect use)?

Answer 8

0.8% (typical) and 0.6% (perfect)

Question 9

What % of women experience an unintended pregnancy in first year of LNG IUD use (typical use and perfect use)?

Answer 9

0.2% (typical) and 0.2% (perfect)

Question 10

What % of women experience an unintended pregnancy in first year of implant use (typical use and perfect use)?

Answer 10

0.05% (typical) and 0.05% (perfect)

Question 11

What % of women experience an unintended pregnancy in first year of combined pill and progestin-only pill use (typical use and perfect use)?

Answer 11

9% (typical) and 0.3% (perfect)

Question 12

How does the copper IUD prevent pregnancy?

Answer 12

Primarily by preventing fertilization through inhibition of sperm migration and viability

Question 13

The FDA approved use of the copper IUD for how long? How long does research support use for?

Answer 13

Up to 10 years of continuous use (FDA), up to 12 years (based on three studies)

Question 14

What is the 10 year failure rate of the copper IUD?

Answer 14

1.9 per 100 women over 10 years

Question 15

What are the most common adverse events reported by women with the copper IUD?

Answer 15

Heavy menstrual bleeding and pain

Question 16

What are the types of levonorgestrel IUDs (names and dosage)?

Answer 16

Mirena - 52mg total, releases 20mcg/day
Liletta - 52mg total, releases 18.6mcg/day
Kyleena - 19.5mg total, releases 17.5mcg/day
Skyla - 13.5mg total, releases 14mcg/day

Question 17

How does the LNG-IUD prevent pregnancy?

Answer 17

Prevents fertilization by causing a profound change in the amount and viscosity of cervical mucus, making it impenetrable to sperm

Question 18

For how long is the LNG-20 IUD (Mirena) FDA approved for? How long does research support use for?

Answer 18

5 years (FDA), research trials support 7 years

Question 19

For how long is the LNG-18.6 IUD (Liletta) FDA approved for? How long does research support use for?

Answer 19

4 years (FDA), Current data supports 5 years

Question 20

For how long is the LNG-19.5 IUD (Kyleena) FDA approved for?

Answer 20

5 years

Question 21

What is the 5 year cumulative pregnancy rate with Kyleena (LNG-19.5 IUD) use?

Answer 21

0.31 per 100 women-years

Question 22

For how long is the LNG-13.5 IUD (Skyla) FDA approved for?

Answer 22

3 years

Question 23

What is the 3 year cumulative pregnancy rate with Skyla (LNG-13.5 IUD) use?

Answer 23

0.33 per 100 women-years

Question 24

What hormone-related effects may women with LNG-IUD experience?

Answer 24

Headaches, nausea, breast tenderness, mood changes, and ovarian cyst formation. Weight gain comparable with copper IUD users. Acne is rarely reported. Does not appear to have adverse effect on bone mineral density or increase risk of fracture.

Question 25

Does LNG-IUD prevent ovulation?

Answer 25

Most women will still ovulate

Question 26

What is the IUD expulsion rate during the first year?

Answer 26

Between 2-10%

Question 27

What is the perforation rate for LNG-IUD and Copper-IUD insertions?

Answer 27

1.4 per 1,000 LNG-IUD insertions. 1.1 per 1,000 copper-IUD insertions

Question 28

What dose of hormone is in the contraceptive implant?

Answer 28

68mg etonogestrel

Question 29

During what year was the contraceptive implant updated to be radioopaque?

Answer 29

2011

Question 30

What is the primary mechanism of action of the contraceptive implant to prevent pregnancy?

Answer 30

Suppression of ovulation. Additional contraceptive efficacy may be conferred by thickening of cervical mucus and alteration of endometrial lining

Question 31

What method is the most effective reversible contraceptive?

Answer 31

Contraceptive implant

Question 32

What are side effects of the contraceptive implant?

Answer 32

Changes in menstrual bleeding pattern (amenorrhea, infrequent, frequent, or prolonged bleeding). GI difficulties, HA, breast pain, vaginitis. No significant change in weight gain compared to copper IUD users. Worsening of acne in 10-14%. No significant effect on bone mineral density.

Question 33

What is the complication rate and what are the complications with contraceptive implant insertion?

Answer 33

Rate 1%. Pain, slight bleeding, hematoma formation, deep or incorrect insertion, and unrecognized noninsertion

Question 34

What is the complication rate for contraceptive implant removal, what types of complications?

