Gynecology Book

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Intrauterine Device

Aka: Intrauterine Device, IUD, Paragard, Copper T-380A IUD, Progestasert, Mirena, Skyla, Liletta
  1. Contraindications: Absolute
    1. Undiagnosed Abnormal Uterine Bleeding
    2. Uterine abnormality that distorts endometrial cavity
    3. Current intrauterine infection
    4. Unresolved abnormal Pap Smear
    5. Current endometrial or Cervical Cancer
    6. Findings suggestive of trophoblastic disease
    7. Wilson's Disease or copper allergy (Copper-T IUD)
    8. Uterine or pelvic infection within last 3 months
      1. Sexually Transmitted Infection
      2. Chorioamnionitis
      3. Endometritis
  2. Contraindications: Historical that are no longer contraindications (restrictions loosened by FDA in 2010)
    1. Nulliparity
      1. More difficult to place if no prior pregnancy
      2. Must be able to sound Uterus to 6 cm or greater
      3. Expulsion rates and longterm device tolerance and continuation rates are similar to women previously pregnant
        1. Paterson (2009) Contraception 79(6): 433-8 [PubMed]
        2. Veldhuis (2004) Eur J Gen Pract 10(3): 82-7 [PubMed]
    2. Adolescents
      1. USMEC recommends IUD for Contraception in this cohort due to high efficacy that outweighs potential risks
      2. Risk of PID or future Infertility does not appear to be increased
    3. Sexually Transmitted Disease history or multiple sexual partners
      1. PID may now be lower risk with modern IUDs
        1. Campbell (2007) Am J Obstet Gynecol 197(2): 193 [PubMed]
      2. Screen women for STIs per CDC guidelines
      3. Delay IUD Placement for 3 months following Sexually Transmitted Infection treatment
    4. Ectopic Pregnancy
      1. Ectopic risk is not increased with IUD use
      2. However, if breakthrough pregnancy occurs, it is much more likely to occur as an Ectopic Pregnancy
  3. Risk Factors
    1. Pelvic Inflammatory Disease
    2. Tubal Infertility
      1. Cohort Study (n=4185)
        1. Primary (Nulliparous) Tubal Infertility Risk
          1. Dalkon Shield Relative Risk: 3.3
          2. Lippes Loop or Saf-T-Coil Relative Risk: 2.9
          3. Copper-T IUD Relative Risk: 1.6
          4. Having only one sexual partner: No increased risk
        2. Secondary (Multiparous) Tubal Infertility Risk
          1. Copper-T IUD Relative Risk: 1.5 (not significant)
          2. Non-Copper IUD Relative Risk: 2.8
      2. References
        1. Cramer (1985) N Engl J Med, 312(15): 941-7 [PubMed]
  4. Adverse Effects
    1. First 3 months after IUD insertion
      1. Perception of vaginal infection
      2. Changes in menstrual flow (30%)
        1. Dysmenorrhea or prolonged flow
        2. Results in 10-15% discontinuation in first year
        3. Reduced with NSAIDs taken 2-3 days with flow onset
    2. Pelvic Inflammatory Disease risk
      1. Risk increases in first 20 days after insertion
      2. Risk is <1 per 1000 insertions
      3. Use of prophylactic antibiotics not warranted (not effective, do not alter course)
    3. Expulsion in first 2 months
      1. Increased expulsion rates if placed immediately after delivery, Cesarean Section or pregnancy loss
      2. Days 1-5: 5% expulsion rate
      3. Days 6-12: 3% expulsion rate
      4. Days >12: 2% expulsion rate
    4. Progestin IUD (Mirena, Skyla) related adverse effects
      1. Headache
      2. Hair Loss
      3. Major Depression
      4. Breast tenderness
      5. Vaginitis
      6. Pelvic Pain
  5. Safety
    1. IUDs are compatible with Lactation
  6. Types: Available in U.S.
    1. Copper T-380A IUD (Paragard): 10 year copper device
      1. First year failure rate: 0.7%
      2. Cumulative ten year failure rate: 2.1%
      3. Recent studies indicate efficacious 12 years
      4. Reduces Ectopic Pregnancy rate significantly
      5. Barium impregnated
    2. Mirena: 5 year Progesterone (Levonorgestrel) device
      1. First year failure rate: 0.2%
        1. Of pregnancies, 50% will be ectopic
        2. Better efficacy than Copper-T IUD
      2. Polyethylene-barium T-shape 52 mg Levonorgestrel
