IUC guideline Flashcards
how do FSRH in their guidelines define the levels of evidence
A,B,C, D and then a tick
so four levels of evidence
In terms of FSRH levels of evidence (A-D) which represents the highest level of evidence
level A
In terms of FSRH levels of evidence (A-D) which represents the lowest level of evidence
level D
What grade of evidence does the ‘tick’ represent in FSRH standards of evidence in guidelines
the ‘tick’ is based on clinical experience good practice from members of the guideline committee writing group
what is the definition of level A evidence
Evidence from at least 1 meta-analysis, 1 Systematic review, 1 RCT rated as 1+++ and is directly applicable to the target population
or a systematic review of RCTs or a body of evidence consisting of studies rated as 1+, directly applicable to the target population and demonsrates overall consistency of results.
what level of evidence is the following description of:-
A body of evidence including studies rated as 2++ directly applicable to the
target population and demonstrating overall consistency of results;
or
Extrapolated evidence from studies rated as 1++ or 1+.
level B
what level of evidence is the following description of:-
A body of evidence including studies rated as 2+ directly applicable to the
target population and demonstrating overall consistency of results;
or
Extrapolated evidence from studies rated as 2++.
level C
what level of evidence is the following description of:-
Evidence level 3 or 4;
or
Extrapolated evidence from studies rated as 2+.
level D
match the coils to the dose of levonergestrel
A) 52mg
B) 13.5mg
C) 19.5mg
kyeleena, jaydess and Mirena/levosert/Benilexa
a) Mirena 52mg
b) Jaydess 13.5mg
c) kyleena 19.5mg
how long can any 52mg LNG IUS be used for contraception if inserted before the age of 45 years
6 years… but note now licence for Mirena for contraception is now good for 8 years
if a 52mg LNG IUS is fitted at age 45 years or older when can you advise a patient to remove or change it based on contracepiton rules
remove age 55 years (no need to change earlier)
if a Cu-IUD with >= 300mm2 of copper is inserted at age 40 when would you advise a patient to change her copper coil to ensure contraception is maintained?
Cu-IUD >=300mm2 can be inserted from age 40 and left in until menopause . it can be removed one year after the last period if this occurred after the age of 50
what is the failure rate of the Cu-IUD in the first year of use?
0.6% (perfect use), 0.8% (typical us)
what is the contraceptive failure rate of the 52 LNG IUS in the first year of use? For typical and perfect use
0.2% failure rate for typical and perfect use
what is the contraceptive failure rate during the licenced use of Jaydess and Kyleena?
0.3%
it is contra-indicated to fit an IUC if a young person has never been sexually active
false
it is contra-indicated to fit an IUC if a patient has never had a baby
false
when are expulsion rates higher in pp IUC insertion? following a c/s or NVD
following a vaginal delivery expulsion rates of IUC are higher, than if an IUC is fitted post c/s
what is the recommended interval that IUC can be fitted following delivery and in the PP period? and why
can fit an IUC within 48 hours post delivery or > 4 weeks PP (UKMEC 1)
do not fit inbetween this interval as higher risk of perforation,
what is the UKMEC for fitting a coil > 48 hours PP to < 4 weeks PP
UKMEC 3
what is the UKMEC for fitting a coil following abortion or miscarriage if you are suspecting post abortion/post miscarriage sepsis
UKMEC 4
what is the UKMEC for fitting a coil if previous ectopic pregnancy
UKMEC 1
how long does FSRH recommend that any 52mg LNG IUS be used for endometrial protection
5 years FSRH guidance (however spc - mirena 4 years licence)
if known fibroids that distort the uterine cavity what is the UKMEC
UKMEC 3
if fitting a coil in someone with uterine cavity distortion due fibroids or congenital malformations for example, what would be your approach
individualised approach
assess uterine cavity size, level of distortion, uterine size and weigh up pros and cons versus alternative options
if fitting a coil in this situation then fit under direct vision during hysteroscopy or USS to allow assessment of uterine cavity.
if fitting a coil in someone with known uterine cavity distortion due to say fibroids how would you counsel them in regards to safety and efficacy of the coil for say contraception
explain that we don’t know if the coil will have reduced contraception efficacy and safety due to cavity distortion.
there is uncertainty around safety and contraception effectiveness of IUC in individuals with uterine cavity distortion.
what is the approach to fitting an IUC following endometrial ablation
individualised approach (not listed on UKMEC)
following ablation get scarring of the endometrium and so technically if the ablation has worked well you wouldn’t be able to fit the coil.
