BEST PRACTICE GUIDELINES - The effective and appropriate use of long-acting reversible contraception

 
Long-acting reversible contraception the effective and appropriate use of long-acting reversible contraception


National Collaborating Centre for Women’s
and Children’s Health
Commissioned by the National Institute for
Health and Clinical Excellence
October 2005
 
RCOG
 
PART-I
 
SUMMARY OF RECOMMENDATIONS FOR USE OF IUCDs AND LNG(IUS)
 
INTRODUCTION
 
Intrauterine devices (IUDs) are small contraceptive devices inserted through the cervix and positioned in the cavity of the uterus. Copper-containing IUDs currently available in the UK include: U-shaped (Multiload Cu375, MultiSafe 375, Multi-Safe 375 Short Loop, Load 375); plain T-shaped (Nova-T 380, Neo-Safe T 380, UT 380, UT 380 Short, Flexi-T 300); banded Tshaped (T-Safe CU 380A, Flexi-T 380, TT 380 Slimline); and frameless (GyneFix). The TT 380 Slimline is licensed for 10 years of use, the T-Safe CU 380A for 8 years and the remaining available IUDs for 5 years of use. The available IUDs have copper on a plastic frame or a thread (frameless), with a small thread that protrudes through the cervical canal into the upper part of the vagina allowing easy removal. The tails also can be checked regularly by the wearer to ensure correct placement. It may occasionally require local anaesthesia and dilation of the cervical canal to aid insertion in nulliparous or perimenopausal women. IUDs vary in structural design and amount of copper.

  • The licensed duration of use for IUDs containing 380mm2 copper ranges from 5 to 10 years, depending on the type of device. [D]

  • Women who are aged 40 years or older at the time of IUD insertion may retain the device until they no longer require contraception, even if this is beyond the duration of the UK Marketing Authorisation. [D]

EFFECTIVENESS

  • Women using the Multiload Cu375 had a higher cumulative pregnancy rate (5.3%) when compared with women using TCu 380A (3.4%) for up to 10 years.

  • Women using Nova-T 380 had a cumulative pregnancy rate of under 2% for up to 5 years.

  •  There was no significant difference in cumulative pregnancy rates between the frameless devices (0% to 2%) and TCu 380A (0.3% to 1.6%) after 3 years of use.

  • Healthcare professionals should be aware that the most effective IUDs contain at least 380 mm2 of copper and have banded copper on the arms. This, together with the licensed duration of use, should be considered when deciding which IUD to use [B]

  • Women should be informed that the pregnancy rate associated with the use of IUDs containing 380mm2 copper is very low (fewer than 20 in 1000 over 5 years) [C]

EXPULSION RATES

  • The expulsion rates are lower with TCu 380A than Multiload Cu375 at 3 years (5.4% versus 6.5%) and at 10 years (11.2% versus 14.8%).

  • The expulsion rates between TCu 380A (2.6%) and frameless IUDs (3.1%) are similar between 2 and 6 years. 
    Women should be informed that IUDs may be expelled but that this occurs in fewer than 1 in 20 women in 5 years [C]

  • Women should be advised how to check for the presence of IUD threads and encouraged to do this regularly with the aim of recognising expulsion [D,GPP]

DISCONTINUATION

  • up to 50% of women stop using IUDs within 5 years

  • the most common reasons for discontinuation are unacceptable vaginal bleeding and pain[C]

ADVERSE EFFECTS

  • IUD use is associated with increased bleeding problems and dysmenorrhoea but 1 year after insertion there is no significant difference in the rates of problems comparing TCu 380A, Multiload Cu375 and MLCu380.

  • Women should be informed of the likelihood of heavier bleeding and/or dysmenorrhoea with IUD use [C]

  • NSAIDs and tranexamic acid are effective in the treatment of heavy bleeding with IUD use [B]

  • Women who find heavy bleeding associated with IUD use unacceptable may consider changing to a levonorgestrel intrauterine system (LNG-IUS) [D/GPP]

  • There is no evidence of significant weight change between IUD and IUS users in European studies.

  • Women should be informed that any changes in mood and libido are similar whether using IUDs or the IUS, and that the changes are small [C]

  • Women should be informed that the risk of ectopic pregnancy when using IUDs is lower than when using no contraception [D]

  • Women should be informed that the overall risk of ectopic pregnancy when using the IUD is very low, at about 1 in 1000 in 5 years [C]

  • If a woman becomes pregnant with the IUD in situ, the risk of ectopic pregnancy is about 1 in 20, and she should seek advice to exclude ectopic pregnancy [C]

  • Women should be informed that the risk of developing pelvic inflammatory disease following IUD insertion is very low (less than 1 in 100) in women who are at low risk of sexually transmitted infections (STIs) [C]
    Women should be informed that the risk of uterine perforation at the time of IUD insertion is very low (less than 1 in 1000) [D]

  • Contraceptive care providers should be aware that the risk of perforation is related to the skill of the healthcare professional inserting the IUD [D/GPP]

IUCD AND PREGNANCY


Women with an intrauterine pregnancy with an IUD in situ should be advised to have the IUD removed before 12 completed weeks’ gestation, whether or not they intend to continue the pregnancy [D/GPP]


ASSESSMENT PRIOR TO INSERTION


Testing for the following infections should be undertaken before IUD insertion:

• Chlamydia trachomatis in women at risk of STIs
• Neisseria gonorrhoeae in women from areas where the disease is prevalent and who are at risk of STIs
• any STIs in women who request it [D/GPP]

If testing for STIs is not possible, or has not been completed, prophylactic antibiotics should be given before IUD insertion in women at increased risks of STIs [D/GPP]


TIMING OF INSERTION

 

Healthcare professionals should be aware that, provided that it is reasonably certain that the woman is not pregnant, IUDs can be inserted:


• at any time during the menstrual cycle
• immediately after first- or second-trimester abortion, or at any time thereafter
• from 4 weeks post partum, irrespective of the mode of delivery.[D/GPP]

TRAINING OF HEALTHCARE PROFESSIONALS
IUDs should only be fitted by trained personnel with continuing experience of
inserting at least one IUD or one IUS a month [C]


CONTRAINDICATIONS


IUDs may be used by adolescents, but STI risk should be considered where relevant. [D/GPP]


Healthcare professionals should be aware that:

• IUD use is not contraindicated in nulliparous women of any age
• women of all ages may use IUDs [D/GPP]
IUD use is not contraindicated in women with diabetes
• emergency drugs including anti-epileptic medication should be available at the time of IUD insertion in a woman with epilepsy because there may be an increased risk of a seizure at the time of cervical dilation
• IUD use is a safe and effective method of contraception for women who are HIVpositive or have AIDS (safer sex using condoms should be encouraged in this group) [D/GPP]

FOLLOW-UP


A follow-up visit should be recommended after the first menses, or 3–6 weeks after insertion, to exclude infection, perforation or expulsion. Thereafter, a woman should be strongly encouraged to return at any time to discuss problems, if she wants to change her method of contraception, or if it is time to have the IUD removed [D/GPP]

  
     

 
         
     

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