Part 1: Who should be offered an IUD, and selection of the appropriate IUD

Dr. Roberto Leon, MD, FRCSC (biography and disclosures)

Disclosures: Received an honorarium from Bayer for a speaking at CME events on IUDs. No conflict of interest. Mitigating potential bias: Only published trials are included.

What frequently asked questions or care gaps I have noticed

Intrauterine devices (IUDs) are a safe, very effective, rapidly reversible and highly acceptable contraception amongst women. Yet it is resisted by many physicians. A recent study in Seattle (1) found that half or fewer of the physicians sampled do not follow the recommended guidelines, advising against using an IUD to nulliparous women, 20 years old or less, or women with a prior history of STI, PID or ectopic pregnancy. Physicians with negative perceptions about infection-related risks and infertility of using LNG-IUS were less likely to practice evidence-based selection of candidates. This is appalling considering the many advantages of the IUDs.

Data that answers these questions or gaps

There are many studies that attest to the safety and efficacy of the IUD in all women, especially in adolescents and nulliparous women. Hall’s large study of IUDs in nulliparous women concluded that in spite of significant pain symptoms with insertion, intrauterine contraception is well tolerated in nulliparous women (2).

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (ACOG) both recommends that Long-Acting Reversible Contraception (LARC methods: IUDs and Implants, but the latter is not available in Canada) should be considered first-line contraceptive choices for adolescents and nulliparous women (3,4)

What I recommend (practice tip)

A systematic approach for choosing a contraceptive is best. I go trough the 7 “Cs” using PowerPoint presentation with all my patients, and give them a pamphlet that reflects the presentation to take home and review.

The 7 “Cs” include the following:

1. Contraception choices: review pros and cons and failures
2. Candidates – is the IUD for me?
3. Contraindications
4. Choosing between Copper vs. Hormone
5. Choosing the right Copper IUD
6. Choosing the right hormone IUD
7. Counselling about insertion – how painful is it?

1. Contraception choices

The most compelling fact here is the failure rate associated with other methods, such as 9% with oral contraceptives, ring and patch and 18% with condoms (5). And the small risk of life threatening VTE (5) associated with estrogen containing contraceptives.

2. Candidate: is the IUD for me?

It depends on the contraceptive goals. Is best for patients whose plan is to

1. Delay a pregnancy by at least 1-2 years,
2. Who are eager to use the most effective and rapidly reversible contraceptive,
3. Are at low risk of acquiring PID, or is fully informed of the risks and prevention
4. In women who need to avoid estrogen products (for example, hypertension, migraine with aura, thrombophilia)

She should be reassured of its safety, and interventions available to minimize the insertion pain.

Some patients with medical conditions such as acne and hirsutism, at risk for osteoporosis, or have functional ovarian cyst may be better off taking an oral contraceptive containing estrogen.

3. Contraindications

For both types of IUDs:

1. Severe distortion of the uterine cavity by fibroids or scars,
2. Acute or recent (within 3 months) PID, endometritis or untreated cervicitis
3. Suspected or confirmed pregnancy

For the Copper IUDs:

1. Wilson disease
2. Known copper allergy

For the hormone IUDs:

1. Acute liver disease or liver tumor
2. Known or suspected breast cancer
3. Known allergy to levonorgestrel

4. Choosing between Copper vs. Hormone

Primarily this depends on the type of spontaneous menstrual cycles that a woman experiences (without taking the oral contraceptives). The hormone IUD is offered if her preference is a reduction in the menstrual bleeding, for the treatment of dysmenorrhea or development of amenorrhea.

The Copper is recommended for women who want to avoid taking hormones and want to continue with regular monthly cycling, notwithstanding that the periods will get 25-50% heavier. Sometimes women use it for emergency contraception, and then keep it.

Recent studies have shown that 80% of women choose the hormone IUD, but if they are randomized to either IUD irrespective of their periods, 88% continue with the assigned one (6).