If wanting a coil need assessment at hyst or USS to detemine cavity suitability.
what is UKMEC for fitting a coil in someone with current PID?
UKMEC 4
what is UKMEC for fitting a coil in someone with GC (symptomatic or asymptomatic)
UKMEC 4
what is UKMEC for fitting a coil in someone with current pelvic TB?
iniation = 4, continuation = 3
what is UKMEC for fitting a coil in someone with symptomatic CT
UKMEC 4
what is UKMEC for fitting a coil in someone with asymptomatic CT
UKMEC 3
what is UKMEC for fitting a coil in someone with purluent cervicitis
UKMEC 4
what is the UKMEC for fitting a coil in someone Vaginitis (including Trichomonas
vaginalis and bacterial vaginosis)
(current)
UKMEC 2 (as not thought to ascend the genital tract)
is contraception effectiveness of the Cu-IUD reduced in patients who are on immunosuppressants? or immunosuppressed
no
If an immunosuppressed patient is having an IUC procedure should we routinely give prophylactic antibiotics?
not routine - discuss with their lead clinician e.g. post transplant patients, ciclosporin, tacrolimus etc
what is the UKMEC for initiation of an IUC in someone with a ‘complicated’ organ transplant
iniaition = 3, continuation 2
‘complex’ - graft versus host, rejected transplant, cardiac allograft vasculopathy
what is the UKMEC for initiation IUC in someone who has an ‘uncomplicated’ pmhx of organ transplant
2
what is the advice for patients at risk of adrenal insufficiency ? addison’s
what other patients taking steroid would you recommend this rule for?
increase steroids pre insertion and post (1 hour prior and up to 24 hours post) to match that of steroid sick days
schedule IUC fitting in the morning (as cortisol levels highest in morning)
patients on long term steroids e.g. <10mg/day pred or high dose inhaled steroid e.g. beclomethasone >800mgc/day) - discuss with their physician
are antibiotic prophylaxis recommended pre coil fit in patients with increased risk of endocarditis?
no
for patients with PoTS where should the IUC fitting take place
often in community as should be straight forward - make sure salt intake, adequate hydration and postural awareness
majority will be straightforward
unless history of postural syncope and PoTS advice taken from cardiology but often in a hospital setting
which pre-existing arrhythmia would you be more concerned about when fitting a coil? where should the coil fitting take place
always seek advice from their cardiologist, often fittings in patients with ventricular tachyarrythmias should be done in hospital.
e.g. pre-existing arrhythmia, Eisenmenger physiology( congenital heart defect causing ventricular hole –> ventricular shunt) , single ventricle circulation, long QT , impaired ventricular function a vasovagal cardiac event could pose a significant risk
what should do if a patient requests an IUC and has a known bleeding disorder e.g. VWD
discuss with their haematologist
what would you advise a patient regarding risk of breast cancer when using LNG IUS
current evidence suggests a possible small increased risk, but absolute risk remains very small.
There is a possible association between current or recent use of HC and breast cancer
what would you advise someone regarding risk of ovarian cysts during LNG IUD use
LNG -IUD does increase incidence of ovarian cysts, it doesn’t appear to be clinically significant and is not a CI
(UKMEC 1 for both types of coil to fit/ continue)
what effect does IUC have on serum estradiol levels and BMD?
no significant effect on either
what would you counsel someone having a Cu_IUD fit in terms of bleeding
can make periods heavier and more painful, can also cause IMB. Often heavier periods will decrease over time.
what side effects can someone experience with LNG-IUDs
acne, mood changes, breast tenderness, headaches and irregular bleeding.
usually these symptoms are more prevalent in first few months and decrease over time.
what examination should always be performed as per FSRH guidance before fitting a coil
bimanual
when an IUC has been inserted within 48 hours of VD/C-s what follow up would be recommend
clinician follow up in 4-6 weeks
what treatment options can be given to patients experiencing unscheduled or HMB following coil insertion?
