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Clinical Conundrums

Clinical Conundrums. Dr Alyson Elliman FFSRH, MIPM Consultant Croydon Health Services NHS Trust With (huge) thanks to Dr Zara Haider. Order of presentation. LARC – what’s new Starting and switching methods Lost threads Migrating implants Managing unscheduled bleeding.

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Clinical Conundrums

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  1. Clinical Conundrums Dr Alyson Elliman FFSRH, MIPM Consultant Croydon Health Services NHS Trust With (huge) thanks to Dr Zara Haider LARC for London March 2012

  2. Order of presentation • LARC – what’s new • Starting and switching methods • Lost threads • Migrating implants • Managing unscheduled bleeding LARC for London March 2012

  3. Nexplanon vs Implanon • Different application device • Less theoretical risk of deep or non-insertion • Different insertion technique • One-handed • Radio-opaque (x-ray, CT as well as USS, MRI) LARC for London March 2012

  4. Nexplanon LARC for London March 2012

  5. New inserter for implant • Your experience? LARC for London March 2012

  6. Implanon failures % Unintended pregnancies Bensouda-Grimaldi et al Gynecol Obstet Fertil 2005; Harrison-Woolrych et al Contraception 2005; data on file, Organon UK LARC for London March 2012

  7. Transverse image (deep Implanon) LARC for London March 2012

  8. Radio opaque implant LARC for London March 2012

  9. New Mirena inserter • Slightly narrower outer diameter of inserter tube • Threads inside the handle • Scale on both sides of inserter tube • Modified slider • No change in actual IUS • Local Bayer events and training cascade LARC for London March 2012

  10. New IUS inserter • Your experience? Current vs. ‘old’ inserter. • Need for improvement of current inserter? LARC for London March 2012

  11. Quick Start – why? • Reduce time at risk of pregnancy • Retain information from consultation • Maintain enthusiasm for method • Removes costs, barriers and need for repeat consultation LARC for London March 2012

  12. Quick Starting Quick starting Pregnancy risk excluded: Offer immediate start any method (additional precautions) Quick Starting Contraception Sept 2010 www.fsrh.org.uk LARC for London March 2012

  13. Quick Starting • Pregnancy not excluded: • Assess for EC • Can quick start CHC (not co-cyprindiol), POP, implant • DMPA only if other methods not acceptable • Advise re theoretical risks, additional precautions*, PT in 3-4 weeks LARC for London March 2012

  14. *Quickstart and extra precautions • Post EHC • Levonorgestrel –additional precautions for 2 days (POP) or 7 days (CHC, implant, injectable) • UPA –additional precautions –add a further 7 days (due to PRM effect) LARC for London March 2012

  15. Bridging • Bridging: • CHC, POP (DMPA) LARC for London March 2012

  16. LARC for London March 2012

  17. LARC for London March 2012 CEU Sept 2010

  18. IUT Problems - Lost Threads Causes Expulsion / perforation / uterine enlargement Exclude pregnancy Consider EC Recommend additional contraception Locate the device refer for scan / x-ray LARC for London March 2012

  19. LARC for London March 2012

  20. Expelling IUD/IUS • No knowing for how long may not have been protective if found at Cx • Non-fundal placement –no evidence of reduced effect • ?Remove and replace with IUD if sure a negative PT excludes very early pregnancy • ?Remove and give EHC LARC for London March 2012

  21. Migrating subdermal implants • 2 papers: • 2005 – 2 cases J Fam Plann Reprod Health Care 2005:31;71-73 (Evans et al.) • 2006 – study of 100 patients looking at migration 3 and 12 months post insertion J Fam Plann Reprod Health Care 2006:32;157-159 (Ismail et al.) LARC for London March 2012

  22. 2 case studies • Case 1 • 33yr old, attending 3+ yrs after insertion • Norplant removed prior to insertion • Distal end 11cm from insertion site, proximal end approaching axilla • Case 2 • 35 yr old, attending 3 yrs after insertion • Norplant removed prior to insertion • Distal end 7.3cm from insertion site LARC for London March 2012

