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Contraception > IUD > Flashcards

IUD Flashcards

1
Q

How much hormone does the Mirena release a day

A

The 52mg LNG-IUS (mirena) releases approximately 20micrograms LNG per day, reducing to 10micrograms per day after 5 years

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2
Q

What are the licensed uses of the mirena

A
  • Contraception (for 5y)
  • Management of heavy menstrual bleeding (for 5y)
  • Endometrial protection in oestrogen replacement therapy (for 4y)
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3
Q

How much hormone does the Jaydess release a day

A

The 13.5mg LNG-IUS releases 14 micrograms per day for the first 24 days, decreasing to 5 micrograms after 3 years

There is initially a faster release of LNG from the 13.5mg LNG IUS due to the open ends of its elastomer core, despite this the pharmacokinetic profile is similar to the mirena.

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4
Q

What are the licensed uses of the Jaydess

A

Contraception

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5
Q

Predominantly pre-implantation or post implantation effects of the IUC’s that lead to pregnancy prevention?

A

While there is potential for IUC to interfere with implantation, reduced rates of blastocyst formation have been observed in IUC users compared to non-users, suggesting pre-fertilisation effects dominate in terms of MOA

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6
Q

How does Cu-IUD prevent pregnancy

A
  • Copper is toxic to ovum and sperm
  • Alterations in the copper content of the cervical mucus also inhibit sperm penetration
  • If fertilisation has already occurred, the endometrial inflammatory reaction has been shown to have an anti-implantation effect
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7
Q

Does the LNG-IUS affect the hypothalamic-pituitary-ovarian axis?

A

It has little effect on this.

Serium estradiol concentrations are not reduced and the majority (>75%) of women continue to ovulate

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8
Q

How does LNG-IUD prevent pregnancy

A
  • Via a progestogenic effect on the endometrium. Within 1 month of insertion, high intrauterine conc of LNG induce endometrial atrophy
  • Progestogenic effects on mucus have been demonstrated but not sure whether this prevents fertilisation

Distinct changes in intercellular junctions between endometrial epithelial and stromal cells, and an increasein endometrial phagocyctic cells may contribute to the contraceptive effect

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9
Q

Risk of pregnancy copper coil

A

0.1-1% after first year of use
2.2% after 12 years

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10
Q

Risk of pregnancy mirena coil

A

1% at 5y
Likely to still work after 5y licence but not enough evidence

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11
Q

woman presents at 6y of having a mirena, wants a new one, what do you do

A

As the risk of pregnancy remains low between 5 and 7 years after Mirena 52 mg LNG-IUS insertion, the FSRH advises that even if a woman has not been using additional contraception the device can be
replaced immediately, providing a pregnancy test is negative. A further pregnancy test, no sooner than 3 weeks after the last episode of unprotected sexual
intercourse (UPSI), should then be advised.

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12
Q

At what point in cycle can you insert Cu-IUD

A

It’s effective immediately, can be inserted at any time in the cycle if ‘reasonably certain woman not pregnant’. No need for additional protection after insertion.

Can also be put in as EC providing it is inserted before implantation
i.e.
- within 5 days of first episode of UPSI in a cycle or
- up to 5 days after the earliest estimated ovulation [shortest cycle minus 15]

dont insert if uncertainty

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13
Q

Criteria for being ‘reasonably certain woman not pregnant’

A

Need any one or more of the following to be met, and no signs or symptoms of pregnancy:

  • not had intercourse since last period
  • correctly using reliable method of contraception
  • within the first 7 days of onset of normal menstrual period
  • not breast feeding and less than 4w from giving birth
  • fully or nearly fully breastfeeding, amenorrhoeic and less than 6mo post partum
  • within 7d post abortion or miscarriage

also need to consider whether she is at risk of becoming pregnant as a result of upsi past 7d

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14
Q

At what point in the cycle can you insert a LNG-IUD

A
  • At any time in cycle if reasonably certain not pregnant or risk of pregnancy
  • Up to day 7 of cycle without need for additional contraception
  • If later then additional contraceptive for 7d
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15
Q

UKMEC risk for postpartum insertion

A

UKMEC 3 if between 48h and 4w
After that its UKMEC 1

WHOMEC1 for insertion in first 48h

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16
Q

Breastfeeding UKMECS for IUDs

A

Cu-IUD - UKMEC/WHOMEC =1
LNG-IUS from birth until 4w = WHOMEC 3 in breast feeding women [increased risk of perforation]

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17
Q

When can you insert coils post abortion

A

Surgical - End of procedure for both copper/ius.
Medical- any time after completion of second part of abortion (passage of products conception) for both

With IUS use additional contraception 7d. Warn of small increased risk of expulsion

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18
Q

When can you insert coils post oral EC

A

Copper - within 5d following first UPSI or within 5d of estimated earliest ovulation. Outside of this cant put it in until preg excluded (PT 3w after last episode of UPSI)
LNG-IUS - cant put it in until preg excluded (PT 3w after last episode of UPSI)

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19
Q

Scenario:
Switching from - any method
To - Cu-IUD

Timing of IUC insertion?
Need for extra precautions?
Extra advice if LNG-IUS to Cu-IUD?