NSAIDs or TXA
or CHC 3 month trial
what risks would you counsel a patient about prior to coil insertion
increased risk of pelvic infection in first 3 weeks following a coil fit (still low <1%), usually do a swab to check for infections at the time of fit.
no contraception is 100% effective, if the coil was to fail and you become pregnant with the coil in situ this would place you at higher risk of ectopic pregnancy (absolute risk is reduced due to coil compared to patients on no contraception)
risk that coils can come out, happens 1 in 20 women and more common if having heavy or painful bleeding
risk of perforation (where we do damage to lining of the womb), this is very rare risk of 2 in 1000
if a patient has a positive pregnancy test with a coil in situ, TV USS dates the pregnancy to be less than 12 weeks, intra-uterine and viable. On speculum examination coil threads are present how would you proceed
usually remove the coil as this would improve later pregnancy outcomes. however could cause spontaneous abortion following removal.
if treating a patient for PID and they have a coil in situ how would you manage their contraception>
start them on PID treatment, advise them to keep the coil in situ and review in 48-72 hours, if improving leave in, if deteriorating then consider removal and need for EC
are there any links to IUC use and BV and candida?
no evidence to suggest causal relationship, patients who experience recurrent symptoms may wish to find an alternative method of contraception
a patient’s cervical cytology has come back with actinomyces-like organisms present, HPV negative. She is asymptomatic, what would you do in terms of treatment and current IUC that is in place for contraception
no need for antibiotics, no need to remove/change IUC
(pts with actinomyces -like organisms on cervical cytology are more likely to be colonised than infected)
what is the guidance on malpositioned IUCs - should they be removed/ replaced or stay in
current evidence is too limited to give advice on what to do for malpositioned IUCs, as evidence is too limited as to guide the failure rate of malpositioned coils. Therefore clinicians should give an individualised approach to care.
However the GDG (guideline development group so ‘tick’ level evidence) suggest removing coils as a general rule if:-
- >2cm from the fundus
- IUC in the cervical canal, fully or partially expelled
-patients are experiencing symptoms relating to malpositioned coil e.g. pain or bleeding.
when is the risk of expulsion with IUCs the highest
risk of expulsion is 1 in 20, appears to be common in first year of use and highest in first 3 months
what situations or medical conditions might increase risk of IUC expulsion
PP fit within 48 hours of delivery
known fibroids with uterine cavity distortion
uterine cavity distortion
post 1st or 2nd trimester abortion fit
HMB
individuals using a menstrual cup
those who have previously expelled an IUC
how would you manage a patient who as had 2 coil expulsions?
request TV pelvic USS to rule out uterine anatomy anomalies and assess uterine cavity prior to re-insertion
what is the rate of uterine perforation with IUC fit and when might this risk increase?
risk of perf is 1-2 per 1000, PP IUC insertion particularly if BF
what signs and symptoms might indicate uterine perf?
lower abdominal pain, bleeding or lost threads could all indicate perf
if suspected uterine perf following IUC fit how would you manage (coil threads missing)
TV USS +/- plain AXR + pelvic X-ray (to locate coil if not seen on TV USS)
consider EC, pregnancy testing and need for bridging contraception.
Wait 6 weeks for perf to heal before fitting another coil, and ideally this should be fitted under USS guidance
what are the rates of missing IUC threads following:
1. standard insertion
2. IUC insertion within 48 hours PP NVD
3. IUC insertion at time of c-section
- standard technique = 18%
- 30%
- 50%
how much LNG does each of the following coils release on average per day?
52mg LNG IUD
19.5mg LNG - IUD(kyleena)
13.5mg LNG - IUD (jaydess)
52mg LNG IUD –> releases approx 20mcg/day
19.5mg LNG IUD –> releases approx 17.5mcg/day
13.5mg LNG IUD–> first 24 days releases 14mcg/day and then reduces to 5mcg/day
what is the main MOA of the Cu-IUD for contracption (SBA):-
A) inhibits ovulation
B) thickens cervical mucus
C) inhibits fertilisation
D) inhibits implantation
C- inhibits fertilisation is main method described by fsrh
Emily has had an EMA 8 weeks at home. She rings up requesting to have a coil fitted. She is currently 10 days post EMA and bleeding has settled what would you advice?
can fit if negative low sensitivity UPT at 2 weeks after misoprostal (as per FSRH guidance).. or if USS available at anytime post EMA/ medical abortion as long as can exclude ongoing pregnancy or RPOC.
