1 / 44

IUDs: Dispelling the Myths

IUDs: Dispelling the Myths. Learning Objectives. 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

kermit-burt
Télécharger la présentation

IUDs: Dispelling the Myths

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. IUDs: Dispelling the Myths

  2. Learning Objectives 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

  3. Contraceptive Users in the United States • 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.

  4. Unintended Pregnancy (n = 3 million) • 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

  5. Contraceptive Methods US

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

  7. Sterilization by Education • 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

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

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

  10. What about an IUD for Shani? • 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

  11. Copper IUDLevonorgestrel IUDParaGard™ Skyla™ Mirena™

  12. Comparison

  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. Mechanism of Action IUDs are NOT abortifacients!

  15. Mechanism of Action:Copper IUD Copper-releasing IUD (ParaGuard™): 380 mm2 copper exposed on plastic T base  • Interferes with sperm motility. • Causes spermicidal foreign-body reaction. • Alters uterine environment, “hostile” to sperm.

  16. Mechanism of Action: Levonorgestrel IUD • 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

  17. Case: Maggie • 35 year old • Heavy smoker

  18. Concerns with Maggie… and evidence for safety • 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

  19. CDC Categories of Safety

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

  21. CDC Contraindications to IUD Use • 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

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

  23. Sexually Transmitted Infections and Pelvic Inflammatory Disease • 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

  24. Sexually Transmitted Infections • 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”

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

  26. Medical Eligibility • 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…

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

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

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

  30. LNG 52 mg IUD - Medical Advantages • 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.

  31. LNG13.5 mg • Only 6% have amenorrhea after one year • No evidence that lower dose means less progestin side effects • Low failure rate, but of failures 50% were ectopic pregnancies

  32. Noncontraceptive Benefits of the LNG 52 mg IUD • 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.

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

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

  35. Timing of IUD Insertion • 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).

  36. IUD Myths Debunked • 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.

  37. More IUD Myths Debunked • 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.

  38. More IUD Myths Debunked • 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)

  39. Proactive Contraception Rules For Success • 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.

  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! • IUDs are good for your patients • The risks are minimal • The benefits are enormous

  44. References and Resources • 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

More Related