Everything You Ever Wanted to Know About IUDs

1. Everything You Ever Wanted to Know About IUDs …. and more!

2. Background • IUDs are one of the oldest methods of contraception • 90 million women use it world wide - 50% of contraceptive users in Asia - 6-27% of contraceptive users in parts of Europe • However, the US has lagged behind other countries in adopting the IUD - only 2% of contraceptive users

3. In the 1970s, 10% of contraceptive users in the US chose IUDs • Then the Dalkon Shield was linked to PID and utilization fell

4. Paragard (TCu380A) • T-shaped, radiopaque intrauterine device with copper wrapped around arms and stem

5. Mirena • T-shaped, radiopaque intrauterine device which releases 20mcg/day of levonorgestrel from stem (this falls to 14mcg/day after 5 years), progestin effect is primarily local

6. Effectiveness

7. Mechanism of Action • Precise MOA unknown, likely several factors involved: - changes in cervical mucous that inhibit sperm transport - chronic inflammatory changes of the endometrium and fallopian tubes, which have spermicidal effects and inhibit fertilization and implantation - thickening and glandular atrophy of the endometrium, which inhibits implantation - direct ovicidal effects • Prevents fertilization and is not an abortifacient

8. Mechanism of Action • Paragard: copper enhances the cytotoxic inflammatory reaction within the endometrium, which is toxic to sperm and ova; in vitro copper interferes with sperm migration, viability, and acrosomal reaction • Mirena: progestin thickens cervical mucous which creates a barrier to sperm penetration into the upper genital tract; it causes endometrial decidualization and glandular atrophy, which are hostile to implantation

9. Paragard Mirena Cost • Although initial cost is high, overall cost decreases with each year of use; within 5 years the Paragard is the most cost-effective method available • Paragard: $475 ($3.96 a month) • Mirena: $515 ($8.58 a month) • Preventing an unplanned pregnancy: priceless

10. Choosing an IUD

11. Change in Hgb During 5 Years of Use

12. convenient private permits spontaneous sexual activity protection against endometrial and cervical cancer good option for women who cannot use hormonal methods rapid return to fertility decreased risk of ectopic pregnancy effective cost-effective can be used as EC can be placed post-placental and immediately postpartum Paragard - Advantages

13. increased blood loss increased dysmenorrhea spotting and cramping post-insertion “something inside” requires surveillance possible partner discomfort requires office visit for insertion, removal may require recent GC/CT increased risk of PID following insertion no protection against STIs can be expelled Paragard - Disadvantages

14. convenient private permits spontaneous sexual activity dysmenorrhea improves menorrhagia improves and associated surgeries declines provides endometrial protection treatment of endometriosis rapid return to fertility decreased risk of ectopic pregnancy effective cost-effective Mirena - Advantages

15. irregular spotting and bleeding amenorrhea hormonal side effects spotting and cramping post-insertion “something inside” requires surveillance possible partner discomfort requires office visit for insertion, removal may require recent GC/CT increased risk of PID following insertion no protection against STIs can be expelled Mirena - Disadvantages

16. Residents as Patients - Story Time

17. Candidates for IUD • Women who desire reversible, long-term contraception who have no contraindications • This includes women who are young, nulliparous, have a history of STI/PID, have a history of ectopic pregnancy, and are not in a monogamous relationship

18. Contraindications to IUD • Refer to the 2004 WHO Medical Eligibility Criteria with update in 2008 1 – use the method in any circumstance 2 – generally use the method 3 – use of the method is not usually recommended unless more appropriate methods are not available or acceptable 4 – method not to be used

19. WHO 4 allergy to copper, Wilson’s disease pregnancy severe uterine distortion unexplained vaginal bleeding current PID or within last 3 months current purulent cervicitis, GC/CT postpartum with puerperal sepsis immediate post-septic AB gestational trophoblastic disease with persistently elevated B-hCG levels or malignant disease cervical CA, endometrial CA WHO 3 postpartum 48h-4wks gestational trophoblastic disease with decreasing or undetectable B-hCG levels ovarian cancer increased risks of STIs (for continuation) AIDS, antiretroviral therapy (for continuation) SLE with severe thrombocytopenia Contraindications - Paragard

20. WHO 4 pregnancy severe uterine distortion unexplained vaginal bleeding current PID or within last 3 months current purulent cervicitis, GC/CT postpartum with puerperal sepsis immediate post-septic AB gestational trophoblastic disease with persistently elevated B-hCG levels or malignant disease cervical CA, endometrial CA, breast CA malignant liver tumor/hepatoma WHO 3 postpartum < 48h if breast feeding postpartum 48h-4wks active DVT/PE current and history of ischemic heart disease (for continuation) migraine with aura (for continuation) gestational trophoblastic disease with decreasing or undetectable B-hCG levels past breast CA, ovarian CA increased risks of STIs (continuation) AIDS, antiretroviral therapy (continuation) severe decompensated cirrhosis, benign hepatocellular adenoma SLE with positive or unknown antiphospholipid antibodies Contraindications - Mirena

21. Complications • Perforation • Expulsion • Strings not visible • Infection • Cramping/pain • Abnormal bleeding • Pregnancy

22. Perforation • All perforations occur or begin at insertion but may go unrecognized for weeks • Occurs in 1 in 1000 procedures • Risk factors: clinician inexperience, immobile uterus, retroverted uterus, presence of a myometrial defect • Clinical signs: pain, loss of resistance to advancement of instrument, instrument introduced deeper than uterus thought to be on bimanual exam; women with delayed diagnosis typically present with an associated complication (ie, anemia, peritonitis)

