IUDs INTRAUTERINE DEVICES

1. IUDsINTRAUTERINE DEVICES R.O.M.E. Conference-May 2009 Barbara E. Walker, D.O Associate Professor in Family Medicine UNCCH

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3. 3 The History of IUDs 1909- Dr. Richard Richter inserted a ring of silkworm gut into the uterus 1920’s Grafenberg ring- silkworm gut with silver ring-later replaced all with metal alloy ring: copper, nickel, zinc 1949- Dr Mary Halton used silkworm gut coiled around her finger and then inserted into a gelatin capsule- gelatin dissolved and string remained in uterus: failure rate of 1.1% in 266 in 468 women years 1959- with better plastics, new IUD shapes and forms-some with and some without metal (Lippes Loop: barium impregnated polyethylene) Tales of putting pebbles into the uterus of camels before long desert treks. Silver had to be replaced because it was absorbed into the body and caused argyrosis of the gums (similar to the lead line). Pandemic of gonorrhea after and policies Tales of putting pebbles into the uterus of camels before long desert treks. Silver had to be replaced because it was absorbed into the body and caused argyrosis of the gums (similar to the lead line). Pandemic of gonorrhea after and policies

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5. 5 History of IUDs 1980’s – Dalkon Shield with its multifilament nylon string caused increased risk of infection, amnionitis, ectopic pregnancies, tubo-ovarian abscesses, infertility, hysterectomy, death. Robbins Company subsequently recalled and later became bankrupt from lawsuits. Other companies pulled their IUDs. 1990s-Paragard- later Mirena

6. 6 IUDs: Who Should Use Mutually monogamous relationship patients Desire for >2years of pregnancy protection Inability to use hormonal BC (ParaGard) Women with heavy menses, cramps or anemia, or DUB Nulligravid with low risk for STI (controversial) 4/27/09 Precepting Physician addendum: History and examination reviewed with resident at time of patient visit. I agree with the medical decision-making and plan as stated above. I was present and available in the clinic during the entire encounter. 4/27/09 Precepting Physician addendum: History and examination reviewed with resident at time of patient visit. I agree with the medical decision-making and plan as stated above. I was present and available in the clinic during the entire encounter.

7. 7 IUD: Non-candidates Pregnancy Current STI or recent (last 3 months), or multiple partners Uterus <6cm or >9cm (10-12cm?) Undiagnosed vaginal bleeding Active cervicitis or active pelvic infection Known symptomatic actinomycosis Severe anemia (Mirena could be used)

8. 8 IUD: More Non-candidates Recent endometritis Allergy to copper; Wilson’s disease (ParaGard) Abnormal uterus that would prevent fundal placement AIDS or HIV (potential increased risk of other infections-WHO recommendation, not evidence based) Known or suspected uterine or cervical cancer Unresolved abnormal PAP

9. 9 IUDs: Insertion Timing Any time in cycle (confirm negative pregnancy)- ParaGard Within first 7 days of onset of cycle –Mirena (allows hormone levels to be established prior to ovulation)

10. 10 IUDs: Patient Instructions Ask first: Will a change in your menstrual bleeding pattern be acceptable for you? Check for strings regularly- especially after each menses (give pt trimmed strings) Take regularly dosed NSAIDs for the first 2-3 days of menses for the first 3 months Use condoms if at risk of STI

11. 11 Warning Signs: PAINS P: Period late (pregnant); abnormal spotting or bleeding A: Abdominal pain; pain with intercourse I: Infection exposure; abnormal vaginal discharge N: Not feeling well; fever or chills S: String missing: shorter or longer

12. 12 IUDs: Types ParaGard – Ten years Mirena – Five years Gynefix (not available in U.S.)- Five years

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14. 14 Intrauterine Copper IUDParaGard T380A T shaped made of radiopaque polyethylene 2 flexible arms bend down for insertion and then open into uterus to hold copper sleeves against fundus Fine copper wire wrapped around stem (380mm) Monofilament polyethylene tail string threaded through and knotted below ball at base of stem creates double strings that protrude from vagina

15. 15 Levonorgestrel Intrauterine System Mirena T shaped polyethylene frame-32mm Releases 20mcg/day of levonorgestrel from a steroid reservoir around vertical stem Reservoir covered by a silicone membrane Release falls to 14mcg/day after 5 years Mono polyethylene thread attached to loop at the end of the vertical stem of the T-body.

