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Patient selection and counselling
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Selection
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Ideally suited to:
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- mutually monogamous relationship
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- light to normal menstrual loss (NB: except when levonorgestrel containing IUD 'Mirena' is used to treat menorrhagia)
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Contraindications for IUDs
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Absolute:
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- known / suspected pregnancy
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- undiagnosed vaginal bleeding
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- Wilson's Disease (for copper IUD's).
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Relative
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- past history: PID, ectopic
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- uterine congenital anomalies, fibroids
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- menorrhagia, dysmenorrhoea
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- HIV / immunosuppressed states
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Benefits of IUDs
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- effective long term contraception
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- prompt return of fertility
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Choice of IUD
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- CuT380 recommended - 8 year duration, failure rate 0.4/100women years use, easy removal;
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- Multiload Cu 375 available if preferred - 5 years duration);
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- Mirena (levonorgestrel containing IUD) - 5 year duration, failure 0.3/100women/year, associated with significant reduction in menstrual loss after 5-6 months but short term menstrual irregularity.
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IUDs of all types are available to hospital patients at a standard prescription charge - discount for health care card holders.
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Risks of IUDs
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- insertion problems - pain, misplacement, perforation
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- expulsion - most likely in first 3 months
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- approx 30% increase in menstrual loss and dysmenorrhoea with copper IUD, 60-70% decrease with Mirena
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- PID -related to post insertion (up to 3 weeks) and subsequently to risk of PID / number of sexual partners
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Insertion prerequisites, timing and procedure
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Prerequisites
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Sexual history to identify risk of sexually transmitted infection:
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- pelvic examination to exclude pelvic pathology;
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- current Pap smear result;
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- swabs (refer to table below).
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These recommendations are an absolute minimum. Consideration should be given on clinical grounds and local population prevalence screening in addition for Neisseria gonorrhoeae and other STIs. In Victoria the occurrence of gonorrhoea in the last several years has been predominantly in the male homosexual population and therefore screening for gonorrhoea is of an individually identified risk basis at the Royal Women's Hospital Choices Clinic.
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Swabs should be correctly labelled re site and tests specifically requested.
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| - high vaginal swab for smear - screen for bacterial vaginosis
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| | | - endocervical swabs for microscopy and culture including actinomyces culture
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Timing
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- after swabs results checked
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- 6 weeks post partum (3 months after caesarean section)
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- last few days of menses, early follicular phase preferable
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- or any time during menstrual cycle if pregnancy can be excluded
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Procedure
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- clinic procedure with premed (Buscopan/Ponstan) usually minimal discomfort
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- insertion takes five minutes but visit will involve approx 1 hour for pre-insertion assessment, preparation and post insertion observation (plus any waiting time)
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- GA can be arranged if preferred /or unsuccessful clinic insertion (not same day)
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Follow up visit (can be done by LMO)
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- assess effect on menses, other symptoms
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- check if patient able to feel strings
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- examination to check IUD strings are visible and shaft not palpable
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Subsequently 6/12 suggested for new IUD and then 2 yearly with Pap smear and actinomyces culture.
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Instruct to report early with abnormal pain and bleeding or if pregnant.
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Management of abnormal screening swabs
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Detection of N. gonorrhoeae or Chlamydia trachomatis would indicate treatment of patient and partner, contact tracing if appropriate and contraindicate the insertion of an IUD.
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Detection of a significant growth of other vaginal or bowel commensal organisms (with varied virulence potential) particularly with a large number of pus cells or bacterial vaginosis on smear indicate appropriate antibiotic therapy and subsequent negative swabs before insertion/changeover.
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IUD Problems
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Missing strings
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These can sometimes be retrieved by probing endo cervix with cytobrush. If unable to locate string, then check presence of IUD on ultrasound- NB recommend alternative contraception until presence confirmed. If correct placement can be left till routine IUD change required. If U/S does not locate IUD, Xray pelvis & abdo - if intra abdominal laparoscopic removal is usually required.
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Actinomyces
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If actinomyces found on routine swab culture IUD should be removed with penicillin prophylaxis. Can be reinserted 2-3/12 later if swabs negative.
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Antibiotic therapy (high dose penicillin) is only indicated if patient is symptomatic suggestive of upper tract infection eg. PID.
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Actinomyces like organisms (ALO) reported in Pap smear should be confirmed on culture before IUD removal in asymptomatic woman as smear results have a high false positive rates for ALO. If culture is negative no action is required.
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Symptoms of abnormal pain and bleeding
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If unequivocal PID (tenderness, fever, discharge at os) is present removal of the IUD and antibiotic therapy is indicated on clinical grounds together with cervical swab culture (microscopy and culture including exclusion of chlamydia and actinomyces). If the diagnosis is uncertain consider leaving the IUD in place, taking swabs, +/- antibiotic therapy and arranging early review.
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Pregnancy
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If confirmed remove IUD if accessible to reduce risk of spontaneous abortion. If not accessible warn patient of symptoms and signs of infection.
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Ultrasound examination to confirm site and viability.
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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