Iucd

1. INTRAUTERINE INTRAUTERINE
CONTRACEPTIVE CONTRACEPTIVE
DEVICESDEVICES
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2. Worldwide, over 100 million Worldwide, over 100 million
women have used the women have used the
intrauterine contraceptive intrauterine contraceptive
device device (IUD).(IUD).
However, in North America However, in North America
less than 1%less than 1% of women use of women use
this highly effective method of this highly effective method of
contraception.contraception.
INTRODUCTIONINTRODUCTION
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3. 2 copper IUDs 2 copper IUDs (Nova-T and Flexi-(Nova-T and Flexi-
T 300)T 300) and a levonorgestrel- and a levonorgestrel-
releasing device releasing device (Mirena)(Mirena) are are
currently available.currently available.
Mirena is also referred to as a Mirena is also referred to as a
levonorgestrel-releasing levonorgestrel-releasing
intrauterine system intrauterine system (LNG-IUS).(LNG-IUS).
INTRODUCTIONINTRODUCTION
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4. EFFICACYEFFICACY
Intrauterine devices are Intrauterine devices are
highly effectivehighly effective methods methods
of reversible of reversible
contraception. contraception.
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5. In a large trial: In a large trial:
The failure rate of a copper The failure rate of a copper
IUD IUD (Nova-T)(Nova-T) was was 1.26 per 1.26 per
100 women-years100 women-years (WY) and (WY) and
The rate of The rate of ectopic pregnancyectopic pregnancy
was was 0.25 per 100 WY. 0.25 per 100 WY.
EFFICACYEFFICACY
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6. The The failure ratefailure rate of the of the
levonorgestrel-releasing levonorgestrel-releasing
intrauterine system was intrauterine system was
0.09 per 100 WY0.09 per 100 WY and and
The The ectopic pregnancyectopic pregnancy rate rate
was was 0.02 per 100 WY0.02 per 100 WY..
EFFICACYEFFICACY
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7. Although the product monograph for Although the product monograph for
the the Nova-T copper IUDNova-T copper IUD suggests that suggests that
it be replaced every 30 months, it be replaced every 30 months,
clinical trials have shown that it is clinical trials have shown that it is
effective for effective for 5 years5 years..
The The Flexi-T 300 copper IUDFlexi-T 300 copper IUD and the and the
LNG-IUSLNG-IUS should be replaced every should be replaced every
5 years.5 years.
EFFICACYEFFICACY
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8. CONTRAINDICATIONSCONTRAINDICATIONS
The World Health The World Health
Organization (WHO) has Organization (WHO) has
developed a list of developed a list of
absolute and relative absolute and relative
contraindicationscontraindications
to use of an IUD.to use of an IUD.
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9. ABSOLUTE CONTRAINDICATIONSABSOLUTE CONTRAINDICATIONS
lPPregnancy :current, recurrent, or recent (within past regnancy :current, recurrent, or recent (within past
3 months)3 months)
lPPelvic inflammatory disease (PID) or sexually elvic inflammatory disease (PID) or sexually
transmitted infection (STI)transmitted infection (STI)
lPPuerperal sepsisuerperal sepsis
lIImmediate post-septic abortionmmediate post-septic abortion
lSSeverely distorted uterine cavityeverely distorted uterine cavity
lUUnexplained vaginal bleedingnexplained vaginal bleeding
lCCervical or endometrial cancerervical or endometrial cancer
lMMalignant trophoblastic diseasealignant trophoblastic disease
lCCopper allergy (for copper IUDs)opper allergy (for copper IUDs)
lBBreast cancer (for LNG-IUS)reast cancer (for LNG-IUS)www.freelivedoctor.comwww.freelivedoctor.com

10. RELATIVE CONTRAINDICATIONSRELATIVE CONTRAINDICATIONS
1. 1. RRisk factor for STIs or human isk factor for STIs or human
immunodeficiency virus (HIV)immunodeficiency virus (HIV)
2. 2. IImpaired response to infectionmpaired response to infection
- in HIV-positive women - in HIV-positive women
- in women undergoing corticosteroid - in women undergoing corticosteroid
therapy from 48 hours to 4 weeks therapy from 48 hours to 4 weeks
postpartumpostpartum
3. 3. OOvarian cancervarian cancer
4. 4. BBenign gestational trophoblastic diseaseenign gestational trophoblastic disease
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11. NON-CONTRACEPTIVE BENEFITSNON-CONTRACEPTIVE BENEFITS
Case-control studies provide some Case-control studies provide some
evidence that use of non-medicated or evidence that use of non-medicated or
copper IUDs copper IUDs reduces the risk of reduces the risk of
endometrial cancer.endometrial cancer.
This protective effect is not related to This protective effect is not related to
the duration or timing of use, and its the duration or timing of use, and its
mechanism is not well understood. mechanism is not well understood.
