#186 Long-Acting Reversible Contraception: Implants and Intrauterine Devices Flashcards
What two types of LARC are available in the United States?
Intrauterine devices and etonogestrel single-rod contraceptive implant
What % of US women rely on LARCin 2011? What % are IUD and what % are implant?
11.6% rely on LARC. 10.3% use IUDs and 1.3% use the implant
What % of pregnancies were unintended in 2011?
45%, decrease from 51% in 2008
What was the Contraceptive CHOICE research project?
Prospective cohort of 9,256 women aged 14-45yo, offered choice of contraceptive method without charge.
What % of participants in the CHOICE project chose LARC?
75%
What did the CHOICE project find in regards to rate on unintended pregnancies and abortion rate of study participants?
Decreased compared to similar population from same geographic area
From the public-payer perspective, after how much time does a LARC become cost neutral compared to short acting methods?
Within 3 years of initiation compared with use of short-acting methods
What % of women experience an unintended pregnancy in first year of copper IUD use (typical use and perfect use)?
0.8% (typical) and 0.6% (perfect)
What % of women experience an unintended pregnancy in first year of LNG IUD use (typical use and perfect use)?
0.2% (typical) and 0.2% (perfect)
What % of women experience an unintended pregnancy in first year of implant use (typical use and perfect use)?
0.05% (typical) and 0.05% (perfect)
What % of women experience an unintended pregnancy in first year of combined pill and progestin-only pill use (typical use and perfect use)?
9% (typical) and 0.3% (perfect)
How does the copper IUD prevent pregnancy?
Primarily by preventing fertilization through inhibition of sperm migration and viability
The FDA approved use of the copper IUD for how long? How long does research support use for?
Up to 10 years of continuous use (FDA), up to 12 years (based on three studies)
What is the 10 year failure rate of the copper IUD?
1.9 per 100 women over 10 years
What are the most common adverse events reported by women with the copper IUD?
Heavy menstrual bleeding and pain
What are the types of levonorgestrel IUDs (names and dosage)?
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
How does the LNG-IUD prevent pregnancy?
Prevents fertilization by causing a profound change in the amount and viscosity of cervical mucus, making it impenetrable to sperm
For how long is the LNG-20 IUD (Mirena) FDA approved for? How long does research support use for?
5 years (FDA), research trials support 7 years
For how long is the LNG-18.6 IUD (Liletta) FDA approved for? How long does research support use for?
4 years (FDA), Current data supports 5 years
For how long is the LNG-19.5 IUD (Kyleena) FDA approved for?
5 years
What is the 5 year cumulative pregnancy rate with Kyleena (LNG-19.5 IUD) use?
0.31 per 100 women-years
For how long is the LNG-13.5 IUD (Skyla) FDA approved for?
3 years
What is the 3 year cumulative pregnancy rate with Skyla (LNG-13.5 IUD) use?
0.33 per 100 women-years
What hormone-related effects may women with LNG-IUD experience?
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.
Does LNG-IUD prevent ovulation?
Most women will still ovulate
What is the IUD expulsion rate during the first year?
Between 2-10%
What is the perforation rate for LNG-IUD and Copper-IUD insertions?
1.4 per 1,000 LNG-IUD insertions. 1.1 per 1,000 copper-IUD insertions
What dose of hormone is in the contraceptive implant?
68mg etonogestrel
During what year was the contraceptive implant updated to be radioopaque?
2011
What is the primary mechanism of action of the contraceptive implant to prevent pregnancy?
Suppression of ovulation. Additional contraceptive efficacy may be conferred by thickening of cervical mucus and alteration of endometrial lining
What method is the most effective reversible contraceptive?
Contraceptive implant
What are side effects of the contraceptive implant?
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.
What is the complication rate and what are the complications with contraceptive implant insertion?
Rate 1%. Pain, slight bleeding, hematoma formation, deep or incorrect insertion, and unrecognized noninsertion
What is the complication rate for contraceptive implant removal, what types of complications?
1.7%. Breakage of implant and inability to palpate or locate the implant because of deep insertion.
How can you localize a contraceptive implant that is unable to be palpated?
high-frequency ultrasonography or MRI (for both radiolucent and radioopaque implants). X-ray, CT, fluoroscopy for barium-containing (after 2011) implant.
What is the name of the evidence-based guidance for contraceptives developed by the CDC?
US Medical Eligibility Criteria for Contraceptive Use (US MEC)
Are intrauterine devices and implants appropriate for nulliparous women? For adolescents?
Yes, all the yes.
What is the first-attempt success rate of IUD insertion for patients aged 13-24 [59% were nulliparous]?
95.5%
Is routine use of misoprostol recommended to ease IUD insertion?
Not recommended
When is an appropriate time to insert an IUD device or contraceptive implant during menstrual cycle?