16. 16 Intrauterine Copper IUDParaGard T380A Reversible sterilization Approved for 10 years use; effective for 12 years at least Perfect use failure rate 1st yr:0.6% Typical use failure rate 1st yr: 0.8% Cumulative 10 yr failure rate 2.1-2.8%

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19. 19 Gynefix Paragard, Gynefix, and Multiload

20. 20 Generations of IUDs Lippes Loop-60’s, Paragard-80’s, Gynefix-2003

21. 21 Gynefix

22. 22 Intrauterine Copper IUDParaGard T380A Works primarily as a spermacide Copper ions inhibit sperm motility and acrosomal enzyme activation: sperm rarely reach fallopian tube and are thus unable to fertilize ovum Sterile inflammatory reaction created in the endometrium phagocytizes the sperm Not abortifacients

23. 23 Levonorgestrel Intrauterine System Mirena Reversible sterilization Effective for up to 5 years Perfect use failure rate 1st yr: 0.1% Typical use failure rate 1st year: 0.1% 5 yr cumulative failure rate: 0.7% 7 year cumulative failure rate: 1.1%

24. 24 Levonorgestrel Intrauterine System Mirena Inhibits ovulation. [1-year study approximately 45% of menstrual cycles were ovulatory and in another study after 4 years 75% of cycles were ovulatory.] Local mechanism of continuously released levonorgestrel enhancing contraceptive effectiveness unclear Studies suggest several mechanisms that prevent pregnancy: thickening of cervical mucus preventing passage of sperm into the uterus, inhibition of sperm capacitation or survival, and alteration of the endometrium.

25. 25 Intrauterine Copper IUDParaGard T380A- Advantages Cost effective over 5 years ($400+$200+insertion fee-NHRMC cost) Safe for women who cannot use hormonal methods Ectopic pregnancy: 1/10th the risk Permits spontaneous activity. No action required at time of use Probable protection against endometrial cancer Possible protection against cervical cancer Rapid return to fertility

26. 26 Levonorgestrel Intrauterine System Mirena Cost: $300-400 ($344.1-NHRMC cost) archfoundation.com: will provide free Mirena for economically disadvantaged Also will cover funds for removal for qualified individuals Mirena units that are contaminated or have to be replaced in 1st 3 months may be replaced free of charge (Berlex)

27. 27 Intrauterine Copper IUDParaGard T380A –Disadvantages May increase menstrual flow by 35% (NSAIDS may diminish this) May increase dysmenorrhea (removal rates for pain 1st yr: 11.9%) Spotting and cramping with insertion and intermittently following insertion

28. 28 Intrauterine Copper IUDPsychological Disadvantages Concern for “foreign body” inside the uterus Discomfort with checking for strings Strings cut too short may cause partner discomfort Requires office procedure to insert and remove May require cervical culture before insertion (for GC and chlamydia)

29. 29 Intrauterine Copper IUDParaGard T380A – Other Disadvantages Increased risk of infection in 1st 20 days after insertion (1/1000 pts will get PID) No protection from HIV/STDs/PID May be expelled spontaneously (if occurs silently, increases risk for pregnancy)[Rate declines over time: cumulative over 1st 5 yrs 11.3%; 5th yr 0.3%] Expulsion of one IUD means 1 in 3 chance of expelling another IUD

30. 30 Complications

31. 31 Levonorgestrel Intrauterine System Mirena - Advantages May decrease menorrhagia May produce amenorrhea (20% after 1 yr, 60% after 5 yrs) Decreased quantity of flow Spontaneous sexual activity; requires no action at time of intercourse Possible protective effect against endometrial cancer

32. 32 Levonorgestrel Intrauterine System Mirena – Other Decreased risk for ectopic pregnancy May be used as the progestin for HRT (off label) Decreased endometrial polyps for patients on Tamoxifen (safety not established for breast cancer patients)

33. 33 Levonorgestrel Intrauterine System Mirena -Disadvantages Increased spotting initially Amenorrhea (psychological effects) Expulsion 2.9% for contraception use; 8.9%-13.6% when used to control heavy bleeding Spotting or bleeding may interfere with sexual activity

34. 34 Levonorgestrel Intrauterine System Mirena -Disadvantages No protection against STI May be expelled (loss of protection) Persistent unruptured follicles may lead to ovarian cysts Headaches, acne, mastalgia Cramping after insertion or removal Insertion tube 2mm wider than ParaGard