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12. Menorrhagia Menorrhagia responds favourably to use of the responds favourably to use of the
LNG-IUS, with reported reductions in menstrual LNG-IUS, with reported reductions in menstrual
blood loss of blood loss of 74 to 97%74 to 97% and favourable effects and favourable effects
on hemoglobin levels.on hemoglobin levels.
In 2 studies of women scheduled to undergo In 2 studies of women scheduled to undergo
hysterectomy for menorrhagia, hysterectomy for menorrhagia, 64 to 80%64 to 80% of of
women randomized preoperatively to LNG-IUS women randomized preoperatively to LNG-IUS
insertion subsequently insertion subsequently cancelled their cancelled their
hysterectomyhysterectomy, compared with 9 to 14% of , compared with 9 to 14% of
women randomized to receive other medical women randomized to receive other medical
treatments.treatments.
NON-CONTRACEPTIVE BENEFITSNON-CONTRACEPTIVE BENEFITS
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13. DysmenorrheaDysmenorrhea may also improve in may also improve in
LNG-IUS users.LNG-IUS users.
A randomized controlled study found A randomized controlled study found
that use of the LNGIUS that use of the LNGIUS protects protects
against endometrial hyperplasia in against endometrial hyperplasia in
women on tamoxifenwomen on tamoxifen..
Small reports support a beneficial Small reports support a beneficial
effect in the treatment of effect in the treatment of fibroid-fibroid-
related menorrhagia.related menorrhagia.
NON-CONTRACEPTIVE BENEFITSNON-CONTRACEPTIVE BENEFITS
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14. SIDE EFFECTSSIDE EFFECTS
1. BLEEDING
PAIN OR DYSMENORRHEA .2
HORMONAL .3
FUNCTIONAL OVARIAN CYSTS .4
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15. Irregular menstrual bleeding or an Irregular menstrual bleeding or an
increase in the amount of bleeding increase in the amount of bleeding
are the most common side effects are the most common side effects
of IUDs in the first months after of IUDs in the first months after
insertion. insertion.
Menstrual blood loss in users of Menstrual blood loss in users of
copper IUDs increases by up to copper IUDs increases by up to
65%65% over non-users. over non-users.
BLEEDING .1BLEEDING .1
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16. Use of non-steroidal anti-Use of non-steroidal anti-
inflammatory agents inflammatory agents
(NSAIDs) or tranexamic (NSAIDs) or tranexamic
acidacid may help to may help to
decrease the amount of decrease the amount of
menstrual blood loss. menstrual blood loss.
BLEEDING .1BLEEDING .1
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17. The average number of days of spotting The average number of days of spotting
or bleeding appears to decrease over or bleeding appears to decrease over
time. time.
Users of copper IUDs have an average of Users of copper IUDs have an average of
13 days13 days of bleeding or spotting in the of bleeding or spotting in the
first month after insertion, decreasing to first month after insertion, decreasing to
an average of an average of 6 days at 12 months after 6 days at 12 months after
insertioninsertion
The cumulative termination rates for The cumulative termination rates for
bleeding problems after 5 years of use are bleeding problems after 5 years of use are
up to up to 20%20% for copper IUDs. for copper IUDs.
BLEEDING .1BLEEDING .1
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18. By contrast, users of the LNG-IUS By contrast, users of the LNG-IUS
experience a reduction in menstrual experience a reduction in menstrual
blood loss of between blood loss of between 74 and 97%.74 and 97%.
Women using the LNG-IUS have an Women using the LNG-IUS have an
average of average of 16 days of bleeding16 days of bleeding or or
spotting at 1 monthspotting at 1 month after insertion, after insertion,
and this decreases to an average of and this decreases to an average of
4 days4 days by by 12 months12 months after insertion. after insertion.
BLEEDING .1BLEEDING .1
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19. The cumulative termination rates for The cumulative termination rates for
bleeding problems after bleeding problems after 5 years5 years of use are of use are
up to up to 14% for the LNG-IUS14% for the LNG-IUS..
Between 16 and 35% of LNG-IUS users Between 16 and 35% of LNG-IUS users
will become will become amenorrheicamenorrheic after one year of after one year of
use. use.
Since information received in advance will Since information received in advance will
improve user satisfaction, patients should improve user satisfaction, patients should
be carefully counselled regarding potential be carefully counselled regarding potential
menstrual changes prior to IUD insertion.menstrual changes prior to IUD insertion.
BLEEDING .1BLEEDING .1
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20. 2. PAIN OR DYSMENORRHEA2. PAIN OR DYSMENORRHEA
Up to Up to 6%6% of copper IUD and LNG-IUS users will of copper IUD and LNG-IUS users will
have discontinued use at have discontinued use at 5 years5 years because of because of
pain.pain.
Pain may be a physiological response to the Pain may be a physiological response to the
presence of the device, but the possibility of presence of the device, but the possibility of
infection, malposition of the deviceinfection, malposition of the device (including (including
perforation), and perforation), and pregnancypregnancy should be should be
excluded. excluded.