A

Timing - can be inserted at any time if other method used correctly and reasonably certain not pregnant

No additional precautions needed

Extra info - ideally if switching from LNG-IUS to Cu-IUD additional contraceptive precautions are advised in 7d prior to changing incase new method can’t be inserted

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20
Q

Scenario:
Switching from - CHC
To - LNG-IUS

Timing of IUC insertion?
Need for extra precautions?
Extra info?

A

Timing - can insert any time but depending when you may need extra precautions

  1. Week 2 or 3 of CHC cycle or day 1 of hormone free interval. No additional precautions if CHC taken correctly. Evidence suggests taking CHC for 7 days prevents ovulation.
  2. After day 1 of the hormone-free interval or in week 1 of CHC cycle. Continue CHC or use other contraception for 7 days. Theoretical risk that ovulation may occur as early as day 10 after stopping CHC (before new coil fully effective).
21
Q

Scenario:
Switching from - POP (traditional)
To - LNG-IUS

Timing of IUC insertion?
Need for extra precautions?

A

Can insert anytime, continue POP or use additional contraception for 7 days

22
Q

Scenario:
Switching from - POP (Desogestrel)
To - LNG-IUS

Timing of IUC insertion?
Need for extra precautions?

A

Insert any time
No need for extra precautions

23
Q

Scenario:
Switching from - Implant
To - LNG-IUS

Timing of IUC insertion?
Need for extra precautions?
Extra info?

A

Up to 3y post insertion no extra precautions needed but after 3y use 7days extra protection and exclude pregnancy prior to insertion

24
Q

Scenario:
Switching from - Progestogen injectable
To - LNG-IUS

Timing of IUC insertion?
Need for extra precautions?
Extra info?

A

<=14w post IM or SC injection - no extra protection needed
>14w since last injection use extra protection for 7d and exclude risk preg prior to insertion

25
Q

Scenario:
Switching from - barrier method
To - LNG-IUS

Timing of IUC insertion?
Need for extra precautions?
Extra info?

A

if day 1-7 of cycle then no extra protection needed but after day 7 use extra for 7d

26
Q

Scenario:
Switching from - Cu-IUD
To - LNG-IUS

Timing of IUC insertion?
Need for extra precautions?
Extra info?

A

Can insert anytime, need 7d extra protection

If UPSI has occured in last 7d advise to leave Cu-IUD in for further 7d and use extra precautions before change

27
Q

STI risk assessment must be done to identify women at risk of having an STI. What are risk factors for this?

A
  • being under 25 and sexually active [lol]
  • new partner past 3mo
  • > 1 partner past year
  • regular partner who has other partners
  • a history of of STIs
  • attending as STI contact
  • alcohol/ substance abuse

An STI screen should be offered to all women who are identified as being at risk of STIs when requesting an IUC

28
Q

What do I do if I think a woman is at risk of STI but not got results back for it?

A

IUC can be inserted without prophylactic abx as long as asymptomatic and can be contacted and treated when results known

If they have symptoms then delay insertion until results available and STI or PID treated. Offer bridging contraception.

29
Q

What if a woman has symptoms of an STI or is high risk as e.g. partner tested positive, and need emergency IUD?

A

Give abx prophylaxis for CT (and GC if local guidance) and give EC IUD

30
Q

What cancer risks are reduced with the 2 coils

A

Mirena can be used to provide endometrial protection in conjunction with oestrogen therapy for up to 5 years

Cooper coil may be assoc with reduced endometrial cancer and cervical cancer risk

31
Q

Benefits of mirena

A
  • Can reduce dysmenorrhoea and is a treatment for pain assoc with endometriosis
  • very effective at reducing menstrual blood loss, licensed for HMB
32
Q

Drawbacks of mirena (and how common)

A
  • Hormonal SEs - more prevalent in first few months after insertion but decrease with time. Reportedly same in Jaydess. Reported as common (1 in 100 to 1 in 10). e.g. acne, breast tenderness, mood changes. Important to note: no significant differences in overall SEs between Cu-IUD and IUS.
33
Q

Important risks/ things to look out for to inform patients of (re: insertion procedure and after)?