Patient preference is important. Some women want menstrual suppression, while others want to avoid taking hormones. If cost is an issue, the generic copper IUDs cost less than $100, and last up to 10 years, while the hormone one cost between $300-400 and last for 3-5 years.

5. Choosing the right Copper IUD

There are 5 groups of Copper IUD’s, and 12 slightly different IUDs

1. Nova T
2. Liberte
3. Mona Lisa
4. SMB
5. Flexi-T

My preference is still the Nova T, the only one that has been extensively researched (7). It contains 200 mg of Copper, and it last for 2.5 years, but it cost twice as much as the “generic” ones that last for 5-10 years. If cost is an issue, or if the patient wants a “10 year” IUD, then either the Mona Lisa 10 or the Liberte TT standard are suitable. The Flexi T is not my favorite because the insertion is more difficult, and it has only 1 string. I suggest you familiarize yourself with 1 of the generics brands (For example, the Mona Lisa has the ML5 or ML10 for the length of protection, and the name is easy to remember). Otherwise, I use the Liberte TT 380 Standard which last for 10 years, or the Liberte TT 380 short for nulliparous women which lasts for 5 years.

6. Choosing the right hormone IUD

The choice is between the Levonorgestrel 52 (Mirena) and the Levonorgestrel 14 (Jaydess). My preference is the Mirena. Initially the Jaydess seems to offer many advantages, especially a lesser amount of hormone, a smaller inserter tube and a smaller IUD size overall. However, the incidence of hormone side effect is essentially the same, but the incidence of amenorrhea is only 10%, comparing to 40-60% with Mirena. I use if it is the patient’s choice, or in women who would rather have their periods, albeit lighter, and occasionally in women who have a small uterine cavity is small (6-7 cm).

7. Counselling about insertion – how painful is it?

This is often a potential deterrent, especially if they have a friend or family who had an insertion without appropriate pain management. I reassured the patient that if we offer her treatments before, during and after the insertion it should not be more than 2-4 out of 10. I explained all the available interventions in detail.

Proper counselling and IUD selection helps to reassure our patients that they are choosing what is best and most effective for them.

Patient Handout

https://med-fom-tcmp.sites.olt.ubc.ca/files/2016/01/TCMP-Dr.-Roberto-Leon-IUD-Handout-1.pdf

References

1. Callegari LS et al: Evidence-Based Selection of Candidates for the Levonorgestrel Intrauterine Device (IUD). J Am Board Fam Med. 2014; 27(1): 26-33. View  DOI: 10.3122/jabfm.2014.01.130142
2. Hall AM, Kutler BA: Intrauterine contraception in nulliparous women: a prospective survey. J Fam Plann Reprod Health Care Published Online First: December 14, 2015.  (Request with CPSBC or view UBC) DOI: 10.1136/jfprhc-2014-101046
3. American Academy of Pediatrics: Policy Statement.
Contraception for Adolescents. Pediatrics. 2014; 134: e1244-e1256. View DOI: 10.1542/peds.2014-2299
4. American College of Obstetrician and Gynecologists: Committee Opinion No 642, October 2015. Increasing Access to Contraceptive Implants and Intrauterine Devices to Reduce Unintended Pregnancy. Obstet Gynecol 2015; 126: e44-48. View DOI: 10.1097/AOG.0b013e3181c6f965
5. Zieman M. Overview of contraception. Up to date, access on December 15, 2015.
6. Achilles SL et all: Acceptability of randomization to levonorgestrel versus copper intrauterine device among women requesting IUD insertion for contraception. Contraception 2015; 92: 572–574. (View with CPSBC or UBC) DOI: 10.1016/j.contraception.2015.08.009
7. Andersson K, Odlind V, Rybo O. Levonorgestrel-releasing and copper- releasing (Nova T) IUDs during five years of use: A randomized comparative trial. Contraception 1994; 49: 56-72. (Request with CPSBC or view UBC) DOI: 10.1016/0010-7824(94)90109-0

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Part 1: Who should be offered an IUD, and selection of the appropriate IUD

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