The LNG-IUS has been associated with a The LNG-IUS has been associated with a
decrease in menstrual pain.decrease in menstrual pain.
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21. HORMONAL .3HORMONAL .3
The LNG-IUS appears to exert The LNG-IUS appears to exert
some systemic hormonal effects, some systemic hormonal effects,
even though the daily dose of even though the daily dose of
levonorgestrel is extremely low.levonorgestrel is extremely low.
Hormonal side effects include Hormonal side effects include
depression, acne, headache, and depression, acne, headache, and
breast tenderness.breast tenderness.
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22. Most studies report a low incidence of Most studies report a low incidence of
such adverse effects, which appear to such adverse effects, which appear to
be maximal at be maximal at 3 months3 months after insertion after insertion
and then decrease. and then decrease.
Although Although weight gainweight gain has been has been
reported as a side effect of LNG-IUS reported as a side effect of LNG-IUS
use, a large trial reported no use, a large trial reported no
significant difference in weight gain significant difference in weight gain
over 5 years in LNGIUS users and over 5 years in LNGIUS users and
copper IUD users.copper IUD users.
HORMONAL .3HORMONAL .3
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23. FUNCTIONAL OVARIAN CYSTS .4FUNCTIONAL OVARIAN CYSTS .4
Functional ovarian cysts have Functional ovarian cysts have
been reported in up to been reported in up to 30% of 30% of
LNG-IUS users.LNG-IUS users.
Since these cysts usually Since these cysts usually
resolve spontaneously, they resolve spontaneously, they
should be managed should be managed
expectantly.expectantly.
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24. RISKSRISKS
1. U1. UTERINE PERFORATIONTERINE PERFORATION
2.2. IINFECTIONNFECTION
3.3. EEXPULSIONXPULSION
4.4. FFAILUREAILURE
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25. UTERINE PERFORATION .1UTERINE PERFORATION .1
Uterine perforation is a rare Uterine perforation is a rare
complication of IUD insertion, complication of IUD insertion,
occurring at a rate of 0.6 to 1.6 per occurring at a rate of 0.6 to 1.6 per
1000 insertions.1000 insertions.
All uterine perforations, either All uterine perforations, either
partial or complete, occur or are partial or complete, occur or are
initiated initiated at the time of IUD at the time of IUD
insertion. insertion.
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26. Risk factors for perforation include:Risk factors for perforation include:
2.2.Postpartum insertion, Postpartum insertion,
3.3.An inexperienced operator, and An inexperienced operator, and
4.4.A uterus that is immobile, A uterus that is immobile,
5.5.Extremely anteverted or Extremely anteverted or
6.6.Extremely retroverted.Extremely retroverted.
UTERINE PERFORATION .1UTERINE PERFORATION .1
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27. INFECTION .2INFECTION .2
Evidence from large cohort Evidence from large cohort
studies ,case-control studies ,case-control
studies, and randomized studies, and randomized
controlled trials indicates controlled trials indicates
that any risk of genital tract that any risk of genital tract
infection after the first infection after the first
month of IUD use is small. month of IUD use is small.
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28. There appears to be an inverse There appears to be an inverse
relation between the risk of infection relation between the risk of infection
and the time since IUD insertion. and the time since IUD insertion.
The WomenThe Women’’s Health Study data s Health Study data
showed a relative risk of PID of 3.8 in showed a relative risk of PID of 3.8 in
the first month after insertion, the first month after insertion,
reaching baseline risk after 4 months. reaching baseline risk after 4 months.
INFECTION .2INFECTION .2
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29. Investigations by the World Health Investigations by the World Health
Organization found the risk to be highest Organization found the risk to be highest
in the first 20 days following insertion.in the first 20 days following insertion.
Although insertion of an IUD contaminates Although insertion of an IUD contaminates
the endometrial cavity with bacteria, the the endometrial cavity with bacteria, the
cavity becomes sterile soon afterwards. cavity becomes sterile soon afterwards.
Exposure to STIs, and not the use of the Exposure to STIs, and not the use of the
IUD itself, is responsible for PID occurring IUD itself, is responsible for PID occurring
after the first month of use.after the first month of use.
INFECTION .2INFECTION .2
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30. It remains unclear whether the It remains unclear whether the
risk of PID is reduced in users of risk of PID is reduced in users of
the LNG-IUS compared to users of the LNG-IUS compared to users of
the copper IUDs.the copper IUDs.
IUD users should continue to use IUD users should continue to use
condoms for protection against condoms for protection against
STIs.STIs.
INFECTION .2INFECTION .2
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31. EXPULSION .3EXPULSION .3
Expulsion of the IUD is most common in the Expulsion of the IUD is most common in the
first year of use (2first year of use (2––10% of users). 10% of users).
The 5-year cumulative expulsion rate for the The 5-year cumulative expulsion rate for the
copper IUD is 6.7% and for the LNG-IUS is copper IUD is 6.7% and for the LNG-IUS is
5.8%.5.8%.