what is the UKMEC for each of the following scenarios:-
- negative hcg post GTD
- decreasing HCG levels post GTD
- Persistently elevated hcg levels
- = 1
2 = 3
3= 4
why is it advised not to fit a coil in someone with GTD who hasn’t got negative HCG levels
increased risk of perforation and risk of dissemination of the tumour
This information is based on guideline development group expert opinion, not any data or evidence
a patient comes to clinic she is age 52 and has been amenorrhoeic with the coil for the past 8 years. She has been counselled that she can keep her mirena until age 55 but really wants it removing and an FSH test what would you advise?
hard to intepret FSH but if adamant won’t keep mirena and wants to know if she still needs contraception, measure FSH if >30 then advise to keep mirena in place for one further year then can remove
what structure in embryology does the uterus form from?
mullerian ducts - two ducts these fuse and then the septum in the middle breaks down/ is reabsorbed. Failure for this to happen can result in congenital uterine anomalies
On examination a patient is noted to have two cervices and two uterus what is the name of this congenital uterine anomaly
uterine didelphys
A sonographer makes the comment that a uterus looks heart shaped - what congenital anomaly are they referring to?
bicornate uterus - heart shaped rather than pear shaped, the uterus will look abnormal shape if doing a laprascopy
what is the difference between a bicornate uterus and a septate uterus?
bicornate uterus has two horns and the uterus looks abnormal shape (heart shaped) at laprascopy
whereas a septate uterus will look normal from outside i.e. during laprascopy but inside the uterus the septum remains creasing to cavities - the septum can be full or partial
A scan is reported as a patient only having a single horn of the uterus, what is the congenital anomaly they are describing
unicornate uterus
what is an arcuate uterus
a small (,1cm) indentation protrudes downwards into the cavity from the fundus
what do FSRH guidance suggest regarding IUC insertion after endometrial ablation
guidance based on expert opinion, no evidence
if fitted at time of ablation could cause higher risk of infection/perf
if wanting to fit at an interval following ablation need to take an individualised approach and assess endometrial cavity first either using USS or hysteroscopy. If USS shows a homogenous triple strip endometrium, with no evidence of haematometra and normal shaped cavity these are favourable findings suggesting a patent cavity. If proceed to fitting should be done with USS guidance or at hyst
removing a coil fitted at ablation is difficult to know how tricky this will be, can attempt removal in OP clinic but if hard refer to hyst
no UKMEC - individualised approach
if at time of LLETZ a coil is removed and not immediately re-inserted when can you refit?
ensure cervix has healed and resolution of bleeding and discharge, examine cervix first usually 4-6 weeks post LLETZ should be fine to fit
what is guidance for coil insertion and Mgen
difficult as can be commensal, no UKMEC
ideally ensure fully treated and symptoms resolved before fitting (esp if caused PID)
if someone has BV/thrush or TV and has come for coil fit what would you do?
treat the infection and insert coil no need to delay
UKMEC 2
someones swab has come back for group b strep and they want a coil what is your advice
fit coil, no need to treat, only treat in pregnancy during labour
a lady has had HVS and results are positive for strep A, she has come requesting coil fit how would you manage
treat group A strep immediately. can be life threatening and cause septicaemia, nec fas , toxic shock syndrome. delay coil insertion until fully treated.
in patients with Ehlers- Danlos requesting coils how would manage
discuss with their specialist
ehlers danlos is a connective tissue disease that can increase risk of uterine rupture, joint hyperlaxity. this may be relevant to coil fitting
what measures would you take if fitting a coil in someone on warfarin or anticoagulation
book appt in workign hours,
use a multitooth tenaculum
local pressure/silver nitrates for bleeding points
contact numbers, check bleeding prior to discharge
warfarin - can fit if INR <3.5
NOAC/LMWH - fit at lowest concentration level, no need to stop/withhold medication.
is it safe for patients with LNG-IUS or Cu-IUD to have MRI scans
yes - but should inform MRI department
52mg LNG-IUDs contain no metalic, magnetic or conductive material and safe at any strength MRI
copper IUD, kyleena or Jaydess okay up to 3 tesla MRI strength
how do you manage an IU pregnancy with an IUC in situ if gestation .>12 weeks
individualised approach, no evidence to guide practice,