35. 35 Post-insertion Visits Recheck 1-3 months after insertion to rule out expulsion or problems (option: after first menses) Check that patient can feel the strings Check that length has not changed New sexual partners? Recheck risks for STI (stress condoms)

36. 36 Problem Solving: Missing Strings Speculum exam: look for strings If normal reassure patient Re-teach patient how to feel strings If strings not found: Pregnancy test Ultrasound to look for IUD Alternative contraception

37. 37 Missing Strings: Pregnant Rule out ectopic: 5-8% of failures are ectopic (ParaGard) If intrauterine pregnancy, check that IUD also in uterus Counsel patient: increased risk of miscarriage, bleeding, infection, preterm labor; ? increased risk of birth defects (with Mirena; birth defects NOT increased with ParaGard)

38. 38 Missing Strings: Nonpregnant Cytobrush twisted inside canal may catch strings that are tangled up inside canal Sound cervix to see if IUD in canal. If IUD in endocervix; remove; replace with new IUD if patient desires continued use If not in the canal, confirm position with ultrasound: If in place, can leave in place or remove

39. 39 Missing Strings: Nonpregnant Can use alligator forceps or IUD hook Refer for removal under hysteroscopic or ultrasound guidance Additional contraception should be recommended

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41. 41 Problem Solving: Infection Candidiasis or Bacterial Vaginosis: treat Trichomonas, Chlamydia, or Gonorrhea: treat; reconsider if patient continued IUD candidate Cervicitis or PID: Start treatment with antibiotics to get adequate levels before IUD removal. If symptoms clearing with antibiotic, may chose to leave IUD in place (If patient still IUD candidate)

42. 42 Actinomycosis If PAP reports “actinomycosis-like organism”: less that 50% will actually have actinomyces; most who do will be asymptomatic If symptomatic: treat x 1 month with antibiotic Asymptomatic: Follow PAP smears; treat if PID signs develop Treat with PenG 500mg qid x 2 weeks, or Tetracycline 500mg qid x 1 month or Doxycycline 100mg bid x 2 weeks, then repeat PAP smear Remove IUD, treat with 1 month antibiotic; repeat PAP, place new IUD if clear Penicillin G, 18-24 million U IV every day in 6 divided doses for 2-6 w, followed by penicillin VK, 250-500 mg PO 4 times a day for at least 6-12 mPenicillin G, 18-24 million U IV every day in 6 divided doses for 2-6 w, followed by penicillin VK, 250-500 mg PO 4 times a day for at least 6-12 m

43. 43 Problem Solving: Pregnant First trimester: Strings visible; advise removal of IUD (risks of SAb and preterm labor) If patient bleeding, miscarriage suspected: remove IUD; consider antibiotics for 7 days; confirm that there is no ectopic

44. 44 Problem Solving: Expulsion Confirmed-IUD seen outside uterus: test for pregnancy; place new IUD Suspected or partial: ultrasound for position or may probe endocervical canal; if in canal, remove; place new IUD if patient not pregnant If new IUD not placed, provide other contraception NEVER PUSH PARTIALLY EXPULSED IUD BACK INTO UTERUS!

45. 45 Problem Solving: Bleeding Rule out pregnancy; if + rule out ectopic Rule out infection Rule out expulsion or partial expulsion CBC: if anemic, tx with iron; assess cause; Hb < 9 consider removal of IUD Stress NSAIDs with menses Consider replacement with Mirena

46. 46 Problem Solving: Cramping Rule out pregnancy; if + rule out ectopic Rule out infection Rule out expulsion or partial expulsion Stress NSAIDs with menses & premenstrual Consider replacement with Mirena If Mirena, conjugated estrogen 1.25 mg or estradiol 1mg p.o. per day x 7

47. 47 Problem Solving: Uterine Perforation Pain or instrument/IUD goes too deep by prior bimanual estimate Remove sound; remove IUD if strings present; stop for resistance, increased pain Monitor with CBC, vitals; if stable, may discharge; provide other contraception Refer for surgery if IUD in pelvis

48. 48 IUD Removal Grasp strings firmly close to the os with forceps and pull slowly and firmly If embedded, rotate strings gently to free IUD Alligator forceps or IUD hook Refer for hysteroscopic or ultrasound guided removal

49. 49 Questions?