Risk factors for expulsion include insertion Risk factors for expulsion include insertion
immediately postpartum, nulliparity, and immediately postpartum, nulliparity, and
previous IUD expulsion.previous IUD expulsion.
A woman who has expelled one IUD has a 30% A woman who has expelled one IUD has a 30%
chance of expelling a subsequent device.chance of expelling a subsequent device.www.freelivedoctor.comwww.freelivedoctor.com

32. FAILURE .4FAILURE .4
If a woman becomes pregnant with an IUD If a woman becomes pregnant with an IUD in in
situsitu, the possibility of ectopic pregnancy must , the possibility of ectopic pregnancy must
be excluded.be excluded.
The risk of spontaneous abortion is increased in The risk of spontaneous abortion is increased in
women who continue a pregnancy with an IUD women who continue a pregnancy with an IUD
in place. in place.
The UK Family Planning Research Network The UK Family Planning Research Network
study found that 75% of pregnancies aborted if study found that 75% of pregnancies aborted if
a copper IUD was left in situ, but that early a copper IUD was left in situ, but that early
removal virtually eliminated the risk of septic removal virtually eliminated the risk of septic
abortion.abortion.
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33. If the IUD was removed, 89% of If the IUD was removed, 89% of
women had a live birth, compared women had a live birth, compared
to 25% of women who left the IUD to 25% of women who left the IUD
in place.in place.
Although the risk of spontaneous Although the risk of spontaneous
abortion appears to be normalized abortion appears to be normalized
after IUD removal, the risk of after IUD removal, the risk of
preterm delivery remains higher.preterm delivery remains higher.
FAILURE .4FAILURE .4
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34. 1. Nulliparous women cannot use IUDs.1. Nulliparous women cannot use IUDs.
2. IUDs increase the risk of ectopic 2. IUDs increase the risk of ectopic
pregnancy.pregnancy.
3. IUDs increase the risk of infertility.3. IUDs increase the risk of infertility.
4. IUDs increase the long-term risk of 4. IUDs increase the long-term risk of
PID.PID.
5. IUDs are not effective contraceptives.5. IUDs are not effective contraceptives.
MYTHS AND MISCONCEPTIONSMYTHS AND MISCONCEPTIONS
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35. MYTHS AND MISCONCEPTIONSMYTHS AND MISCONCEPTIONS
Nulliparous women cannot use IUDs.Nulliparous women cannot use IUDs.
Fact:Fact:
Nulliparity is not a contraindication to Nulliparity is not a contraindication to
IUD use.IUD use.
In carefully selected nulliparous In carefully selected nulliparous
women, IUDs may be successfully women, IUDs may be successfully
used.used.
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36. IUDs increase the risk of ectopic pregnancy.IUDs increase the risk of ectopic pregnancy.
Fact:Fact:
IUDs do not increase the risk of ectopic IUDs do not increase the risk of ectopic
pregnancy.pregnancy.
Because IUDs work primarily by preventing Because IUDs work primarily by preventing
fertilization, IUD users have a lower risk of fertilization, IUD users have a lower risk of
ectopic pregnancy than women who are not ectopic pregnancy than women who are not
using any form of birth control (0.02using any form of birth control (0.02––0.25/100 0.25/100
WY versus 0.12WY versus 0.12––0.5/100 WY). 0.5/100 WY).
However, in women who conceive with an IUD However, in women who conceive with an IUD
in place, the diagnosis of ectopic pregnancy in place, the diagnosis of ectopic pregnancy
should be excluded.should be excluded.
MYTHS AND MISCONCEPTIONSMYTHS AND MISCONCEPTIONS
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37. IUDs increase the risk of infertility.IUDs increase the risk of infertility.
Fact:Fact:
IUDs do not increase the risk of infertility. IUDs do not increase the risk of infertility.
Women who discontinue use of an IUD in Women who discontinue use of an IUD in
order to conceive are able to conceive at order to conceive are able to conceive at
the same rate as women who have never the same rate as women who have never
used an IUD. used an IUD.
Copper IUD use is not associated with an Copper IUD use is not associated with an
increase in tubal factor infertility in increase in tubal factor infertility in
nulliparous women.nulliparous women.
MYTHS AND MISCONCEPTIONSMYTHS AND MISCONCEPTIONS
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38. IUDs increase the long-term risk of PID.IUDs increase the long-term risk of PID.
Fact:Fact:
The incidence of PID among IUD users is less The incidence of PID among IUD users is less
than 2 episodes per 1000 years of use, similar than 2 episodes per 1000 years of use, similar
to that of the general population. to that of the general population.
The increase in risk of PID associated with IUD The increase in risk of PID associated with IUD
use appears to be related only to the insertion use appears to be related only to the insertion
process.process.