23. Perforation - Management • By uterine sound - observe patient for several hours - check VS, evaluate for bleeding, increased abdominal pain/tenderness/distension - if stable, may be sent home - if signs of severe uterine bleeding or vascular or visceral injury, send to surgery for abdominal exploration • By IUD - observe per above - perform U/S - can attempt removal by gently pulling on strings - if resistance encountered, stop and send to surgery • Provide antibiotics per PID and an alternative form of contraception

24. Expulsion • Rates at 1 year: Paragard 3-10%, Mirena 6% Rates at 7 years: Paragard 1.8%, Mirena 2.9% • Risk factors: age less than 20, nulliparity, menorrhagia, severe dysmenorrhea, prior expulsion, insertion immediately after 2nd trimester abortion or postpartum • Clinical signs: asymptomatic; cramping, vaginal discharge, spotting/bleeding, dyspareunia, lengthened or absent strings • Management: - remove if visible; if not visible evaluate via U/S +/- abdominal x-ray - rule out pregnancy

25. Strings Not Visible • Possible explanations: strings curled and retracted into the endocervical canal or uterine cavity, or they are broken; expulsion; perforation • Management - rule out pregnancy - twist a cytobrush in the endocervical canal to try to draw the string out - if unsuccessful, examine the endocervical canal with a uterine sound; remove if the IUD is in the cervix - in still unsuccessful, evaluate for expulsion

26. Infection • PID - relative risk is increased by a factor of 6 in the first 20 days after insertion, but absolute risk is still low - in the first 20 days after insertion risk is 10 per 1000 women, due to the insertion process itself - beyond the first 20 days after insertion risk is 1.4 per 1000 women, due to a newly acquired STI - Mirena is protective against PID because of effect of progestin on cervical mucous - initiate antibiotics, +/- removal of IUD

27. Infection • Asymptomatic GC/CT: standard treatment, re-evaluate patient’s appropriateness for continued use • Vaginitis (BV, trich, candida): standard treatment • Actinomyces: bacteria that is part of the normal flora of the GI tract and may be a normal component of vaginal flora BUT can cause severe infection - if asymptomatic, no treatment required - if signs/symptoms of PID, initiate antibiotics and remove IUD

28. Cramping/pain • Rule out pregnancy, infection, expulsion, perforation • Offer NSAIDs with menses • More common with Paragard, can consider replacement with Mirena or other method

29. Abnormal bleeding • Patients should be counseled about changes in bleeding prior to insertion • Causes of new onset abnormal bleeding after prolonged use: pregnancy, infection, displacement, gynecologic disorders of the cervix or uterus • If Paragard is causing menorrhagia with significant fall in Hct, can remove IUD and consider inserting Mirena

30. Pregnancy • Associated with increased risk of miscarriage, infection, preterm labor and delivery • However, if embedded in the placenta or membranes, removing IUD may cause bleeding, ROM, fetal loss, fetal trauma • Management: - rule out ectopic - perform U/S and pull strings if feasible, otherwise leave in situ - if termination is desired, IUD removal can be performed at time of termination

31. Instructions for Patient and Follow-Up Care • Paragard: no back-up needed • Mirena: no back-up needed if inserted within 7 days from LMP, otherwise back-up for 7 days • Give patient trimmed IUD strings, instruct her to check for them after menses each month • Review warning signs P: period late, heavy bleeding A: abdominal pain, pelvic pain I: infection risk, abnormal vaginal discharge N: not feeling well, fever, chills, syncope S: string missing, shorter or longer • Patient should RTC after her first period

32. IUD Insertion and Removal - Things to Consider

33. Pre-IUD Insertion Visit • Counseling - discuss risks/benefits, etc. - select IUD - summarize insertion process - evaluate for patients who may need paracervical block - no unprotected sex for 2 weeks prior to insertion • Obtain consent • Screening for GC/CT: universal vs. selective • Hct for Paragard

34. Timing • At any time • Insertion during day 5-10 of her cycle probably represents the ideal time for insertion because of the lower risk of expulsion (after menses have completed) and discomfort/side effects with insertion (before the luteal phase) • Some recommend insertion during menses

35. Analgesia • NSAIDs 1 hour prior to insertion • Local anesthetic options for tenaculum site: none, benzocaine gel at tenaculum site and in cervical canal, or 1cc of local anesthetic at tenaculum site • Cervical anesthetic: most will not require this, but can perform paracervical block (5cc of local anesthetic at 3 and 9 o’clock)

36. Steps of Procedure • Pregnancy test • Bimanual exam • Insert speculum, check for signs of cervicitis the remainder of the procedure is sterile • Cleanse cervix with antiseptic • Provide local and cervical anesthetic if desired • Place tenaculum on the anterior lip of the cervix • Sound the uterus (6-9cm) • Insert IUD • Trim strings to about 4 cm • Remove tenaculum and observe for bleeding

37. Insertion Video

38. Postplacental and Immediate Postpartum Insertion • Paragard can be inserted postplacental (preferably with 10 minutes) and immediate postpartum (within first week after delivery, but preferably within 48 hours) • Expulsion rates of 7-15% at 6 months • Pregnancy rates 2-2.8% at 24 months • Perforation rates less than 1 in 1000 • Techniques - IUD strings placed in palm of hand followed by manual insertion at top of fundus - use of ring forceps to insert IUD

39. Removal • Indications: expelling IUD, infection, pregnant, expired IUD, complications with IUD, anemia, no longer a candidate, patient request, menopause • Procedure: grasp the strings close to external os with ring forceps and steadily retract until IUD removed • Complications - embedded IUD: gentle rotation of strings may free IUD, if still stuck may use alligator forceps removal with or without U/S, hysteroscopic removal may be indicated in rare cases - broken strings: remove with alligator forceps, IUD hook or Novak curette

40. Residents as Providers – Story Time

41. Practice Time!