Contraception
Intrauterine Device
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Intrauterine Device
, IUD, Paragard, Copper T-380A IUD, Progestasert, Mirena, Skyla, Liletta
See Also
IUD Insertion
Contraindications
Absolute
Undiagnosed
Abnormal Uterine Bleeding
Uterine abnormality that distorts endometrial cavity
Current intrauterine infection
Unresolved abnormal
Pap Smear
Current endometrial or
Cervical Cancer
Findings suggestive of trophoblastic disease
Wilson's Disease
or copper allergy (Copper-T IUD)
Uterine or pelvic infection within last 3 months
Sexually Transmitted Infection
Chorioamnionitis
Endometritis
Contraindications
Historical that are no longer contraindications (restrictions loosened by FDA in 2010)
Nulliparity
More difficult to place if no prior pregnancy
Must be able to sound
Uterus
to 6 cm or greater
Expulsion rates and longterm device tolerance and continuation rates are similar to women previously pregnant
Paterson (2009) Contraception 79(6): 433-8 [PubMed]
Veldhuis (2004) Eur J Gen Pract 10(3): 82-7 [PubMed]
Adolescents
USMEC recommends IUD for
Contraception
in this cohort due to high efficacy that outweighs potential risks
Risk of PID or future
Infertility
does not appear to be increased
Sexually Transmitted Disease
history or multiple sexual partners
PID may now be lower risk with modern IUDs
Campbell (2007) Am J Obstet Gynecol 197(2): 193 [PubMed]
Screen women for STIs per CDC guidelines
Delay
IUD Placement
for 3 months following
Sexually Transmitted Infection
treatment
Ectopic Pregnancy
Ectopic risk is not increased with IUD use
However, if breakthrough pregnancy occurs, it is much more likely to occur as an
Ectopic Pregnancy
Risk Factors
Pelvic Inflammatory Disease
Tubal
Infertility
Cohort Study (n=4185)
Primary (
Nulliparous
) Tubal
Infertility
Risk
Dalkon Shield
Relative Risk
: 3.3
Lippes Loop or Saf-T-Coil
Relative Risk
: 2.9
Copper-T IUD
Relative Risk
: 1.6
Having only one sexual partner: No increased risk
Secondary (
Multiparous
) Tubal
Infertility
Risk
Copper-T IUD
Relative Risk
: 1.5 (not significant)
Non-Copper IUD
Relative Risk
: 2.8
References
Cramer (1985) N Engl J Med, 312(15): 941-7 [PubMed]
Adverse Effects
First 3 months after IUD insertion
Perception of vaginal infection
Changes in menstrual flow (30%)
Dysmenorrhea
or prolonged flow
Results in 10-15% discontinuation in first year
Reduced with
NSAID
s taken 2-3 days with flow onset
Pelvic Inflammatory Disease
risk
Risk increases in first 20 days after insertion
Risk is <1 per 1000 insertions
Use of prophylactic antibiotics not warranted (not effective, do not alter course)
Expulsion in first 2 months
Increased expulsion rates if placed immediately after delivery,
Cesarean Section
or pregnancy loss
Days 1-5: 5% expulsion rate
Days 6-12: 3% expulsion rate
Days >12: 2% expulsion rate
Progestin
IUD (Mirena, Skyla) related adverse effects
Headache
Hair Loss
Major Depression
Breast
tenderness
Vaginitis
Pelvic Pain
Safety
IUDs are compatible with
Lactation
Types
Available in U.S.