After the first month of use, the risk of infection After the first month of use, the risk of infection
is not significantly higher than in women is not significantly higher than in women
without IUDs.without IUDs.
MYTHS AND MISCONCEPTIONSMYTHS AND MISCONCEPTIONS
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39. IUDs are not effective contraceptives.IUDs are not effective contraceptives.
Fact:Fact:
IUDs are a highly effective method of IUDs are a highly effective method of
birth control. birth control.
In fact, in long-term users of IUDs, the In fact, in long-term users of IUDs, the
failure rate approaches that of tubal failure rate approaches that of tubal
ligation.ligation.
The LNG-IUS appears to be as effective as The LNG-IUS appears to be as effective as
tubal ligation.tubal ligation.
MYTHS AND MISCONCEPTIONSMYTHS AND MISCONCEPTIONS
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40. INITIATIONINITIATION
Prior to insertion, Prior to insertion, informed informed
consentconsent should be obtained should be obtained
and the patient should be and the patient should be
aware of the risks, benefits, aware of the risks, benefits,
and alternative methods of and alternative methods of
contraception. contraception.
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41. Patients should be counselled Patients should be counselled
regarding the potential side effects regarding the potential side effects
associated with the IUD of choice, associated with the IUD of choice,
particularly alterations in the particularly alterations in the
menstrual cycle. menstrual cycle.
Patients should also be reminded that Patients should also be reminded that
the IUD does not protect against STIs the IUD does not protect against STIs
or HIV.or HIV.
INITIATIONINITIATION
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42. The IUD can be inserted The IUD can be inserted
at at any time during the any time during the
menstrual cyclemenstrual cycle once once
pregnancy or the pregnancy or the
possibility of pregnancy possibility of pregnancy
can be excluded. can be excluded.
INITIATIONINITIATION
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43. Although the advantages of inserting Although the advantages of inserting
the IUD during or shortly after the IUD during or shortly after
menses include ruling out pregnancy menses include ruling out pregnancy
and the masking of insertion-related and the masking of insertion-related
bleeding, bleeding, there is no evidence to there is no evidence to
support the common practice of support the common practice of
inserting the IUD only during mensesinserting the IUD only during menses. .
INITIATIONINITIATION
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44. In fact, In fact, infection and expulsion infection and expulsion
rates may be higherrates may be higher when when
inserted during menses.inserted during menses.
The IUD can be removed and The IUD can be removed and
replaced at the same time on replaced at the same time on
any day of the menstrual cycle.any day of the menstrual cycle.
INITIATIONINITIATION
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45. Postpartum women may be Postpartum women may be
candidates for immediate IUD candidates for immediate IUD
insertion insertion (within 10–15 minutes (within 10–15 minutes
after delivery of the placenta).after delivery of the placenta).
These women are at higher risk of These women are at higher risk of
expulsion and uterine perforation.expulsion and uterine perforation.
INITIATIONINITIATION
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46. In most circumstances, it is best to In most circumstances, it is best to
wait to insert the IUD until the wait to insert the IUD until the
uterus is completely involuted, uterus is completely involuted,
usually at usually at 4 to 6 weeks postpartum4 to 6 weeks postpartum. .
Women should wait until 6 weeks Women should wait until 6 weeks
post-partum to have the LNG-IUS post-partum to have the LNG-IUS
inserted. inserted.
INITIATIONINITIATION
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47. An IUD can be safely inserted An IUD can be safely inserted
immediately after a first trimester immediately after a first trimester
pregnancy termination.pregnancy termination.
The cost-effectiveness of screening for The cost-effectiveness of screening for
gonorrhea and chlamydia infection gonorrhea and chlamydia infection
prior to IUD insertion is unclear. prior to IUD insertion is unclear.
INITIATIONINITIATION
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48. The cervix should be carefully The cervix should be carefully
inspected prior to IUD insertion, inspected prior to IUD insertion,
and, and,
if there is any evidence of if there is any evidence of
mucopurulent discharge or pelvic mucopurulent discharge or pelvic
tenderness, cervical swabs should tenderness, cervical swabs should
be performed and IUD insertion be performed and IUD insertion
delayed until the results are known.delayed until the results are known.
INITIATIONINITIATION
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49. ANTIBIOTIC PROPHYLAXISANTIBIOTIC PROPHYLAXIS
A Cochrane Collaboration review A Cochrane Collaboration review
concluded that neither doxycycline nor concluded that neither doxycycline nor
azithromycin before IUD insertion azithromycin before IUD insertion
conferred benefit.conferred benefit.
According to the American Health According to the American Health
AssociationAssociation’’s 1997 guidelines for s 1997 guidelines for
prevention of bacterial endocarditis (SBE), prevention of bacterial endocarditis (SBE),
antibiotic prophylaxis is not necessary antibiotic prophylaxis is not necessary
prior to IUD insertion if there is no prior to IUD insertion if there is no
obvious infection.obvious infection.