A
  • Risk of perforation - up to 2 per 1000 insertions (and is approx 6 fold higher in breast feeding women). Symptoms: Lower abdo pain, lost threads, changes in bleeding.
  • Risk of infection - greatest first few weeks following IUC insertion. Symptoms: pain, abnormal bleeding, no threads, gen unwell - get checked
  • Symptoms of ectopic pregnancy
  • Risk of expulsion is 1 in 20 and is most common in the first year of use, particularly within 3 months of insertion
  • Functional ovarian cysts are common possible SE (1 in 100 - 1 in 10), Most are asymptomatic and resolve spontaneously.
  • Vasovagal reaction during insertion due to cervical stimulation - bradycardia, usually simple resus sorts it, occasionally atropine needed.

Advice: check threads regularly / at each period. If can’t be felt to come and get checked and use additional contraception.

34
Q

Affect on IUC on weight

A

Weight gain has been observed with use of IUC but there is no significant difference between hormonal and non hormonal methods and evidence to support a causal association is lacking. It is likely to be a consequence of confounding factors such as increasing age.

35
Q

Tell me about bleeding patterns IUC

A

For both:
- 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

LNG-IUS:
- at 1 year, infrequent bleeding is usual and some will have amenorrhoea.

Cu-IUD
- discontinuation due to pain and bleeding are similar for different types of framed and unframed Cu-IUDs

36
Q

Does use of IUC affect bone mineral density

A

No, not for either

37
Q

How do you approach a patient with h/o breast cancer w/r to IUC?

A
  • Evidence does not support a link between breast ca and use of the LNG-IUS
    however
  • non-hormonal contraception is most appropriate for women with a h/o breast ca. Any consideration of the LNG-IUS should be carried out with consultation of br ca specialist.

LNG-IUS: current br ca = UKMEC 4, h/o br ca = UKMEC 3

38
Q

CV health - any association between LNG-IUS and CV health? What is the guidance in terms of UKMEC for initiation / continuation in regard to CVD risk factors? Anything to remember for insertion?

A

There’s little or no increased risk of VTE or MI assoc with LNG-IUS

UKMEC2 - for initiating a patient on IUS with current or RFs for stroke / CVD / IHD / VTE but it is a UKMEC3 for continuing the use of LNG-IUS in a women who develops these while on it.

SLE/ positive antiphospholipid antibodies = UKMEC 2

Women with cardiac disease - decision to use IUC should involve cardiologist and it should be fitted in a hospital setting if a vasovagal reaction presents a high risk e.g. in women with single ventricle circulation, eisenmenger physiology, tachycardia.

39
Q

Affect of IUC on libido

A

Existing evidence fails to support a negative effect on libido (so it doesnt as far as we know)

40
Q

What is the risk of ectopic pregnancy with IUC?

A
  • The overall risk of ectopic pregnancy is reduced with use of IUC compared to using no contraception
  • If pregnancy does occur with an intrauterine method in situ, the risk of an ectopic pregnancy is increased. It is 1 in 1000 at 5 years.

A previous ectopic pregnancy is not a contraindication to use IUC (UKMEC 1)

41
Q

Return to fertility for IUC

A

Not loads of data but return to fertility generally similar to after discontinuation of oral contraceptives and barrier methods

42
Q

Thrush and BV relation?

A

Cu-IUD is possible RF for recurrent candida, and BV is assoc with Cu-IUD too. Users with recurrent BV or thrush may wish to consider alternative contraception.

43
Q

Evidence around pain relief for procedure

A

No evidence currently to support use of topical lidocaine, misprostol or NSAIDs for improving ease of insertion or pain reduction during procedure

however

NSAIDs do reduce pain after insertion

44
Q

Treatment options for LNG-IUS with unscheduled bleeding

A

No evidence for most appropriate treatment but can try COC for 3 months

45
Q

Treatment options for Cu-IUD with unscheduled bleeding

A

NSAIDs

46
Q

Potential causes of non visible threads? Management of this

A

expulsion, perforation, pregnancy, threads in cervical canal or uterus

do PT, if negative advice alternative contraception and arrange USS. Consider EC.
If on USS it cannot be visualised, request XR abdo and pelvis - if seen, then confirms perf - arrange elective lap removal. If not there = expulsion.

47
Q

Do you remove IUC in PID?

A

not routinely but it should be removed if no response to treatment after 72h

48
Q

Moon cup and tampon advice

A

dont seem to be assoc with increased risk of expulsion but allow 6w before using to be safe

Contraception (13 decks)

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