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1. IUDsINTRAUTERINE DEVICES R.O.M.E. Conference-May 2009
Barbara E. Walker, D.O
Associate Professor in Family Medicine
UNCCH
2. 2
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
4. 4
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
13. 13
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%
17. 17
18. 18
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
40. 40
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?