Intrauterine Contraception - CEU- October 2015

Question 1

Intrauterine Contraception

Eligibility

Answer 1

Health professionals should be familiar with the UK Medical Eligibility Criteria for intrauterine methods.

Question 2

Intrauterine Contraception

Efficacy

Answer 2

• Women should be advised of the very low failure rates associated with use of intrauterine contraception (IUC).
• The most effective methods of IUC are levonorgestrel intrauterine system (LNG-IUS) methods and T-shaped copper intrauterine devices (Cu-IUDs) with at least 380 mm2 copper and copper bands on the transverse arms.

Question 3

Insertion of IUC and duration of use

Answer 3

• A medical and sexual history should be carried out as part of the routine assessment for IUC to assess suitability for use of the method and need for STI testing.
• In asymptomatic women attending for insertion of IUC there is no need to wait for STI screening results or to provide antibiotic prophylaxis providing the woman can be contacted and treated promptly in the event of a positive result.
• Prophylactic antibiotics are not routinely required for the insertion or removal of IUC even in women with conditions where the risk of infective endocarditis may be
  increased.
• The 52 mg LNG-IUS can be used to provide endometrial protection in conjunction with estrogen therapy for up to 5 years (outside product licence).

Question 4

Health benefits and risks of IUS

Answer 4

• Use of a Cu-IUD may be associated with a reduced risk of endometrial cancer and cervical cancer.
• The 52 mg LNG-IUS may reduce pain associated with primary dysmenorrhoea, endometriosis or adenomyosis.
• The 52 mg LNG-IUS is effective in reducing menstrual blood loss and can be used in management of heavy menstrual bleeding.
• Women considering LNG-IUS can be informed that systemic absorption of progestogen occurs with these devices. The 13.5 and 52 mg LNG-IUS have similar sideeffect profiles (such as acne, breast tenderness/pain and headache) and hormonal side effects often settle with time. Rates of discontinuation due to side effects are not significantly different from Cu-IUD users.
• Women should be advised that existing evidence fails to support a negative effect on libido associated with IUC use.
• Weight gain has been observed with use of IUC. There is no significant difference between hormonal and non-hormonal intrauterine methods and evidence to support
  a causal association is lacking.
• In the 3-6 months following IUC insertion women may experience irregular, prolonged or frequent bleeding but menstrual bleeding patterns tend to improve with time.
• At 1 year infrequent bleeding is usual with the LNG-IUS and some women will experience amenorrhoea.
• Discontinuation due to bleeding and pain are similar for different types of framed and unframed Cu-IUDs.
• Evidence does not support a link between breast cancer and use of the LNG-IUS.
• Non-hormonal contraception is most appropriate for women with history of breast cancer. Any consideration of the LNG-IUS should be carried out in consultation with the woman’s cancer specialist.
• Evidence suggests there is little or no increased risk of venous thromboembolism or myocardial infarction associated with the use of a LNG-IUS.

Question 5

Ectopic pregnancy & IUS

Answer 5

• The overall risk of ectopic pregnancy is reduced with use of IUC when compared to using no contraception.
• If pregnancy does occur with an intrauterine method in situ, the risk of an ectopic pregnancy occurring is increased and in some studies half of the pregnancies that occurred were ectopic.
• Data are insufficient to determine if the 13.5 mg LNG-IUS is associated with greater risk of ectopic pregnancy than other IUC methods.
• IUC users should be informed about symptoms of ectopic pregnancy. The possibility of ectopic pregnancy should be considered in women with an intrauterine method who present with abdominal pain especially in connection with missed periods or if an amenorrhoeic woman starts bleeding. If a pregnancy test is positive an ultrasound scan is urgently required to locate the pregnancy.

Question 6

Complications of IUC

Answer 6

• The risk of expulsion with IUC is around 1 in 20 and is most common in the first year of use, particularly within 3 months of insertion.
• There is no need to delay insertion of an IUC post-abortion providing a woman has been informed of the small increased risk of expulsion.
• Although ovarian cysts may occur when using the LNG-IUS, most cysts are asymptomatic and resolve spontaneously.
• The rate of uterine perforation associated with IUC is up to 2 per 1000 insertions and is approximately six-fold higher in breastfeeding women.
• Return of fertility after IUC use is generally similar to fertility rates after discontinuation of oral contraceptives and barrier methods.
• Cu-IUD users with recurrent bacterial vaginosis or vulvovaginal candida may wish to consider an alternative method of contraception.

Question 7

At the time of insertion IUS

Answer 7

• Valid consent should be given by women prior to both pelvic examination and IUC insertion or removal.
• An appropriately trained assistant who can monitor the condition of the woman and assist in an emergency should be present during insertion of IUC.
• There is no evidence from current trials to support the use of topical lidocaine, misoprostol or non-steroidal inflammatory drugs (NSAIDs)for improving ease of insertion or reducing pain during insertion of intrauterine methods.
• Local anaesthetic block administered by cervical injection is not routinely required for IUC insertion but should be offered when cervical dilatation is required or difficult IUC insertion or removal is anticipated/experienced.
• NSAIDs can be offered to women who experience pain after insertion of an intrauterine method.
• A bimanual pelvic examination should be performed on all women before inserting IUC.
• There is no evidence to suggest that cervical cleansing prior to IUC insertion reduces subsequent pelvic infection.

Question 8

Management of complications IUS

Answer 8

• There is no evidence as to the most appropriate treatment option for women with unscheduled bleeding with the LNG-IUS. For women with unscheduled bleeding who wish to continue with the LNG-IUS and are medically eligible, a combined oral contraceptive could be tried for up to 3 months (this can be in the usual cyclic manner or continuously without a pill-free interval – unlicensed use).
• NSAIDS can be considered in the management of problematic bleeding with use of Cu-IUDs.
• Insertion or reinsertion of an intrauterine method can be carried out in asymptomatic women with actinomyces-like organisms (ALOs).
• There is no need to remove IUC in asymptomatic women with ALOs.
• IUC removal is not routinely required in women with pelvic inflammatory disease but it should be removed if there is no response to treatment (approximately 72 hours).
• Women should be offered instruction on how to check for the IUC and advised that if the threads cannot be felt the device may have perforated the uterus or been
  expelled. Additional contraception should be used until they seek medical advice.
• Women should be advised to seek medical assistance at any time if they develop symptoms of pelvic infection, pain, abnormal bleeding, late menstrual period (IUD),
  non-palpable threads or can feel the stem of the IUC.

Question 9

Other issues to consider in IUS

Answer 9

• Women requesting intrauterine methods should be informed about the use of additional precautions for protection against STIs and advised about the appropriate timings of STI testing after an episode of unprotected sexual intercourse.
• Health professionals should inform women about the availability of EC and when it may be required with intrauterine methods.
• A routine follow-up visit can be advised after the first menses following insertion of IUC or 3–6 weeks later. However, it is not essential and it may be more important to advise women as to signs and symptoms of infection, perforation and expulsion, returning if
  they have any problems relating to their intrauterine method.
• Mooncups and tampons do not appear to be associated with an increased risk of IUC
  expulsion.
• Use of intrauterine methods should not be restricted based on parity or age alone.
• For women with cardiac disease the decision to use IUC should involve a cardiologist. The IUC should be fitted in a hospital setting if a vasovagal reaction presents a particularly high risk, for example, women with single ventricle circulation, Eisenmenger
  physiology, tachycardia or pre-existing bradycardia.