At any time during the menstrual cycle as long as pregnancy may be reasonable excluded
For how long after copper IUD placement is a backup contraceptive method recommended?
No backup method needed regardless of when in menstrual cycle it is inserted
For how long after LNG-IUD placement is a backup contraceptive method recommended?
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
For how long after contraceptive implant placement is a backup contraceptive method recommended?
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
Is insertion of LARC immediately after an induced or spontaneous abortion safe? Effective?
Yes and yes
How soon after an abortion can ovulation resume?
As soon as 10 days after abortion
Can you do immediate IUD placement after second trimester abortion?
yes, but higher rate of expulsion compared to 1st trimester
Can you do immediate IUD placement after septic abortion?
No, contraindicated
For patients undergoing medical abortion with mife/miso regimen, can you place contraceptive implant at time patient receives mife?
Yes
What % of women have unprotected intercourse before the routine 6-week postpartum visit?
Between 40 and 57%
What is the definition of immediate postpartum IUD insertion
Placed within 10 minutes of placental delivery in vaginal and cesarean deliveries
When is immediate postpartum IUD insertion contraindicated?
uterine infection (ie, peripartum chorioamnionitis, endometritis, or puerperal sepsis) or ongoing postpartum hemorrahge
What is the expulsion rate for immediate postpartum IUD placement?
As high as 10-27%
Can you place contraceptive implant immediately postpartum?
yes
Does immediate postpartum LARC (IUD or implant) affect breastfeeding?
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
When is an intrauterine device appropriate for emergency contraception?
Copper IUD, most effective when inserted no later than 5 days after unprotected intercourse
What is pregnancy rate (%) after placement of copper IUD for emergency contraception?
0.23%
How long is the etonogestrel implant effective?
At least 4 years. Two studies of total of 300 women with no pregnancies through 5 years of use.
Is routine screening for STIs required before insertion of IUD?
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
If STI screening performed at time of insertion of IUD comes back positive, do you remove the IUD?
No, can treat STI without removal of IUD
Does prescreening women for STIs prior to IUD insertion compared to screening day of insertion decrease the incidence of PID?
No
Do women with an undiagnosed STI at time of IUD insertion have higher risk of developing PID than women without STI?
Yes, however, even in women with an STI, risk appears low
What is the recommendation regarding IUD placement for patient with gonorrhea or chlamydia infection? With purulent cervicitis?
Delay IUD insertion until treatment course is complete, symptoms have resolved, cervical exam results appear normal, bimanual exam without masses or tenderness.
Due to high risk of reinfection, after how much time should you retest women who have been treated for gonorrhea or chlamydia infection
At 3 months
Is routine antibiotic prophylaxis recommended prior to IUD insertion?
No
When does most of the risk of IUD-related infection occur?
Within the first few weeks to months after insertion
What is the absolute risk of developing PID with IUD user?
Less than 0.5%
What is the most effective treatment for dysmenorrhea or bothersome bleeding from copper IUD?
NSAIDs
Does bleeding and dysmenorrhea increase, decrease, or remain stable over time in copper IUD users?
Decrease over time
For how long after LNG-IUD placement is irregular or prolonged spotting common?
First 90 days, lessens over time
What does evidence support using for treatment of bleeding and spotting associated with LNG-IUD use?
NSAIDs.
By what % does LNG-20 IUD use decrease menstrual blood loss?
By 79-97%
Does the contraceptive implant affect dysmenorrhea?
Yes, improves it
What is the bleeding profile with the contraceptive implant?
From CHOICE project: 42% decreased bleeding frequency, 35% increased bleeding frequency at 3mo. 48% decreased and 21% increased at 6mo
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?
50% chance of improving
What are options to improve unfavorable bleeding with contraceptive implant use?
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.
What gynecologic procedures can be performed with an IUD in place?
EMB, colposcopy, cervical ablation or excision, and endocervical sampling
What is recommended management of asymptomatic patient with IUD who has actinomyces idenitifed on cervical cytology screening?
Incidental finding, no antimicrobial treatment needed, IUD may be left in place
What is the concern about pelvic actinomyces? What is the prevalence?
Pelvic actinomycosis characterized by granulomatous pelvic abscesses, prevalence estimated to be less than 0.001%
For women who are pregnant, with an IUD in place, and want a medical abortion, what steps should be taken?
Confirm IUP and not ectopic. Remove IUD prior to medication-induced abortion
For women pregnant with an IUD are adverse pregnancy outcomes greater in setting of IUD removal or retention?
IUD retention
For women who become pregnant (IUP) with IUD in place, what are the risks of pregnancy with an IUD in place?
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.
Does IUD use lead to higher absolute risk of ectopic pregnancy?
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
When should an IUD or implant be removed in a menopausal woman?
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
When is IUD removal recommended in pregnant women?
When strings are visible or can be safely removed from cervical canal