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50. FOLLOW UPFOLLOW UP
A follow-up visit should be scheduled post-A follow-up visit should be scheduled post-
insertion. insertion.
This allows for:This allows for:
3.3.the exclusion of infection, the exclusion of infection,
4.4.an assessment of bleeding patterns, an assessment of bleeding patterns,
5.5.an assessment of patient and partner satisfaction, an assessment of patient and partner satisfaction,
and and
6.6.an opportunity to reinforce the issue of condom use an opportunity to reinforce the issue of condom use
for protection against STIs and HIV. for protection against STIs and HIV.
After this visit, an IUD user should continue After this visit, an IUD user should continue
annual well-woman care as for any sexually annual well-woman care as for any sexually
active woman.active woman.
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51. An IUD user should be instructed to contact her An IUD user should be instructed to contact her
healthcare provider if any of the following healthcare provider if any of the following
occur:occur:
lShe cannot feel the IUDShe cannot feel the IUD’’s threadss threads
lShe or her partner can feel the lower end of the IUDShe or her partner can feel the lower end of the IUD
lShe thinks she is pregnantShe thinks she is pregnant
lShe experiences persistent abdominal pain, fever, or She experiences persistent abdominal pain, fever, or
unusual vaginal dischargeunusual vaginal discharge
lShe or her partner feel pain or discomfort during She or her partner feel pain or discomfort during
intercourseintercourse
lShe experiences a sudden change in her menstrual She experiences a sudden change in her menstrual
periodsperiods
lShe wishes to have the device removed or wishes to She wishes to have the device removed or wishes to
conceiveconceive
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52. TROUBLESHOOTINGTROUBLESHOOTING
1. LOST STRINGS1. LOST STRINGS
2. PREGNANCY WITH AN IUD IN PLACE2. PREGNANCY WITH AN IUD IN PLACE
3. AMENORRHEA OR DELAYED MENSES3. AMENORRHEA OR DELAYED MENSES
4. PAIN AND ABNORMAL BLEEDING4. PAIN AND ABNORMAL BLEEDING
5. DIFFICULTY REMOVING THE IUD5. DIFFICULTY REMOVING THE IUD
6. STI IDENTIFIED WITH IUD IN PLACE6. STI IDENTIFIED WITH IUD IN PLACE
7. ACTINOMYCOSIS ON PAP SMEAR7. ACTINOMYCOSIS ON PAP SMEAR
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53. 1. LOST STRINGS1. LOST STRINGS
If an IUD user is unable to palpate the If an IUD user is unable to palpate the
IUD strings, a speculum exam should be IUD strings, a speculum exam should be
performed. performed.
If the strings are not seen in the cervical If the strings are not seen in the cervical
os, the device os, the device
3.3.May have been expelled, May have been expelled,
4.4.May have perforated the uterine wall, or May have perforated the uterine wall, or
5.5.The strings may have been drawn up into The strings may have been drawn up into
the cervical canal. the cervical canal. www.freelivedoctor.comwww.freelivedoctor.com

54. Pregnancy should be excluded.Pregnancy should be excluded.
Once pregnancy is excluded, the Once pregnancy is excluded, the
cervical canal should be explored cervical canal should be explored
(with a cotton (with a cotton
swab, forceps, or similar swab, forceps, or similar
instrument)instrument) to see if to see if
the strings can be found. the strings can be found.
1. LOST STRINGS1. LOST STRINGS
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55. If the strings cannot be found, If the strings cannot be found,
ultrasoundultrasound is the preferred is the preferred
method to identify the location of method to identify the location of
the IUD. the IUD.
If the device is seen within the If the device is seen within the
uterus, it can be left uterus, it can be left in situin situ..
1. LOST STRINGS1. LOST STRINGS
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56. If the device is not identified If the device is not identified
within the uterus or the pelvis, a within the uterus or the pelvis, a
plain x-ray of the abdomenplain x-ray of the abdomen should should
be performed to determine be performed to determine
whether the device has perforated whether the device has perforated
the uterine wall. the uterine wall.
Both the LNG-IUS and the copper Both the LNG-IUS and the copper
IUD are IUD are radio-opaque.radio-opaque.
1. LOST STRINGS1. LOST STRINGS
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57. Once she get pregnant, the diagnosis Once she get pregnant, the diagnosis
of an ectopic pregnancy has been of an ectopic pregnancy has been
excluded, excluded,
The IUD should be removed if The IUD should be removed if
possible.possible.
If the strings are visibleIf the strings are visible, gentle , gentle
traction is applied to remove the traction is applied to remove the
device. device.
If the strings are not visibleIf the strings are not visible, gentle , gentle
exploration of the cervical canal is exploration of the cervical canal is
performed. performed.
PREGNANCY WITH AN IUD IN PLACE .2
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58. If no strings are foundIf no strings are found, the possibility of , the possibility of
perforation must be considered. perforation must be considered.
This is best excluded by pelvic ultrasound. This is best excluded by pelvic ultrasound.
