Intrauterine_Contraceptive_Devices_Flashcards

Question 1

What types of intrauterine contraceptive devices (IUDs) are there?

Answer 1

Conventional copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirenaµ).

Question 2

How effective are IUDs and IUSs?

Answer 2

Both are more than 99% effective.

Question 3

What is the primary mode of action of an IUD?

Answer 3

Prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions).

Question 4

What is the mode of action of an IUS?

Answer 4

Levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening.

Question 5

When can an IUD be relied upon following insertion?

Answer 5

Immediately following insertion.

Question 6

For how long are the majority of IUDs effective?

Answer 6

5 years for those with copper on the stem only, and up to 10 years for those with copper on the stem and the arms of the T.

Question 7

When can an IUS be relied upon following insertion?

Answer 7

After 7 days.

Question 8

For how long is the Mirenaµ IUS effective?

Answer 8

5 years, but only licensed for 4 years if used as endometrial protection for women taking oestrogen-only hormone replacement therapy.

Question 9

What are the potential problems with IUDs?

Answer 9

Make periods heavier, longer, and more painful.

Question 10

What are the potential problems with IUSs?

Answer 10

Initial frequent uterine bleeding and spotting, later intermittent light menses with less dysmenorrhoea, and some women become amenorrhoeic.

Question 11

What is the risk of uterine perforation with IUD/IUS?

Answer 11

Up to 2 per 1000 insertions, higher in breastfeeding women.

Question 12

How does the risk of ectopic pregnancy compare with IUD/IUS use?

Answer 12

The proportion of pregnancies that are ectopic is increased, but the absolute number of ectopic pregnancies is reduced compared to a woman not using contraception.

Question 13

What is the risk of pelvic inflammatory disease after IUD insertion?

Answer 13

There is a small increased risk in the first 20 days after insertion, but after this period, the risk returns to that of a standard population.

Question 14

What is the risk of IUD/IUS expulsion?

Answer 14

Around 1 in 20, most likely to occur in the first 3 months.

Question 15

What are the new IUS systems?

Answer 15

Jaydessµ (licensed for 3 years, smaller frame, less LNG), Kyleenaµ (licensed for 5 years, smaller than Mirenaµ, lower serum levels of LNG, less amenorrhoea compared to Mirenaµ).

Question 16

Summarise intrauterine devices

Answer 16

Intrauterine contraceptive devices

Intrauterine contraceptive devices comprise both conventional copper intrauterine devices (IUDs) and levonorgestrel-releasing intrauterine systems (IUS, Mirenaµ). The IUS is also used in the management of menorrhagia

Effectiveness
both the IUD and IUS are more than 99% effective

Mode of action
IUD: primary mode of action is prevention of fertilisation by causing decreased sperm motility and survival (possibly an effect of copper ions)
IUS: levonorgestrel prevents endometrial proliferation and causes cervical mucous thickening

Counselling
IUD
can be relied upon immediately following insertion
the majority of IUDs with copper on the stem only are effective for 5 years, whereas some of the IUDs that have copper on the stem and the arms of the T may be effective for up to 10 years
IUS
can be relied upon after 7 days
the most common IUS (i.e. Mirenaµ - levonorgestrel 20 mcg/24 hrs) is effective for 5 years
if used as endometrial protection for women taking oestrogen-only hormone replacement therapy they are only licensed for 4 years

Potential problems
IUDs make periods heavier, longer and more painful
the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic
uterine perforation: up to 2 per 1000 insertions and higher in breastfeeding women
the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months

New IUS systems

The Jaydessµ IUS is licensed for 3 years. It has a smaller frame, narrower inserter tube and less levonorgestrel (LNG) than the Mirenaµ coil (13.5 mg compared to 52 mg). This results in lower serum levels of LNG.

The Kyleenaµ IUS has 19.5mg LNG and is also smaller than the Mirenaµ but is licensed for 5 years. It also results in lower serum levels of LNG. The rate of amenorrhoea is less with Kyleenaµ compared to Mirenaµ.

Question 17

A 27-year-old female asks for advice regarding the Mirena (intrauterine system). What is the most likely effect on her periods?

Continual, light bleeding is seen in 70%
Initially irregular bleeding later followed by periods that are generally heavier and longer
Heavy period approximately every 3 months
Amenorrhoea in > 90% after 2 months
Initially irregular bleeding later followed by light menses or amenorrhoea

Answer 17

Initially irregular bleeding later followed by light menses or amenorrhoea

The correct answer to this question is Initially irregular bleeding later followed by light menses or amenorrhoea. The Mirena intrauterine system (IUS) releases a small amount of the hormone levonorgestrel into the uterus each day. This can initially cause irregular bleeding or spotting, but over time it typically results in lighter periods or no periods at all (amenorrhoea). According to the Faculty of Sexual and Reproductive Healthcare guidelines, approximately 20% of women using a levonorgestrel-releasing IUS will experience amenorrhoea after one year.

Now let’s discuss why the other options are incorrect.

Continual, light bleeding is seen in 70%: This statement is inaccurate. While some women may experience light bleeding or spotting during the first few months after insertion of an IUS, continual light bleeding does not occur in 70% of users.

Initially irregular bleeding later followed by periods that are generally heavier and longer: This option is incorrect because one of the common effects of Mirena is to reduce menstrual flow rather than increase it. In fact, it’s often used as a treatment for heavy menstrual bleeding.

