IUS Flashcards
What conditions can the IUS be used for? (Excluding contraception)
- Heavy menstrual bleeding and dysmenorrhoea
- Endometrial hyperplasia (with no atypia on histology)
- Use as the progestogen part of HRT for menopausal symptoms
A mirena fitted for contraception after the age of (BLANK) can remain in place until a woman is (BLANK)
A mirena fitted for contraception after the age of 45 can remain in place until a woman is 55
Who is the IUS NOT suitable for?
- unexplained vaginal bleeding
- post partum women between 48 hours and 4 weeks post-delivery
- post-partum/abortion sepsis
- persistently high b-HCG or malignant gestational trophoblastic disease
- cervical ca awaiting treatment
- endometrial ca
- current PID
- symptomatic chlamydia OR gonorrhoea
- known pelvic TB
- known serious cardiac conditions/arrhythmias where vasovagal could be fatal
- HIV +ive with CD4 <200
What is the mechanism of action of IUS?
- MAIN: thickening of cervical mucus and utero-tubal fluid, which inhibits sperm penetration and migration
- Also down regulates oestrogen and progesterone receptors in the endometrium making it less sensitive to oestrogen - causing atrophy and prevention of implantation
- Reduction in sperm motility and function
- Ovulation can be suppressed in a small number of women in the 1st year by reducing LH surge - but serum oestradiol levels are unchanged
What are the advantages of IUS?
- long acting and effective
- not affected by liver enzyme inducing drugs
- immediate return to fertility once removed
- reduction in menstrual loss
- can prevent fibroids
- can reduce dysmenorrhoea
- no evidence it affects BMD
- reduces risk of ectopic
- reduces incidence of PID
- can be used (in part) for HRT
- protects against endometrial hyperplasia
- 3 year continuation rate over 70%
What are the disadvantages of IUS?
- can cause irregular/prolonged bleeding
- in 4-6% may be expelled/displaced
- fitting can be painful
- risk of failure to fit in 1-2%
- risk of PID increases 6 fold immediately after fitting, then drops after 20 days
- can develop functional ovarian cysts (often self-resolved but rarely needs surgical intervention)
- non visible threads- therefore needs transvaginal USS to locate IUS
- risk of perforation (2 per 1000) - higher in breastfeeders
- progestogenic symptoms (breast tenderness, acne, bloating)
- in IUS failure, 25-50% of pregnancies will be ectopic (but overall risk of ectopic lower than general population)
- cannot be used as EC
When is expulsion rate highest?
in the first 3 months post-insertion and during menstruation
What should you do if the threads are not visible?
- PT test
- advise use of alternative method of contraception
- refer for USS
- if not found by USS, refer for AXR before assuming expulsion
Evidence supported methods on management of IUS insertion pain
- naproxen 500mg 1 hour before, or NSAIDs post-insertion
- lidocaine 10% spray (4 puffs) and waiting 3 mins
- 5% lidocaine/prilocaine cream applied to anterior cervical lip and around the os, and waiting for 7 mins
- paracervical/intracervical block for those needing cervical dilation or very anxious
What to do if pregnancy associated with IUS
- <12 weeks and threads visible: remove IUS but do not instrument uterus
- > 12 weeks - leave IUS in situ and it should be expelled with the placenta. if not found at delivery, do AXR
Management of syncope and bradycardia during insertion
- stop the procedure, raise the foot of the exxamination couch, measure pulse and BP, and supplement O2
- if pulse <40 and IUS is in situ,remove it and administer atropine 500micrograms IV or IM. If no improvement after 5 mins, call for emergency assistance. Repeat dose after 5 mins if given IV or 10 mins if given IM
Name and dose of each coil (Mirena, Kyleena and Jaydess)?
Mirena: LEVONORGESTREL 52mg
Kyleena: LEVONORGESTREL 19.5mg
Jaydess: LEVONORGESTREL 13.5mg