Despite reports of successful Despite reports of successful
hysteroscopic IUD removal during the first hysteroscopic IUD removal during the first
trimester, if the device remains in the trimester, if the device remains in the
uterus then usually uterus then usually no attempt is made to no attempt is made to
remove it. remove it.
Note should be made of recovery of the Note should be made of recovery of the
IUD at the time of delivery.IUD at the time of delivery.
PREGNANCY WITH AN IUD IN PLACE .2
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59. AMENORRHEA OR DELAYED MENSES .3AMENORRHEA OR DELAYED MENSES .3
Pregnancy must be excluded. Pregnancy must be excluded.
Once pregnancy has been excluded, Once pregnancy has been excluded,
investigation should be as for a woman without investigation should be as for a woman without
an IUD.an IUD.
Up to 35% of LNG-IUSUp to 35% of LNG-IUS users may experience users may experience
amenorrhea.amenorrhea.
If proper positioning of the LNG-IUS is If proper positioning of the LNG-IUS is
confirmed, it is unnecessary to perform confirmed, it is unnecessary to perform
repeated pregnancy tests. repeated pregnancy tests.
If the IUD user is If the IUD user is post-menopausalpost-menopausal, the device , the device
should be removed.should be removed.
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60. PAIN AND ABNORMAL BLEEDING .4PAIN AND ABNORMAL BLEEDING .4
Increased menstrual bleeding with or Increased menstrual bleeding with or
without an increase in menstrual cramping without an increase in menstrual cramping
may occur in IUD users. may occur in IUD users.
In the event of partial expulsion or In the event of partial expulsion or
perforation, the device should be removed perforation, the device should be removed
and consideration given to inserting and consideration given to inserting
another IUD. another IUD.
In the first few months after insertion, In the first few months after insertion,
pain and spotting can also occur between pain and spotting can also occur between
menses. menses.
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61. Once partial expulsion, perforation, Once partial expulsion, perforation,
pregnancy, and infection are ruled pregnancy, and infection are ruled
out, treatment with NSAIDs may be out, treatment with NSAIDs may be
helpful in treating these symptoms. helpful in treating these symptoms.
The number of days of bleeding or The number of days of bleeding or
spotting usually decreases over time.spotting usually decreases over time.
If pain or bleeding persists or If pain or bleeding persists or
worsens, removing the IUD must be worsens, removing the IUD must be
considered.considered.
PAIN AND ABNORMAL BLEEDING .4PAIN AND ABNORMAL BLEEDING .4
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62. DIFFICULTY REMOVING THE IUD .5DIFFICULTY REMOVING THE IUD .5
Grasping the string with a ring forceps Grasping the string with a ring forceps
and exerting gentle traction can and exerting gentle traction can
usually accomplish removal of an IUD. usually accomplish removal of an IUD.
If the strings cannot be seen, If the strings cannot be seen,
manoeuvres such as those described manoeuvres such as those described
above can be used to assist in above can be used to assist in
localizing the strings. localizing the strings.
If further manoeuvres are needed, a If further manoeuvres are needed, a
paracervical block may be considered. paracervical block may be considered. www.freelivedoctor.comwww.freelivedoctor.com

63. A uterine sound can be passed A uterine sound can be passed
into the endometrial cavity to into the endometrial cavity to
localize the IUD. localize the IUD.
Cervical dilation may be required. Cervical dilation may be required.
Once localized, the IUD can be Once localized, the IUD can be
subsequently grasped with a small subsequently grasped with a small
grasping instrument directed grasping instrument directed
towards it. towards it.
DIFFICULTY REMOVING THE IUD .5DIFFICULTY REMOVING THE IUD .5
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64. If removal is not easily If removal is not easily
performed, direct visualization performed, direct visualization
of the IUD with ultrasound or of the IUD with ultrasound or
hysteroscopy may be required. hysteroscopy may be required.
Occasionally general anesthetic Occasionally general anesthetic
may be needed to carry out may be needed to carry out
IUD removal.IUD removal.
DIFFICULTY REMOVING THE IUD .5DIFFICULTY REMOVING THE IUD .5
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65. 6. STI IDENTIFIED WITH IUD IN PLACE6. STI IDENTIFIED WITH IUD IN PLACE
Appropriate antibiotic therapy should be Appropriate antibiotic therapy should be
initiated for an IUD user initiated for an IUD user (and her sexual (and her sexual
contacts)contacts) found to have chlamydial or found to have chlamydial or
gonoccocal cervicitis. gonoccocal cervicitis.
If there is a suggestion of PID, the device If there is a suggestion of PID, the device
should be removed after pre-treating the should be removed after pre-treating the
woman with antibiotics.woman with antibiotics.
She should be counselled regarding the She should be counselled regarding the
use of barrier contraceptive methods for use of barrier contraceptive methods for
STI prevention.STI prevention.