Heavy period approximately every 3 months: This choice is also incorrect. The Mirena IUS typically leads to lighter periods over time, not heavier ones. And while some women might experience infrequent heavy periods with certain types of birth control methods, this isn’t typically the case with Mirena.

Amenorrhoea in > 90% after 2 months: While amenorrhoea can occur with Mirena use, it doesn’t happen this quickly nor in such a high percentage of users. As mentioned earlier, about 20% of women will have no periods after one year.

Question 18

A 25-year-old female presents to her GP asking for advice about contraception. She decides to have the intrauterine system inserted. What is the most common side effect occurring within the first 6 months of insertion of the intrauterine system she should be advised about?

Menorrhagia
Irregular bleeding
Uterine perforation
Pelvic inflammatory disease
Weight gain

Answer 18

Irregular bleeding

In the first 6 months following insertion of the intrauterine system, irregular bleeding is a common side effect. Eventually, most women using the IUS become oligomenorrhoeic or amenorrhoeic, which benefits those who suffer from menorrhagia or do not wish to have periods.

Question 19

A 27-year-old female asks for advice regarding the Mirena (intrauterine system). What is the most likely effect on her periods?

Continual, light bleeding is seen in 70%
Initially irregular bleeding later followed by periods that are generally heavier and longer
Heavy period approximately every 3 months
Amenorrhoea in > 90% after 2 months
Initially irregular bleeding later followed by light menses or amenorrhoea

Answer 19

Initially irregular bleeding later followed by light menses or amenorrhoea

The correct answer to this question is Initially irregular bleeding later followed by light menses or amenorrhoea. The Mirena intrauterine system (IUS) releases a small amount of the hormone levonorgestrel into the uterus each day. This can initially cause irregular bleeding or spotting, but over time it typically results in lighter periods or no periods at all (amenorrhoea). According to the Faculty of Sexual and Reproductive Healthcare guidelines, approximately 20% of women using a levonorgestrel-releasing IUS will experience amenorrhoea after one year.

Now let’s discuss why the other options are incorrect.

Continual, light bleeding is seen in 70%: This statement is inaccurate. While some women may experience light bleeding or spotting during the first few months after insertion of an IUS, continual light bleeding does not occur in 70% of users.

Initially irregular bleeding later followed by periods that are generally heavier and longer: This option is incorrect because one of the common effects of Mirena is to reduce menstrual flow rather than increase it. In fact, it’s often used as a treatment for heavy menstrual bleeding.

Heavy period approximately every 3 months: This choice is also incorrect. The Mirena IUS typically leads to lighter periods over time, not heavier ones. And while some women might experience infrequent heavy periods with certain types of birth control methods, this isn’t typically the case with Mirena.

Amenorrhoea in > 90% after 2 months: While amenorrhoea can occur with Mirena use, it doesn’t happen this quickly nor in such a high percentage of users. As mentioned earlier, about 20% of women will have no periods after one year.

Question 20

A 43-year-old woman presents to the GP regarding contraception. She has recently entered a new relationship and is not interested in using barrier methods. Her medical history includes hypertension which is controlled with ramipril. Her periods are generally heavy and she takes tranexamic acid.

The patient is comfortable taking any form of contraception and does not have any preferences except for avoiding anything that can cause weight gain.

What is the most appropriate contraceptive choice?

Combined oral contraceptive pill
Depo Provera (medroxyprogesterone injection)
Intrauterine device (copper device)
Intrauterine system (Mirena)
Progesterone-only pill

Answer 20

Intrauterine system (Mirena)

An intrauterine system (e.g. Mirena) is particularly useful if patients have underlying medical problems (e.g. hypertension) +/- menstrual problems such as heavy periods

Intrauterine system (Mirena) (IUS) is correct. This patient is willing to use any form of contraception (except for injections) that is appropriate for them and has a history of hypertension and heavy and irregular periods. Of the options listed, the most appropriate form of contraception would be the IUS (such as the Mirena IUS) as it is associated with initial frequent uterine bleeding and spotting, but menses become lighter, and some women become amenorrhoeic. The IUS is generally helpful in patients with underlying conditions such as hypertension that would increase the risk of adverse effects in other contraceptive choices and helps with menstrual problems such as heavy periods.

Intrauterine device (copper device) (IUD) is incorrect. Although this does not contain a hormonal component, reducing the risks of adverse effects such as venous thromboembolism as seen in oral oestrogen-containing hormonal contraceptives, the IUD often makes periods heavier, longer, and more painful, which is less appropriate in this scenario as this patient has heavy periods and takes tranexamic acid.

Combined oral contraceptive pill (COCP) is incorrect as controlled hypertension is classed by the UK Medical Eligibility Criteria (UKMEC) as UKMEC 3, where the disadvantages (such as venous thromboembolism and stroke) generally outweigh the advantages. If this patient had uncontrolled hypertension, this would be UKMEC 4, where there is an unacceptable health risk.

Depo Provera (medroxyprogesterone injection) is incorrect as out of the options listed, this contraceptive is most associated with weight gain. This patient has stated they do not want any form that contributes to weight gain.

Progesterone-only pill (POP) is incorrect as a key side effect is irregular vaginal bleeding. Although both the POP and IUS cause this, the IUS is associated with lighter menses over time, and some people become completely amenorrhoeic, which may be helpful in this patient as she has heavy periods.

Question 21

A 44-year-old female has a Mirena (intrauterine system) fitted for contraception on day 12 of her cycle. How long will it take before it can be relied upon as a method of contraception?

Immediately
2 days
5 days
7 days
Until first day of next period

Answer 21

Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS