Amber Anderson

  1. Describe the three different types of IUDs Used for Contraception in the U.S.  2. Identify Patients in which IUDs can be inserted  3. List Advantages of IUD Use for Contraception  4. List Adverse Effects of IUDs. Objectives

  Intrauterine Devices (IUDs) are long acting reversible contraceptives (LARCs) that are considered to be one of the most effective forms of contraception.  IUDs require a single act of motivation for long-term use, eliminating adherence and user-dependence from limiting effectiveness Introduction

  IUDs are chosen by % of women using contraception in the United States  By comparison, IUD prevalence is 14.1% in the developing world broadly. IUD Prevalence

 In many other countries, the IUD use rate is considerably higher  % in U.S  30% in Israel  34% in China  49% in Korea  52% in Uzbekistan. IUD Prevalence

 An increase in IUD use has the potential to reduce unintended pregnancy rates and abortions  Approximately 3 million pregnancies in the U.S. each year, 50% of which are unplanned and thought to be secondary to contraceptive failure.  82% unplanned pregnancies in those age 19 and younger in U.S  In 2010, 765,651 legal induced abortions were reported to CDC Concern with unplanned pregnancies/Abortions in the U.S

  ACOG recommends that they be offered as first-line contraceptive methods and encouraged as options for most women.  Oral Contraceptive Pills (42%) and condoms (20%) are currently the most common used forms of contraception in the U.S. First Line Contraception



  Implant- 0.05%  Male Sterilization- 0.15%  Levonorgestrel IUD- 0.2%  Female Sterilization- 0.5%  Copper IUD- 0.8%  Injection (Depo-Provera)- 6%  Combined Pill and Progestin only pill- 9%  Patch- 9%  Vaginal Ring- 9%  Male Condom- 18%; Female Condom- 21%  Withdrawal- 22% % of Women Experiencing Unintended Pregnancy in 1 st Year With Typical Use

  There are 3 types of IUDs that are approved for use in the United States 1. Copper T380 A (Paragard) 2. Levonorgestrel (Mirena) 3. Levonorgestrel (Skyla) Intrauterine Devices

  IUDs first gained popularity in the U.S. in 1959 after the first major article about this method of contraception was published in the American Journal of Obstetrics and Gynecology. Lippes Loop first type used in U.S.  In 1971, the Dalkon Shield was released. Because it was difficult to remove, the Dalkon Shield was designed with a multifilament string which facilitated the ascent of bacteria from the vagina into the uterus, leading to pelvic inflammatory disease (PID) and other adverse outcomes  Shortly after its release, reports of serious complication, including infection and septic abortion, became widespread. More than 300,000 shield related law suits were filed  The Food and Drug Administration (FDA) advised the manufacturer of the Dalkon Shield to remove it from the market in 1974 Hesitation for use of IUDs in the U.S. d.html

  T-shaped polyethylene device with 380 mm2 of exposed surface area of copper on its arms and stem.  MOA: Released copper ions interfere with sperm mobility and incite a foreign-body reaction that results in a spermicidal environment  Can remain in place for up to 10 years Copper T380 IUD (Paragard)

  Radiopaque T-shaped device with 52 mg of levonorgestrel on its arms and stem released at a rate of 20 mcg per day.  Can remain in place for up to five years Levonorgestrel (Mirena)

 Levonorgestrel (Skyla)  Consists of a T-shaped radiopaque polyethylene device with 13.5 mg of levonorgestrel on its arms and stem released at a rate of 14 mcg per day.  A ring composed of 99.95% pure silver is located at the top of the vertical stem close to the horizontal arms and is visible by ultrasound.  Can remain in place for up to three years

 Levonorgestrel  MOA: *thickening of cervical mucus preventing passage of sperm into the uterus *inhibition of sperm capacitation or survival *alteration of the endometrium.

