1. IUDs: Dispelling the Myths

2. Participants in this seminar will be able to: List the indications and contraindications to IUD use Describe the pros and cons of hormonal vs. non- hormonal IUD use Explain the role of higher efficacy, non-user dependent, contraceptive methods like the IUD in the prevention of unintended pregnancy Learning Objectives

3. 62 million women of childbearing age in US. 43 million are sexually active and do not want to become pregnant. 62% reproductive age women use some form of contraception. 6 million pregnancies per year. Guttmacher Institute. Contraceptive Users in the United States

4. Contraception and unintended pregnancies: – 25% method failure – 25% imperfect use – 50% no contraception Half of unintended pregnancies end in abortion: – 1.06 million per year Unintended Pregnancy (n = 3 million)

5. Contraceptive Methods US

6. Case: Shani 21 year old Post-partum 4 weeks Asking about tubal sterilization

7. If graduated college, 13% had tubal ligation If some college, 29% had BTL If graduated HS, 42% had BTL If no HS graduation, 55% had BTL Sterilization by Education

8. 20% of women selecting sterilization at age 30 years or younger later express regret. Young Women and Sterilization

9. Laparoscopic BTL $3545 Essure$2367 Oral contraceptive $2579 3-month injectable $2195 IUD –Copper$1646 –Levonorgestrel $1678 Charges for Contraception for 5 years

10. Lower discontinuation rates in post-partum women 4 weeks postpartum is a good time to insert (CDC says can be done at 4 wks) Immediate post partum now covered by NY Medicaid! Non-patient-dependent method enhances adherence What about an IUD for Shani?

11. Copper IUD Levonorgestrel IUD ParaGard ™ Skyla ™ Mirena ™

12. Comparison Copper IUD (ParaGuard™) Levonorgestrel 52 mg IUD (Mirena™) Levonorgestrel 13.5 mg IUD (Skyla™) No hormone Menses continues, slightly heavier Long lasting: 10 years (12 evidence-based) Progestin treats menorrhagia, anemia Causes amenorrhea 5 years (7 evidence- based) No evidence yet for menorrhagia, anemia Good for 3 years

13. Comparison of two LNGs 52 mg LNG –Initially releases 20 mcg/day –By 5 years, down to 10 mcg/day –Continued efficacy to 7 years 13.5 mg LNG –Initially releases 14 mcg/day –By 3 years down to 5 mcg/day –No studies yet for extended use

14. IUDs are NOT abortifacients! Mechanism of Action

15. Copper-releasing IUD (ParaGuard™): 380 mm 2 copper exposed on plastic T base  Interferes with sperm motility. Causes spermicidal foreign-body reaction. Alters uterine environment, “hostile” to sperm. Mechanism of Action: Copper IUD

16. Hormone-releasing IUD - levonorgestrel on its arms and stem released at decreasing rate with time Thickens cervical mucus (acting as a sperm barrier) Inhibits sperm capacitation & survival. Thins uterine lining. Partial inhibition of ovulation. Presence of plastic alone may have some efficacy Mechanism of Action: Levonorgestrel IUD

17. Case: Maggie 35 year old Heavy smoker

18. Age –No restriction for either IUD –CDC category “2” for women <20 Consider expulsion risk and baseline STI risk Smoking: regardless of amount –No restriction for any IUD Concerns with Maggie… and evidence for safety

19. CDC Categories of Safety

20. Is discreet. Patient and partner do not feel IUD body. Although unlikely, partner may feel strings. An IUD for Maggie

21. Pregnancy Uterine infection Unexplained vaginal bleeding *** Cervical or endometrial cancer (awaiting treatment) *** Breast cancer (Progestin IUD only) Trophoblastic disease Current PID or STD *** Pelvic Tuberculosis *** Initiation is category 4, continuation is category 2 CDC Contraindications to IUD Use

22. Case: Krystal 24 year old G2P1 History of Chlamydia as a teen

23. IUDs do not increase rates of STIs –STIs dependent on local prevalence –In high prevalence areas, reasonable to screen for STIs at IUD insertion –Do not remove IUD for STI treatment –No need for antibiotic prophylaxis at IUD insertion PID may be transiently higher for 20 days after IUD insertion, then back to baseline population levels –Even lower PID rates with good insertion technique and low baseline STI rate –Modern IUD strings do not facilitate ascent of infection –Do not remove IUD for initial PID treatment Sexually Transmitted Infections and Pelvic Inflammatory Disease

24. Current PID or current gonorrhea or chlamydia is “4” for insertion. PID, gc, chlamydia is a “2” for continuation. Trichimonas and Bacterial Vaginosis are a “2” for insertion. HIV infected or clinically well on ARV: “2” Very high risk for STI or HIV, not well, “3” Sexually Transmitted Infections

