Contraception Part III: Long Acting Reversible Contraceptives Flashcards
Intrauterine Contraception
§ Levonorgestrel Intrauterine System (LNG-IUS)
- Inhibits normal sperm movement, thicken cervical mucus, thining ling of uterus, does not inhibit ovulation
§ Copper Intrauterine Device (Cu-IUD)
LNG-IUS Uses:
§ Contraception – as effective as permanent
contraception methods, also high continuation rates.
§ Treatment of heavy or abnormal uterine bleeding
§ Dysmenorrhea
§ Provide endometrial protection from estrogens
(individuals who can not tolerate progesterone) - not
approved indication
Has been used for menopausal women, endometrial protection
Lower progestin for ppl who cannot tolerate
Two LNG-intrauterine systems (IUS) in Canada
LNG-IUS 52 mg
(Mirena®*)
32mm wide (larger)
5 years Initial 20 μg/day, reduced to 10 μg/day by 5 years (systemic levels ~150 – 200 pg/ml)
Intiially a bit of absorption which declines over time
(Kyleena®*)
28 mm wide
5 years Initial 17 μg/day, reduced to 15 μg/day by 2 months, then 7 μg/day
by 5 years
data shows longer than 5 yrs up to 7 yrs
Costs - ~$350+
LNG-IUS AE
§ Majority have reduced vaginal bleeding, with amenorrhea
common (up to 70% in 2 years)
§ Adverse effects:
–Irregular bleeding – spotting is common for the first 3– 6 months
–Pain with placement, abdominal/pelvic pain
–Systemic LNG levels (though much lower than COC) may lead to mood effects, breast tenderness, headache, etc
–Rare: malposition, expulsion
Intrauterine Contraception: Cu-IUD
MOA
duration
§ Mechanism: copper ions inhibits sperm
movement and ability to fertilize ovum.
Foreign body and ions prevent normal sperm movement
§ Duration: most are 5 to 10 years
depending on model
§ Types of Cu-IUD:
–10 yrs: Liberte TT standard, Mona Lisa 10
–5 yrs: Liberte UT & TT short; Mona Lisa 5 (note
Mona Lisa N is for 3 years), Flexi T
§ Cost ~95+ cheaper
dont memorize brands
Intrauterine Contraception: Cu-IUD
AE
advantages
–Irregular bleeding/BTB – more compared to LNG-IUS
–Increase in dysmenorrhea/pelvic pain/cramps compared to LNG-IUS
§ Advantage: cheaper, no hormonal side effects, may be alternative for choosing non-hormonal option
§ Works immediately, backup contraception not necessary
MOST EFFECTIVE EMERGENCY CONTRACEPTIVE
More BTB
Progestin and levogesterol IUD helss revents thinning, of lining causing bleeding but not copper IUD
More pelvic pain or cramping
Intrauterine Contraception
Contraindications:
Category 4:
Pregnancy
Current PID (pelvic inflamm disease)
Current breast cancer (PR positive) - LNG-IUS only
Undiagnosed abnormal uterine bleeding.
Puerperal sepsis (infection of genital tract after childbirth)
Cervical or endometrial cancer (awaiting treatment)
Category 3: past history PR+ve breast cancer (LNG-IUS), liver
disease (LNG-IUS), postpartum >48 hours to <4 weeks
If assessing IUC, must make sure not pregnant!
What questions should you ask?
is misoprostil needed?
§ Insertion pain is often mild for most individuals and is not prolonged. Can pre-medicate with NSAID/acetaminophen.
§ Misoprostil administration prior to insertion is usually not necessary.
–What does misoprostil do in this setting?
Can soften the cervix allows easier penetration of IUD
Not necessary for majority, sometimes used if difficult insertion
§ Patients who develop STI while on IUC should have STI treated, removal of IUC is not necessary.
Risks with Intrauterine Contraception
expulsion: most common in 1st y, 3-10%
uterine perforation: rare, inexp inserter, postpartum or breastfeeding women
PID: risk is first month of insertion, higher risk if BV, cervicitis, contam with instrument
vasovagal/fainting w/ insertion: prior vasovagal reaction, cervical stenosis
What about ectopic pregnancy (preg if fallopian tubes)? Does not increase risk of ectopic pregnancy (actually
lower), but if pregnancy does occur (which is very low chance) while on IUC, it is more likely ectopic.
Common Myths and Misconceptions
Regarding Intrauterine Contraception (IUC)
IUC increases sexually transmitted diseases and PID
They do not increase STD or PID
IUC can lead to infertility There is normal return to fertility after discontinuation
IUC can only be used by parous individuals
They can be used in nulliparous as well
IUC can lead to uterine perforations The risk of uterine perforation is rare
IUC can increase ectopic pregnancy They do not increase risk of ectopic pregnancy
Contraceptive Implant
Subdermal progestin implant (Nexplanon®)
§ Single 4 cm long implant
§ Contains etonogestrel 68 mg* 3rd gen progestin
§ Duration: 3 years
§ Placed under skin of upper arm (with a
preloaded inserter)
*Releases 60 mcg etonogestrel daily for the first month, then decreases down to ~30 mcg daily at the end of 3 years of use (initial release is high)
Contraceptive Implant
§ MOA
suppression of ovulation is primary effect, also thickens
cervical mucous, atrophic endometrium
§ Can be inserted at any time of menstrual cycle - use back up x 7 days after insertion.
§ Quick return to fertility after removal – within a mont
Contraceptive Implant
§ Adverse effects:
Irregular bleeding is main adverse effect
–About a quarter become amenorrheic, while others continue to have BTB or spotting.*
–Others: progestin related adverse effects
–Insertion/removal complications are rare
*For bothersome, ongoing BTB consider short course of NSAIDs or estrogen therapy (similar to BTB management with CHC – see Part 1)
Contraceptive Implant
§ Drug interactions:
potential with CYP 3A4 inducers, clinical significance unknown.
§ Possibility of reduced efficacy in obese individuals (>130% of IBW) – though studies excluded overweight, more recent studies have not seen reduced efficacy.
Switching to LARC
Switching to LNG-IUS or Implant from:
§ CHC oral/patch/ring: continue the CHC for 7 days after insertion for LNG-IUS or Implant
§ Depot medroxyprogesterone: Insert LNG-IUS or Implant no later than 13 weeks after last injection.
Make syre there is overlap
Can do at 12 wks so there is still overlap