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66. ACTINOMYCOSIS ON PAP SMEAR .7ACTINOMYCOSIS ON PAP SMEAR .7
Actinomycosis is considered a commensal Actinomycosis is considered a commensal
vaginal organism but may be associated vaginal organism but may be associated
with frank infection. with frank infection.
Up to 20% of cervical smears in long-term Up to 20% of cervical smears in long-term
copper IUD users show evidence of copper IUD users show evidence of
Actinomycosis, although this finding is Actinomycosis, although this finding is
only noted in up to 3% of LNG-IUS users.only noted in up to 3% of LNG-IUS users.
Removal of the device in women with Removal of the device in women with
Actinomycosis on their Pap smear may not Actinomycosis on their Pap smear may not
be necessary.be necessary. www.freelivedoctor.comwww.freelivedoctor.com

67. In the In the asymptomatic womanasymptomatic woman, it is , it is
reasonable to leave the IUD in place, reasonable to leave the IUD in place,
follow her with annual Pap smears follow her with annual Pap smears
and pelvic examinations, and warn and pelvic examinations, and warn
her of potential symptoms of PID. her of potential symptoms of PID.
If the decision is made to treat, If the decision is made to treat,
antibiotic therapyantibiotic therapy with penicillin G, with penicillin G,
tetracycline, or doxycycline may be tetracycline, or doxycycline may be
given. given.
ACTINOMYCOSIS ON PAP SMEAR .7ACTINOMYCOSIS ON PAP SMEAR .7
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68. If the woman is If the woman is symptomaticsymptomatic, ,
the IUD should be removed after the IUD should be removed after
antibiotic preloading. antibiotic preloading.
If the If the infection is severeinfection is severe, she , she
should be hospitalized, treated for should be hospitalized, treated for
PID, and investigated for possible PID, and investigated for possible
abscess.abscess.
ACTINOMYCOSIS ON PAP .7 ACTINOMYCOSIS ON PAP .7
SMEARSMEAR
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69. SUMMARY STATEMENTSSUMMARY STATEMENTS
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70. In women who are In women who are
at low risk of acquiring at low risk of acquiring
STIs, the use of an STIs, the use of an
intrauterine device may intrauterine device may
be an excellent be an excellent
contraceptive option. contraceptive option.
(Level II)
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71. Efficacy rates for the Efficacy rates for the levonorgestrel-levonorgestrel-
releasing intrauterine systemreleasing intrauterine system
approach those of surgical approach those of surgical
sterilization; sterilization;
it is therefore an excellent it is therefore an excellent
alternative to surgical sterilization alternative to surgical sterilization
for women who seek long-term for women who seek long-term
contraception. contraception.
(Level II)
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72. The copper IUDs The copper IUDs
(Nova-T and Flexi-T 300)(Nova-T and Flexi-T 300)
and the LNGIUS and the LNGIUS (Mirena)(Mirena)
provide effective provide effective
contraception for 5 years.contraception for 5 years.
(Level I)
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73. The risk of genital tract The risk of genital tract
infection after the first month infection after the first month
of IUD use is small. of IUD use is small.
There appears to be an There appears to be an
inverse relation between risk inverse relation between risk
of infection and time since of infection and time since
IUD insertion. IUD insertion.
(Level II)
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74. Although the relative risk of pelvic Although the relative risk of pelvic
inflammatory disease (PID) in the first inflammatory disease (PID) in the first
month after insertion is increased month after insertion is increased
slightly, the absolute risk is still low. slightly, the absolute risk is still low.
Exposure to sexually transmitted Exposure to sexually transmitted
infections, and not the use of the IUD infections, and not the use of the IUD
itself, is responsible for PID occurring itself, is responsible for PID occurring
after the first month of use. after the first month of use.
(Level II)
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75. Both types of IUDs provide Both types of IUDs provide
excellent contraceptive efficacyexcellent contraceptive efficacy
(Level 1) (Level 1)
•In addition, the copper IUD may
decrease the risk of endometrial
cancer
(Level II)
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76. The levonorgestrel releasing The levonorgestrel releasing
IUS may provide an IUS may provide an
acceptable alternative to acceptable alternative to
hysterectomyhysterectomy, by decreasing , by decreasing
menorrhagia and increasing menorrhagia and increasing
hemoglobin concentrations.hemoglobin concentrations.
(Level I)(Level I)
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77. RECOMMENDATIONSRECOMMENDATIONS
Health-care professionals Health-care professionals
providing family planning providing family planning
services should be familiar services should be familiar
with the use of the with the use of the
intrauterine device (IUD). intrauterine device (IUD).
(Grade A)
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78. Appropriately trained personnel in Appropriately trained personnel in
adequately equipped facilities adequately equipped facilities
should be available in order to should be available in order to
ensure that women have access ensure that women have access
to the IUD if they desire this to the IUD if they desire this
method of contraception. method of contraception.

RECOMMENDATIONSRECOMMENDATIONS
(Grade A)
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