  IUDs can be inserted at anytime during menstrual cycle as long as pregnancy is excluded and there is no active pelvic inflammation Insertion

 IUDs can be inserted immediately after birth (10 min after placental separation) or abortion  Advantages - Patients are highly motivated to use contraception - Safe and Effective  Disadvantage - High expulsion rate (24%) *Benefits outweigh the risk *Contraindicated if Chorioamnionitis, Endometritis, or Puerperal Sepsis Insertion- Postpartum

  In high risk patients, physicians should screen for STIs. Can be done same day as IUD placement.  Insertion of IUD should be postponed if: 1. mucopurulent discharge 2. known chlamydia or gonorrhea cervicitis 3. symptoms of PID present IUDs and STIs

  No back-up method of contraception required after Copper IUD  Should use back-up for Levonorgestrol IUD for 7 days, unless 1. Inserted within 5 days of menses initiation 2. immediately after birth or abortion 3. Immediately after switching from another hormonal contraceptives Back-Up Contraception after Insertion

  High effectiveness, continuation rates, and user satisfaction  Highly cost-effective, long term  Reversible, with rapid return to fertility after removal  Do not require: - user motivation and adherence - frequent visits for resupply - additional funding for consistent use once placed Advantages of Intrauterine Devices

 Common Adverse Effects, >5% Copper IUD  Heavy Menstrual bleeding/Abdominal Pain- Cramping(from 11.9% in the first year to 2.2% in year 9)  Expulsion (5.7%)

 Common Adverse Effects, >5% Mirena  Amenorrhea (23.9%)  Intermenstrual bleeding and spotting (23.4%)  Abdominal/pelvic pain (12.8%)  Ovarian cysts (12%),  Headache/migraine (7.7%)  Acne (7.2%)  Depressed/altered mood (6.4%)  Menorrhagia (6.3%)  Breast tenderness/pain (4.9%)  Vaginal discharge (4.9%)  IUD expulsion (4.9%). Skyla  Vulvovaginitis (20.2 %)  Abdominal/pelvic pain (18.9%)  Acne/seborrhea (15.0%)  Ovarian cyst (13.2 %)  Headache (12.4%)  Dysmenorrhea (8.6%)  Breast pain/discomfort (8.6%)  Increased bleeding (7.8%)  Nausea (5.5%)

  1. Expulsion: 2-10% in the 1 st year  2. Method Failure: % in the 1 st year (this small population with increased risk of ectopic pregnancy)  3. Perforation: 1/1000 or less Complications

  Physician Knowledge, Skill and Comfort  Low Patient Awareness  High Upfront Costs Barriers to Use

  Cannot be used in nulliparous women or adolescents  Associated with infertility and ectopic pregnancy  Causes Pelvic Inflammatory Disease  Before inserting, you must screen for STIs and have negative results  Must be placed during menses Misconceptions of IUD use

  Long-acting reversible contraceptive methods have few contraindications, and almost all women are eligible for implants and IUDs.  Nulliparous women and adolescents can also be offered IUDs.  Insertion of an IUD or an implant may occur at any time during the menstrual cycle as long as pregnancy may be excluded.  Immediate postpartum IUD insertion, which is an insertion within 10 minutes of placental separation, appears safe and effective.  For women at high risk of STIs, it is reasonable to screen for STIs and place the IUD on the same day.  No Screening for STIs required in low risk patients Key Points

  1. American College of Obstetricians and Gynecologists. Increasing Use of Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy. ACOG Available at: _and_Intrauterine_Devices_To_Reduce_Unintended_Pregnancy _and_Intrauterine_Devices_To_Reduce_Unintended_Pregnancy  2. American College of Obstetricians and Gynecologist. Long Acting Reversible Contraception: Implants and Intrauterine Devices. ACOG Available at: Acting_Reversible_Contraception_--_Implants_and_Intrauterine_Devices Acting_Reversible_Contraception_--_Implants_and_Intrauterine_Devices  3. Anderson SL, Borgelt, LM. Case Report: Risk of Uterine Perforation from IUDs Is Greatest During Postpartum Period. Am Fam Physician Nov 13; 88 (10):  4. Carr S, Espey E. Intrauterine Devices and Pelvic Inflammatory Disease Among Adolescents. Journal of Adolescent Health April; 52 (4)  5. Heinbert EM et al. The Perforated Intrauterine Device: Endoscopic Retrieval. JSLS. 2008; 12:  6. Johnson BA. Insertion and Removal of Intrauterine Devices. Am Fam Physician Jan 1; 71 (1):  7. McNicholas C, Peipert JF. Initiation of Long-Acting Reversible Contraceptive Methods (IUDs and Implant) at Pregnancy Termination Reduces Repeat Abortion. Eved Based Med  8. Randel A. Guidelines for the Use of Long-Acting Reversible Contraceptives. Am Fam Physician Feb 15; 85 (4):  9. Williams DD. IUDs, Implants Most Effective Birth Control. Scientific Daily Available at:: Websites    References