25. Case: Kerry 18 year old Type 1 DM G0P0

26. Levonorgestrel IUD does not alter glycemic control in patients with type 1 diabetes, does not affect blood pressure Copper IUD is approved for almost all medical conditions: cardiovascular disease, hypertension, migraines, smoking, lipid disorders, diabetes… Medical Eligibility

27. Nulliparity is NOT a contraindication to IUD use! WHO Contraindications

28. Case: Tammy 35 year old Very heavy periods Anemia

29. Spotting, bleeding, and cramping: Increased in 1 st 3 months Amenorrhea: 20% of users by 1 yr, 60% by 5 yrs Expulsion: 2-12% in 1 st yr Perforation: <.01% at time of insertion Headaches, acne, mastalgia: < 3% in 1 st months LNG 52 mg IUD - Side Effects

30. Cramps & menorrhagia improve. 90% decrease in overall blood loss. Decreases number of invasive treatments for DUB, fibroids. Decreases risk of ectopic pregnancy. May protect against endometrial cancer, STIs. Decreases perimenopausal symptoms. LNG 52 mg IUD - Medical Advantages

31. LNG 13.5 mg Only 6% have amenorrhea after one yearOnly 6% have amenorrhea after one year No evidence that lower dose means less progestin side effectsNo evidence that lower dose means less progestin side effects Low failure rate, but of failures 50% were ectopic pregnanciesLow failure rate, but of failures 50% were ectopic pregnancies

32. Treatment of menorrhagia, including in women with uterine fibroids and adenomyosis. Treatment of pain in women with endometriosis. Alternative to hysterectomy for women w/ menorrhagia Prevention of endometrial hyperplasia in menopausal women using estrogen therapy. Prevention of endometrial proliferation and polyps in breast cancer survivors taking tamoxifen. Noncontraceptive Benefits of the LNG 52 mg IUD

33. Adapted from Coutinho EM. Is Menstruation Obsolete? 1999. Number of Cycles 50 0 100 150 200 250 300 350 400 450 Prehistoric 160 Colonial America 450 Modern 500 Lifetime Number of Menstrual Cycles

34. Must IUDs be inserted during menses? Can the IUD be used as emergency contraception? Questions about IUDs

35. All IUDs can be inserted at any point in menstrual cycle. Copper IUD can be used for emergency contraception within 5-7 days of unprotected sex-with nearly 100% efficacy. Progestin IUD cannot be used for EC (yet). Timing of IUD Insertion

36. IUDs DO NOT cause Abortion: –IUDs thicken cervical mucus, suppress endometrium; progestin IUD has some anovulatory effect IUDs DO NOT increase risk of PID: –IUD itself carries no risk of infection. Transient risk w/ insertion. Progestin IUD: may protect against PID, 5-year PID associated removal risk 0.8. IUD Myths Debunked

37. IUDs DO NOT increase risk of ectopic pregnancy. IUDs DO NOT increase rates of breast cancer. May insert at any point in the menstrual cycle. More IUD Myths Debunked

38. Okay to use in nulliparous women. No need for prophylactic antibiotics. Okay to do STI testing at time of insertion (& treat infections w/ IUD in place) More IUD Myths Debunked

39. Encourage prompt initiation. Use patient-centered counseling to enhance adherence. Inform about high-efficacy methods - don’t limit IUDs unnecessarily. Educate about all contraceptive options: if she qualifies, let her decide. Proactive Contraception Rules For Success

40. Troubleshooting IUD issues Bleeding pattern problems –NSAIDs or OCPs plus time Pain problems –NSAIDs plus time (check placement w USN) String issues –Leave long (can always shorten), cut at right angle, tuck behind cervix Pregnant w IUD – urgent need for USN!!!

41. Difficult Insertions

42. Sound vs Sound w dilation

43. Take Home Messages You can do this!You can do this! IUDs are good for your patientsIUDs are good for your patients The risks are minimalThe risks are minimal The benefits are enormousThe benefits are enormous

44. Hatcher et al, Contraceptive Technology 2011 Managing Contraception – book online @ www.managingcontraception.org CDC Medical Eligibility Criteria for Contraceptive Use Association of Reproductive Health Professionals www.arhp.org Alan Guttmacher Institute www.agi-usa.org www.contraceptiononline.org Planned Parenthood www.plannedparenthood.org The Cochrane Collaboration www.cochrane.org www.Not-2-Late.com Reproductive Health Access Project www.reproductiveaccess.org References and Resources