      3. Releases 20 mcg/day of Levonorgestrel
      4. Progesterone adverse effects may occur
        1. Headache
        2. Acne Vulgaris
      5. Conception occurs for 80% within 12 months of removal
      6. Mechanism (Primarily spermicidal)
        1. Thins endometrium and thickens Cervical Mucus
        2. Inhibits sperm movement and function
        3. May also suppress Ovulation
      7. Reduces Menstrual Bleeding
        1. Consider for Dysfunctional Uterine Bleeding
        2. Irregular bleeding may occur in first 6 months
        3. Amenorrhea at one year of use if common (20%)
    3. Skyla: 3 year Progesterone (Levonorgestrel) device
      1. New in 2014 from Bayer (also makes Mirena)
      2. Releases 14 mcg/day of Levonorgestrel (lower dose than Mirena)
      3. Similar inserter as Mirena
      4. Marketed for nulliparous patients (but other IUDs are also considered safe in this cohort)
      5. First year failure rate: 0.9%
        1. Less effective than either Mirena or Copper-T IUD
      6. Conception occurs for 77% within 12 months of removal
    4. Liletta: Progesterone (Levonorgestrel) device
      1. Releases 19 mcg/day of Levonorgestrel (similar to Mirena)
      2. Released in 2015 and approved for 3 years of protection
        1. Studies are ongoing with goal of ultimately showing 7 years of protection
  7. Types: Discontinued
    1. Progestasert: 1 year Progesterone device (discontinued in U.S. in 2001)
      1. First year failure rate: 2%
      2. Ethylene/vinyl acetate T-shape 38 mg Progesterone
      3. Higher rate of ectopic compared with Copper IUD
      4. Less bleeding complications
      5. Progesterone adverse effects may occur
  8. Indications: Prophylactic Antibiotics on insertion
    1. Routine prophylaxis no longer indicated
      1. No difference in outcomes
    2. Prior indications for antibiotic prophylaxis
      1. History of Bacterial Vaginosis
      2. Difficult insertion
      3. SBE Prophylaxis (not indicated in IUD insertion)
  9. Procedure
    1. See IUD Insertion
  10. Protocol: Switching between contraceptives
    1. Switch to Mirena IUD from pill, patch, ring
      1. Use pill, patch, ring, or barrier protection for the first 7 days after Mirena insertion
      2. Switch may be made before the scheduled end of use of the prior contraceptive
    2. Switch to Mirena IUD from Copper-T IUD
      1. Use barrier protection for first 7 days
    3. Switch to Depo Provera from Copper-T IUD
      1. Give first injection 7 days prior to Copper-T-IUD removal (or use barrier contraceptive for 1 week)
    4. Switch to Implanon (Progestin implant) from Copper-T-IUD
      1. Implanon should be inserted 4 days prior to Copper-T IUD removal (or use barrier contraceptive for 4 days)
    5. Switch to contraceptive pill, patch or ring from the IUD
      1. Start the new contraceptive 7 days before IUD removal
    6. Switch to Copper IUD from other methods
      1. Insert Copper-T IUD no more than 5 days after stopping other contraceptive (or 16 weeks after last Depo Provera injection)
  11. Management: Complications
    1. Sexually Transmitted Infection without signs of Pelvic Inflammatory Disease
      1. IUD may be left in place and STD treated
      2. Remove IUD for Pelvic Inflammatory Disease or other symptomatic Sexually Transmitted Infection
    2. Pregnancy with IUD in place
      1. Transvaginal Ultrasound to exclude Ectopic Pregnancy (critical)
      2. IUD Removal
        1. UltrasoundUterus to confirm IUD in place if strings can not be found
        2. IUD removal is recommended to reduce pregnancy loss as well as Placental Abruption, preterm delivery, and low birth weight
        3. However, pregnancy loss occurs in at least 40% of women after IUD removal
        4. Saav (2007) Hum Reprod 22(10): 2647-52 [PubMed]
  12. References
    1. (2001) Med Lett Drugs Ther 43(1096):7-8 [PubMed]
    2. Andersson (1994) Contraception 49:56 [PubMed]
    3. French (2000) Br J Obstet Gynaecol 107:1281 [PubMed]
    4. Hardeman (2014) Am Fam Physician 89(6): 445-50 [PubMed]
    5. Herndon (2004) Am Fam Physician 69(4):853-60 [PubMed]