Copper T-380A IUD (Paragard): 10 year copper device
First year failure rate: 0.7%
Cumulative ten year failure rate: 2.1%
Recent studies indicate efficacious 12 years
Reduces
Ectopic Pregnancy
rate significantly
Barium impregnated
Mirena: 5 year
Progesterone
(
Levonorgestrel
) device
First year failure rate: 0.2%
Of pregnancies, 50% will be ectopic
Better efficacy than Copper-T IUD
Polyethylene-barium T-shape 52 mg
Levonorgestrel
Releases 20 mcg/day of
Levonorgestrel
Progesterone
adverse effects may occur
Headache
Acne Vulgaris
Conception occurs for 80% within 12 months of removal
Mechanism (Primarily spermicidal)
Thins endometrium and thickens
Cervical Mucus
Inhibits sperm movement and function
May also suppress
Ovulation
Reduces
Menstrual Bleeding
Consider for
Dysfunctional Uterine Bleeding
Irregular bleeding may occur in first 6 months
Amenorrhea
at one year of use if common (20%)
Skyla: 3 year
Progesterone
(
Levonorgestrel
) device
New in 2014 from Bayer (also makes Mirena)
Releases 14 mcg/day of
Levonorgestrel
(lower dose than Mirena)
Similar inserter as Mirena
Marketed for
Nulliparous
patients (but other IUDs are also considered safe in this cohort)
First year failure rate: 0.9%
Less effective than either Mirena or Copper-T IUD
Conception occurs for 77% within 12 months of removal
Liletta:
Progesterone
(
Levonorgestrel
) device
Releases 19 mcg/day of
Levonorgestrel
(similar to Mirena)
Released in 2015 and approved for 3 years of protection
Studies are ongoing with goal of ultimately showing 7 years of protection
Preparations
Discontinued
Progestasert: 1 year
Progesterone
device (discontinued in U.S. in 2001)
First year failure rate: 2%
Ethylene/vinyl acetate T-shape 38 mg
Progesterone
Higher rate of ectopic compared with Copper IUD
Less bleeding complications
Progesterone
adverse effects may occur
Indications
Prophylactic Antibiotics on insertion
Routine prophylaxis no longer indicated
No difference in outcomes
Prior indications for antibiotic prophylaxis
History of
Bacterial Vaginosis
Difficult insertion
SBE Prophylaxis
(not indicated in IUD insertion)
Procedure
See IUD Insertion
Protocol
Switching between contraceptives
Switch to Mirena IUD from pill, patch, ring
Use pill, patch, ring, or barrier protection for the first 7 days after Mirena insertion
Switch may be made before the scheduled end of use of the prior contraceptive
Switch to Mirena IUD from Copper-T IUD
Use barrier protection for first 7 days
Switch to
Depo Provera
from Copper-T IUD
Give first injection 7 days prior to Copper-T-IUD removal (or use barrier contraceptive for 1 week)
Switch to
Nexplanon
(
Progestin
implant) from Copper-T-IUD
Nexplanon
should be inserted 4 days prior to Copper-T IUD removal (or use barrier contraceptive for 4 days)
Switch to contraceptive pill, patch or ring from the IUD
Start the new contraceptive 7 days before IUD removal
Switch to Copper IUD from other methods
Insert Copper-T IUD no more than 5 days after stopping other contraceptive
Insert Copper-T IUD no more than 16 weeks after last
Depo Provera
injection
Management
Complications
Sexually Transmitted Infection
without signs of
Pelvic Inflammatory Disease
IUD may be left in place and STD treated
Remove IUD for
Pelvic Inflammatory Disease
or other symptomatic
Sexually Transmitted Infection
Pregnancy with IUD in place
Transvaginal Ultrasound
to exclude
Ectopic Pregnancy
(critical)
IUD Removal
Ultrasound
Uterus
to confirm IUD in place if strings can not be found
Recommended to reduce pregnancy loss,
Placental Abruption
, preterm delivery, and low birth weight
However, pregnancy loss occurs in at least 40% of women after IUD removal
Saav (2007) Hum Reprod 22(10): 2647-52 [PubMed]
References
(2001) Med Lett Drugs Ther 43(1096):7-8 [PubMed]
Andersson (1994) Contraception 49:56 [PubMed]
French (2000) Br J Obstet Gynaecol 107:1281 [PubMed]
Hardeman (2014) Am Fam Physician 89(6): 445-50 [PubMed]
Herndon (2004) Am Fam Physician 69(4):853-60 [PubMed]
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