Answer 34

1.7%. Breakage of implant and inability to palpate or locate the implant because of deep insertion.

Question 35

How can you localize a contraceptive implant that is unable to be palpated?

Answer 35

high-frequency ultrasonography or MRI (for both radiolucent and radioopaque implants). X-ray, CT, fluoroscopy for barium-containing (after 2011) implant.

Question 36

What is the name of the evidence-based guidance for contraceptives developed by the CDC?

Answer 36

US Medical Eligibility Criteria for Contraceptive Use (US MEC)

Question 37

Are intrauterine devices and implants appropriate for nulliparous women? For adolescents?

Answer 37

Yes, all the yes.

Question 38

What is the first-attempt success rate of IUD insertion for patients aged 13-24 [59% were nulliparous]?

Answer 38

95.5%

Question 39

Is routine use of misoprostol recommended to ease IUD insertion?

Answer 39

Not recommended

Question 40

When is an appropriate time to insert an IUD device or contraceptive implant during menstrual cycle?

Answer 40

At any time during the menstrual cycle as long as pregnancy may be reasonable excluded

Question 41

For how long after copper IUD placement is a backup contraceptive method recommended?

Answer 41

No backup method needed regardless of when in menstrual cycle it is inserted

Question 42

For how long after LNG-IUD placement is a backup contraceptive method recommended?

Answer 42

7 days after insertion, unless inserted immediately after surgical abortion, within 21 days of childbirth, upon transition from another reliable contraceptive method, within the first 7 days since menstrual bleeding started

Question 43

For how long after contraceptive implant placement is a backup contraceptive method recommended?

Answer 43

7 days after insertion, unless inserted immediately after surgical abortion, within 21 days of childbirth, upon transition from another reliable contraceptive method, within the first 5 days since menstrual bleeding started

Question 44

Is insertion of LARC immediately after an induced or spontaneous abortion safe? Effective?

Answer 44

Yes and yes

Question 45

How soon after an abortion can ovulation resume?

Answer 45

As soon as 10 days after abortion

Question 46

Can you do immediate IUD placement after second trimester abortion?

Answer 46

yes, but higher rate of expulsion compared to 1st trimester

Question 47

Can you do immediate IUD placement after septic abortion?

Answer 47

No, contraindicated

Question 48

For patients undergoing medical abortion with mife/miso regimen, can you place contraceptive implant at time patient receives mife?

Answer 48

Yes

Question 49

What % of women have unprotected intercourse before the routine 6-week postpartum visit?

Answer 49

Between 40 and 57%

Question 50

What is the definition of immediate postpartum IUD insertion

Answer 50

Placed within 10 minutes of placental delivery in vaginal and cesarean deliveries

Question 51

When is immediate postpartum IUD insertion contraindicated?

Answer 51

uterine infection (ie, peripartum chorioamnionitis, endometritis, or puerperal sepsis) or ongoing postpartum hemorrahge

Question 52

What is the expulsion rate for immediate postpartum IUD placement?

Answer 52

As high as 10-27%

Question 53

Can you place contraceptive implant immediately postpartum?

Answer 53

yes

Question 54

Does immediate postpartum LARC (IUD or implant) affect breastfeeding?

Answer 54

Progestin-only contraceptives do not appear to adversely affect a woman’s ability to successfully initiate and continue breastfeeding or an infant’s growth and development

Question 55

When is an intrauterine device appropriate for emergency contraception?

Answer 55

Copper IUD, most effective when inserted no later than 5 days after unprotected intercourse

Question 56

What is pregnancy rate (%) after placement of copper IUD for emergency contraception?

Answer 56

0.23%

Question 57

How long is the etonogestrel implant effective?

Answer 57

At least 4 years. Two studies of total of 300 women with no pregnancies through 5 years of use.

Question 58

Is routine screening for STIs required before insertion of IUD?

Answer 58

Patient should receive CD-recommended STI screening at time of insertion without delaying awaiting test results. Asymptomatic women who are at low risk and have previously undergone screening do not need additional screening at time of insertion

Question 59

If STI screening performed at time of insertion of IUD comes back positive, do you remove the IUD?

Answer 59

No, can treat STI without removal of IUD

Question 60

Does prescreening women for STIs prior to IUD insertion compared to screening day of insertion decrease the incidence of PID?

