Tutorial 20A: Long Acting Reversible Contraception Flashcards
What are the functions of a Copped IUD?
- Contraceptive: Immobilise sperm preventing fertilisation.
-
Interceptive
- if sperm were to get past the IUD, the embryo would be inhibited from implanting into uterine wall.
- If used after sex, prevents implantation.
What are the two types of Copper IUD’s available?
- Multiload CU 375- failure rate of 1 pregnancy per 100 women per year
- Copper T 380 - can be inserted into a smaller os.
When can a copper IUD be inserted?
If no unprotected intercourse = Can be placed at any time of cycle (except heavy menses).
If unprotected intercourse, place within 5 days of calculated ovulation.
6 weeks post delivery
TOP: immediately post First Tri Termination.
How long can a Copper IUD be left in place?
- Leave for 5 years.
- IUD only needs changing once in 40s (as frequency of ovulation decreases) then can stay until menopause
- They also expected us to mention the obvious – IUD does not prevent STI transmission.
What are some advantages of using the copper IUD?
- reversible
- effective (failure rate 1/100 women years)
- safe
- no day to day pills
- can stay in place for 5 years
- no hormones.
What are some side effects of the copper IUD?
- Breast tenderness
- Acne
- Spotting/light bleeding
- Headaches
- Nausea
IUDs DO NOT PROTECT PATIENT FROM STI’s
What are 5x risks associated with the copper IUD?
-
Miscarriage rate increased if get pregnant.
- 25% if IUD removed, 50% if IUD remains.
- No teratogenic effect, PROM more likely.
- Ectopic pregnancy decreases overall rate but increases risk of ectopic pregnancy by 5 times among those who do get pregnant.
- Perforation: at time of insertion 1/1000 insertions
- Infection post insertion associated with STIs. Most suitable for those in long-term relationship. Does not increase risk of PID/infertility for women in mutually monogamous relationships.
- Expulsion of IUD occurs in 2-3%. Most common during 1st or 2nd period after insertion.
What are some contraindications for Copper IUD?
Absolute C/I:
- pregnancy
- genital malignancy
- undiagnosed genital bleeding
- distorted uterine cavity or cavity >5.5cm.
- Wilson’s disease (a disorder of copper metabolism, characterized by copper deposition in multiple organs) (always mention Wilson’s disease even though they will most probably laugh at you)
- previous bacterial endocarditis
- severe PID
Stong C/I:
- active STI (gonococcal or chlamydial infection)
- PID
What is the function and success rate of Mirena?
- Similar to the standard copper IUD but contains progestogen hormone: levonorgestrel.
- Functions:
- Inhibition of sperm function
- Inhibition of endometrial proliferation
- Alters cervical mucus
- Inhibits ovulation (approx 1/3 do not ovulate at all)
- 99.9% Success rate
What are the advantages associated with using a Mirena?
Same as copper: reversible, effective (failure rate 1/100 women years), safe, no day to day pills, can stay in place for 5 years,
Effective treatment for menorrhagia
- Free for patients with menorrhagia but expensive if contraceptive alone
- qualification for funding required failed medical tx for HMB with Hb <120, Ferritin <40
What are the disadvantages associated with using the Mirena?
- (same as copper IUD.) Miscarriage, exctopic pregnancy, perforation, infection, expulsion, doesnt prevent transmission of STIs
- Irregular bleeding and lower abdominal cramps common in first 3 months.
- Systemic dose 1/3rd of POP so low SEs.
- Cost $300+.$315 at Family Planning in 2009.
- Small risk of pelvic infection when IUD put in.
What are Pre- and Post- IUD insertion measures are taken?
Pre-IUD visit:
- Endocervical swab for GC culture and Chlamydia
- Urethral swab if ELIZA test for Chlamydia.
Insertion: non-touch aseptic insertion technique used
Post-IUD visit: 6 week post insertion follow up.
- Expulsion 2-3%, Perforation 1/1000
What are the functions of the Depo-Provera?
Function/MoA:
- Prevents ovulation/egg being released each month. (Suppresses ovulation at hypothalamo-pituitary level)
- Thickens cervical mucus
- Inhibits endometrial proliferation to inhibit implantation
Injection of progestogen into buttock every 12 weeks
- 4 week leeway (up to 16w)
Chance of getting pregnant: <1%, 1/100 women years
What are the advantages of using Depo-Provera?
- Usually no periods – stops endometrial proliferation, so nothing to shed as period.
- One injection lasts 12 weeks
- Doesn’t interfere with sexual intercourse
- Useful for women who can’t take OCP.
What are the disadvantages associated with using Depo-Provera?
- Irregular bleeding
- Weight change
- Mood changes
- Headache
- Reduction in libido
- Delay in fertility
- For some women this is fairly immediate for others it may take longer – occasionally up to 18 months. Within 10 months of the last injection about 50% of women who have stopped it to conceive will be pregnant.
- Needs to be discussed with women before starting on the injection
- No causal association between headache, mood changes and reduction in libido and the injection
Does Depo-Provera have any effect on fertility long-term?
Some woman experience a delay in fertility after stopping the Depo-Provera:
- For some women this is fairly immediate for others it may take longer – occasionally up to 18 months.
- Within 10 months of the last injection about 50% of women who have stopped it to conceive will be pregnant.
They potential for delay in re-experiencing fertility needs to be discussed with women before starting on the injection
What are the contraindications for starting Depo-Provera?
same as POP:
- Absolute C/I:
- pregnancy
- undisclosed genital bleeding
- Relative C/I: malabsorption, arterial disease, liver adenoma, severe liver disease
When can you start the depo-provera?
- Immediately: if Menstruation day 1-5 = will provideiImmediate protection
- All other times: apply 7 day rule
What follow-up regime occurs for depo-provera?
- 3 monthly
- Women who present late for repeat injection:
- can have a further injection
- but they need a pregnancy test ~3 weeks later to exclude an early pregnancy.
What is the function of the Jadelle/Implant?
- Functions
- Thickening mucus in cervix
- May inhibit ovulation (ovaries from releasing egg)
- Progesterone released from 1 or 2 rods implanted under the skin of arm
- Jadelle – 2 rods – releases levonorgestrel. $3 as script + cost of consultation and supplies to insert it.
- Implanon – 1 rod – releases etonogestrel. Not effective if using enzyme inducing medication. Not subsidised - $240
- Failure rate
- <1% for first 4 years
- 1% in 5th year.
What are the two types of implants?
Progesterone released from 1 or 2 rods implanted under the skin of arm
-
Jadelle – 2 rods – releases levonorgestrel.
- $3 script + cost of consultation + insertion equipment.
-
Implanon – 1 rod – releases etonogestrel.
- Not effective if using enzyme inducing medication.
- Not subsidised - $240
What are the disadvantages of using Implanon instead of Jadelle?
- Implanon is not effective if using enzyme inducing medication
- Implanon isn’t subsidised ($240)
What are the advantages of using a contraceptive implant?
- Lasts 3-5 years
- Useful for women who can’t take combined pill
- Useful for those who forget pills or injection appointments
What are the disadvantages of using a contraceptive implant?
- Irregular bleeding. Often gets better with time.