  23. Newcastle study • 100 women, implanon inserted: • Location verified after insertion, 3 months and 12 months • Same doctor inserting all SDI • After insertion, distal end of all was 1cm from insertion site J Fam Plann Reprod Health Care 2006:32;157-159 LARC for London March 2012

  24. At 3 months J Fam Plann Reprod Health Care 2006:32;157-159 LARC for London March 2012

  25. At 12 months J Fam Plann Reprod Health Care 2006:32;157-159 LARC for London March 2012

  26. Conclusion • Significant migration unlikely to occur if SDI is correctly inserted • If there is migration, more likely to be caudal and by less than 2cm LARC for London March 2012

  27. Migration of implant • Your experience?? LARC for London March 2012

  28. Implants continued • If impalpable or no “pop – up” do not attempt to remove • Refer to deep implant removal centre • Deep implants – incorrect insertion (less theoretically likely with Nexplanon) or weight increase • Failed insertion – not with Nexplanon (look at the other arm!!) • Etonogestrel levels –contact company LARC for London March 2012

  29. Implants continued • Multirod implants – Norplant (6) and Jadelle (2), removal by specialist with ultrasound LARC for London March 2012

  30. Implants continued • Some other SDI (inserted abroad) with 2-6 rods – scan to confirm how many are in situ prior to removal LARC for London March 2012

  31. Troublesome bleeding – a case study • 28yr old, Nexplanon in situ since 4 months. 2 month history of irregular bleeding. Bleeding unpredictable, variable amount. Several occasions, postcoital. • Amenorrhoeic for 2 months after SDI insertion • Management……….. LARC for London March 2012

  32. History • Other symptoms • Pelvic pain, dyspareunia, • Menstrual pattern prior to SDI • Pregnancy risk • Drug interactions with SDI (inc. OTC preparations like St. Johns Wort) • Cervical screening history • Sexual history • Partner health • Partner change • Previous STI check LARC for London March 2012

  33. Examination • PT • STI tests • Cervical smear if indicated • Speculum and bimanual examinations • TVS • Endometrial biopsy???? • Exclude other causes before implicating SDI LARC for London March 2012

  34. fsrh.org LARC for London March 2012

  35. Irregular bleeding with Implanon • 923 women in 11 clinical trials • Amenorrhoea 22.2% • Infrequent bleeding 33.6% • Frequent 6.7% and/or prolonged bleeding 17.7% Eur J Contracept Reprod Health Care 2008;13(Suppl 1):13-28 LARC for London March 2012

  36. Implanon: Bleeding patterns Amenorrhoea Infrequent bleeding Frequent bleeding Prolonged bleeding 60 50 40 30 Percentage 20 10 0 1 2 3 4 5 6 7 8 Three-monthly assessments LARC for London March 2012 FSRH 2003

  37. Bleeding patterns with implant • Your experience?? LARC for London March 2012

  38. Mechanism of irregular bleeding with SDI • Incompletely understood • Incomplete oestrogen suppression • Increased follicular diameter • Increased endometrial thickness • Unstable endometrium • Fragile surface vessels • Epithelium detaches easily from underlying stroma • Defective epithelium repair mechanisms LARC for London March 2012

  39. Treatment • 3/12 COC (if no contraindications) 30 – 35μg containing norethisterone or levonorgestrel, continuously or cyclically (unlicensed) CEU • Mefanamic acid bd or tds 500mg 5/7 CEU • No published evidence: • High dose cyclical progestogen for up to 3/12 (MPA or NET) • Desogestrel POP for 3 months LARC for London March 2012

  40. Discontinuation rates with Progestogen only LARC methods LARC for London March 2012

  41. Research needed Exploration of methods to stabilise/repair endometrium • Mifepristone • Doxycycline – potent inhibitor of matrix metalloproteinase enzymes of endometrium LARC for London March 2012

  42. Conclusion • Theory and practice need to be reconciled in real life scenarios • Remember cultural acceptance/non-acceptance of frequent or absent bleeding • LARC targets affected by word of mouth, wish for regular and non-heavy bleeds LARC for London March 2012

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