IUD & IUS

Question 1

What is the difference between the IUD & IUS?

Answer 1

intrauterine system (LNG-IUS):

• describes the levonorgestrel intrauterine system
• this contains progestogen that is slowly released into the uterus

intrauterine device (Cu-IUD):

• describes the copper coil
• creates a hostile environment for pregnancy

Question 2

How does removal of a coil affect fertility?

Answer 2

fertility returns to normal as soon as the device is removed

Question 3

What are the contraindications to coil fitting?

Answer 3

• pelvic inflammatory disease / infection
• pelvic cancer
• unexplained vaginal bleeding
• immunosuppression
• uterine cavity distortion (e.g. fibroids)
• pregnancy

Question 4

What test must be performed prior to insertion of a coil?

Answer 4

screening for chlamydia + gonorrhoea

• performed in all women at higher risk
  
  • i.e. under 25 years

Question 5

What is involved in the insertion of a coil?

Answer 5

• bimanual is performed to check the position + size of uterus
• speculum is inserted to fit the device
• forceps are used to stabilise the cervix during insertion
• BP + HR should be recorded before and after insertion

Question 6

What may women experience after insertion of a coil?

Answer 6

temporary crampy period type pain

• NSAIDs can be used to help with discomfort after the procedure

Question 7

How should women be followed up following insertion of the coil?

Answer 7

• they should be taught to feel the strings to ensure the coil remains in place
• they should be seen 3-6 weeks after insertion to check the threads

Question 8

What are the risks relating to insertion of the coil?

Answer 8

• bleeding
• pain on insertion
• vasovagal reactions (syncope / bradycardia / arrhythmias)
• uterine perforation
• PID (especially in first 20 days)
• expulsion of the coil
  
  • risk is highest in the first 3 months

Question 9

What advice is given to women about contraception and removal of the coil?

Answer 9

• women must use condoms for 7 days PRIOR to removal of the coil
• they should also use condoms for the first 7 days after insertion if the coil was not inserted during their menstrual cycle

Question 10

What 3 things must be excluded when the threads cannot be palpated?

Answer 10

• expulsion
• pregnancy
• uterine perforation

Question 10

What 3 things must be excluded when the threads cannot be palpated?

Answer 10

• expulsion
• pregnancy
• uterine perforation

Question 11

What advice is given to women when they can’t find their coil strings?

Answer 11

use extra contraception (i.e. condoms) until the coil is located

Question 12

What is the first line investigation when coil strings cannot be palpated?

Answer 12

ultrasound

• this can be used to confirm the correct placement of the IUD within the uterine cavity

Question 13

What may be performed when the IUD cannot be seen on USS?

Answer 13

pelvic XR:

• this looks for the coil elsewhere in the abdomen / peritoneal cavity after uterine perforation
• hysteroscopy / laparoscopic surgery may be required depending on the location of the coil

Question 14

How long can the copper coil be left in for?

What are the uses of this IUD?

Answer 14

• depending on the device, it can be left in for 5-10 years
• it can be used as emergency contraception being inserted up to 5 days after UPSI

Question 15

When is the copper IUD contraindicated?

Answer 15

Wilson’s disease

• a genetic condition resulting in the build-up of copper in the organs

Question 16

How does the copper IUD work?

Answer 16

• copper is toxic to the ovum and sperm
• it also enters the endometrium to make it less accepting of implantation
• the copper IUD does NOT contain any hormones

Question 17

What are the benefits to using the Cu-IUD?

Answer 17

• it can be inserted at any time during the menstrual cycle and is effective immediately
• reliable contraception
• does not contain hormones so can be used in women with VTE risk or history of hormone-related cancers
• may reduce risk of endometrial + cervical cancer

Question 18

What are the drawbacks to using the Cu-IUD?

Answer 18

• can cause heavy / Intermenstrual bleeding
• may cause pelvic pain
• does not protect against STIs
• increased risk of ectopic pregnancy
• IUDs can occasionally fall out

Question 19

What are the 4 types of IUS?

Answer 19

Mirena:

• effective for 5 years for contraception
• licensed for use for menorrhagia & HRT
  • only licensed for 4 years use for HRT

Levosert:

• effective for 5 years for contraception
• licensed for use for menorrhagia

Kyleena:

• effective for 5 years

Jaydess:

• effective for 3 years

!! these all contain levonorgestrel !!

Question 20

How does the LNG-IUS work?

Answer 20

it releases levonorgestrel (progestogen) into the local area:

• thickening of the cervical mucus
• altering of the endometrium to make it less accepting of implantation
• it inhibits ovulation in a small number of women

Question 21

When should the LNG-IUS be inserted?

Answer 21

• it can be inserted up to day 7 of the menstrual cycle without the need for additional contraception
• if inserted after day 7, condoms should be used for 7 days after insertion

Question 22

What are the benefits to using the LNG-IUS?

Answer 22

• can make periods lighter / stop altogether
• can improve dysmenorrhoea / endometriosis-related pain
• no effect on bone mineral density (unlike Depo)
• no increase in thrombosis risk (unlike COCP)
• can be used in obese patients (unlike COCP)
• additional uses for HRT and in menorrhagia

Question 23

What are the drawbacks of the LNG-IUS?

Answer 23

• can cause spotting / irregular bleeding
• may cause pelvic pain
• does not protect against STIs
• increased risk of ectopic pregnancies
• increased risk of ovarian cysts
• IUS can occasionally fall out
• systemic absorption causes side effects of acne, headaches + breast tenderness

Question 24

What advice is given to women about bleeding following insertion of the LNG-IUS?

Answer 24

* irregular bleeding is **common after insertion** * it should have settled within the **_first 6 months_** * if problematic bleeding continues, **further investigations** are required * *pregnancy test* * *sexual health screen* * *cervical screening*

Question 25

What may be prescribed to help with problematic bleeding following LNG-IUS insertion?

Answer 25

* **_COCP**_ can be taken in addition to the LNG-IUS for _**3 months_** * this should help to **settle problematic bleeding**

Question 26

What is discovered incidentally during cervical screening in women with a coil?

Answer 26

**_actinomyces-like organisms (ALO)_** * these ***do not require treatment*** unless symptomatic * if the woman has pelvic pain / abnormal bleeding, **removal of the coil** is considered