Answer 60

No

Question 61

Do women with an undiagnosed STI at time of IUD insertion have higher risk of developing PID than women without STI?

Answer 61

Yes, however, even in women with an STI, risk appears low

Question 62

What is the recommendation regarding IUD placement for patient with gonorrhea or chlamydia infection? With purulent cervicitis?

Answer 62

Delay IUD insertion until treatment course is complete, symptoms have resolved, cervical exam results appear normal, bimanual exam without masses or tenderness.

Question 63

Due to high risk of reinfection, after how much time should you retest women who have been treated for gonorrhea or chlamydia infection

Answer 63

At 3 months

Question 64

Is routine antibiotic prophylaxis recommended prior to IUD insertion?

Answer 64

No

Question 65

When does most of the risk of IUD-related infection occur?

Answer 65

Within the first few weeks to months after insertion

Question 66

What is the absolute risk of developing PID with IUD user?

Answer 66

Less than 0.5%

Question 67

What is the most effective treatment for dysmenorrhea or bothersome bleeding from copper IUD?

Answer 67

NSAIDs

Question 68

Does bleeding and dysmenorrhea increase, decrease, or remain stable over time in copper IUD users?

Answer 68

Decrease over time

Question 69

For how long after LNG-IUD placement is irregular or prolonged spotting common?

Answer 69

First 90 days, lessens over time

Question 70

What does evidence support using for treatment of bleeding and spotting associated with LNG-IUD use?

Answer 70

NSAIDs.

Question 71

By what % does LNG-20 IUD use decrease menstrual blood loss?

Answer 71

By 79-97%

Question 72

Does the contraceptive implant affect dysmenorrhea?

Answer 72

Yes, improves it

Question 73

What is the bleeding profile with the contraceptive implant?

Answer 73

From CHOICE project: 42% decreased bleeding frequency, 35% increased bleeding frequency at 3mo. 48% decreased and 21% increased at 6mo

Question 74

If a woman has an unfavorable bleeding patter within the first 3 months of use of contraceptive implant, what is the likelihood that it will improve?

Answer 74

50% chance of improving

Question 75

What are options to improve unfavorable bleeding with contraceptive implant use?

Answer 75

5-7 day course of NSAIDs. Low-dose combined oral contraceptive pill (if medically eligible). Possible improvement with mifepristone in combo with ethinyl estradiol or doxycycline. Bleeding resumed after hormonal treatment.

Question 76

What gynecologic procedures can be performed with an IUD in place?

Answer 76

EMB, colposcopy, cervical ablation or excision, and endocervical sampling

Question 77

What is recommended management of asymptomatic patient with IUD who has actinomyces idenitifed on cervical cytology screening?

Answer 77

Incidental finding, no antimicrobial treatment needed, IUD may be left in place

Question 78

What is the concern about pelvic actinomyces? What is the prevalence?

Answer 78

Pelvic actinomycosis characterized by granulomatous pelvic abscesses, prevalence estimated to be less than 0.001%

Question 79

For women who are pregnant, with an IUD in place, and want a medical abortion, what steps should be taken?

Answer 79

Confirm IUP and not ectopic. Remove IUD prior to medication-induced abortion

Question 80

For women pregnant with an IUD are adverse pregnancy outcomes greater in setting of IUD removal or retention?

Answer 80

IUD retention

Question 81

For women who become pregnant (IUP) with IUD in place, what are the risks of pregnancy with an IUD in place?

Answer 81

Increased risk of spontaneous abortion, septic abortion, chorioamnionitis, preterm delivery. A study with copper IUD showed increased rates of placental abruption, placenta previa, preterm delivery, cesarean delivery, low-birth-weight infants, and chorio.

Question 82

Does IUD use lead to higher absolute risk of ectopic pregnancy?

Answer 82

No. If pregnancy occurs with IUD in place, pregnancy is more likely to be ectopic, but IUDs prevent pregnancy so effectively the absolute risk is not increased

Question 83

When should an IUD or implant be removed in a menopausal woman?

Answer 83

No compelling evidence for guidance. Advisable to await 1 year of amenorrhea in women with copper IUD. Given that amenorrhea may be secondary effect of LNG-IUD and implant, reasonable to continue methods until age 50-55

Question 84

When is IUD removal recommended in pregnant women?

Answer 84

When strings are visible or can be safely removed from cervical canal