Intrauterine Devices (C0021900)

Definition (UMD) Contraceptive devices placed high in the uterine fundus with a string extending from the device through the cervical os into the vagina.
Definition (MSH) Contraceptive devices placed high in the uterine fundus.
Definition (NCI_NCI-GLOSS) A small, plastic T-shaped device that is placed inside the uterus (the small, hollow, pear-shaped organ in a woman's pelvis in which a fetus develops) to prevent pregnancy. Intrauterine devices prevent sperm from fertilizing an egg, and prevent fertilized eggs from implanting in the uterus. The use of intrauterine devices is also being studied in the prevention and treatment of endometrial cancer and other conditions.
Definition (NCI_NICHD) An Intra Uterine Contraceptive Device is a form of birth control that involves an object placed in the uterus to prevent fertilization of the egg by sperm. An IUCD can be a coil, loop, triangle, or T in shape; its material can be impregnated with a pharmaceutical agent.
Definition (NCI) A device usually made of plastic or metal, inserted into the uterus to prevent conception. IUCD can be a coil, loop, triangle, or T in shape; its material can be impregnated with a pharmaceutical agent. The primary action of all IUCDs is the induction of a foreign-body reaction within the endometrium. This sterile inflammatory process is toxic to gametes, primarily spermatozoa, and effectively prevents viable sperm from passing into the fallopian tubes. The copper-bearing device has an independent toxic effect on spermatozoa. The progestin-releasing devices produce changes in endometrial architecture and function that reduce the potential for implantation of a fertilized egg. The progestin effect on the cervical mucus also reduces the penetrability of sperm.
Concepts Medical Device (T074)
MSH D007434
SnomedCT 385253002, 78765007, 268460000, 135622008
LNC LA6527-1
English Contraceptive Device, Intrauterine, Contraceptive Devices, Intrauterine, Device, Intrauterine, Device, Intrauterine Contraceptive, Devices, Intrauterine, Devices, Intrauterine Contraceptive, Intrauterine Contraceptive Devices, IUCD - I/uter contracep device, IUCD - Intrauterine contraceptive device, Intra-uterine contraceptive device, IUCD, Intra-Uterine Device (IUD), Intrauterine Contraceptive Device, Intrauterine Device, IUDs, Intrauterine contracep device, Intrauterine device (product), Intra-uterine device, intrauterine devices (IUD) (medication), intrauterine devices (IUD), Intrauterine contraceptive device (physical object), Intrauterine contraceptive device, Contraceptive IUD, IUD, Contraceptive, IUDs, Contraceptive, Contraceptive IUDs, devices intrauterine, intrauterine devices, device intrauterine, intra uterine device, devices intra uterine, iucd, intra-uterine device, iuds, Intrauterine device (physical object), IUD - Intrauterine device, Intrauterine device (qualifier value), Intra Uterine Device, intrauterine device, IUD, Intrauterine device, INTRAUTERINE DEVICE, Intrauterine Devices
Italian Dispositivo contraccettivo intrauterino, Dispositivo intrauterino, Dispositivo anticoncezionale intrauterino, Dispositivi contraccettivi intrauterini, IUD, IUDs, Dispositivi intrauterini
Dutch IUCD, intra-uterien contraceptief hulpmiddel, Contraceptiva, intrauterine, Contraceptivum, intrauterien, IUD, Intra-uterine devices, Intrauterien contraceptivum
French DIU, DCIU, Appareils contraceptifs intra-utérins, Appareils intra-utérins, Dispositifs intra-utérins, Dispositifs contraceptifs intra-utérins, Stérilets, DIU (Dispositif Intra-Utérin), Dispositif intra-utérin
German IUD, IUCD, Intrauterinpessar, Intrauterinpessare, Kontrazeptive intrauterine Vorrichtungen
Portuguese DIU, Dispositivos Intrauterinos, Anticoncepcionais Intrauterinos, Diu, Dispositivo contraceptivo intra-uterino
Swedish Spiraler
Japanese シキュウナイヒニング, 避妊具-子宮内, 子宮内避妊具, 子宮内ペッサリー, ペッサリー-子宮内, 避妊リング, ペッサリー-子宮頸管内, 子宮内器具, 子宮頸管内ペッサリー
Czech nitroděložní tělíska, nitroděložní antikoncepční prostředky, IUD, Nitroděložní tělísko
Spanish dispositivo intrauterino (producto), Anticonceptivos Intrauterinos, dispositivo anticonceptivo intrauterino (objeto físico), dispositivo anticonceptivo intrauterino, Intrauterine contraceptive device, dispositivo intrauterino (calificador), DIU, dispositivo intrauterino, dispositivo intrauterino anticonceptivo, dispositivo intrauterino (objeto físico), Contraceptivos Intrauterinos, Dispositivo anticonceptivo intrauterino, Dispositivos Intrauterinos
Finnish Kohdunsisäiset ehkäisimet
Russian VNUTRIMATOCHNYE USTROISTVA, KONTRATSEPTIVNYE SREDSTVA VNUTRIMATOCHNYE, PESSARII VNUTRIMATOCHNYE, PESSARII VNUTRISHEECHNYE, ВНУТРИМАТОЧНЫЕ УСТРОЙСТВА, КОНТРАЦЕПТИВНЫЕ СРЕДСТВА ВНУТРИМАТОЧНЫЕ, ПЕССАРИИ ВНУТРИМАТОЧНЫЕ, ПЕССАРИИ ВНУТРИШЕЕЧНЫЕ
Croatian KONTRACEPCIJSKA POMAGALA, INTRAUTERINA
Polish Środki antykoncepcyjne wewnątrzmaciczne
Hungarian Intrauterin fogamzásgátló eszköz, Méhen belüli fogamzásgátló eszköz
Norwegian Intrauterine innlegg, Livmorinnlegg, Spiraler, Intrauterine prevensjonsmidler, Intrauterine antikonseptiva
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Mirena (C0591811)

Concepts Pharmacologic Substance (T121) , Steroid (T110)
MSH D016912
Italian Levonorgestrel, Berlex, Levonorgestrel, Schering, Mirena
English mirena, Berlex Brand of Levonorgestrel, Levonorgestrel Berlex Brand, Schering Brand 1 of Levonorgestrel, Mirena
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Progestasert (C1515395)

Concepts Steroid (T110) , Pharmacologic Substance (T121) , Hormone (T125)
English Progestasert
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Skyla (C3531219)

Concepts Pharmacologic Substance (T121) , Hormone (T125)
English Skyla
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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