Tutorial 20A: Long Acting Reversible Contraception

Question 1

What are the functions of a Copped IUD?

Answer 1

1. Contraceptive: Immobilise sperm preventing fertilisation.
2. Interceptive
   
   • if sperm were to get past the IUD, the embryo would be inhibited from implanting into uterine wall.
   • If used after sex, prevents implantation.

Question 2

What are the two types of Copper IUD’s available?

Answer 2

1. Multiload CU 375- failure rate of 1 pregnancy per 100 women per year
2. Copper T 380 - can be inserted into a smaller os.

Question 3

When can a copper IUD be inserted?

Answer 3

If no unprotected intercourse = Can be placed at any time of cycle (except heavy menses).

If unprotected intercourse, place within 5 days of calculated ovulation.

6 weeks post delivery

TOP: immediately post First Tri Termination.

Question 4

How long can a Copper IUD be left in place?

Answer 4

• Leave for 5 years.
• IUD only needs changing once in 40s (as frequency of ovulation decreases) then can stay until menopause
• They also expected us to mention the obvious – IUD does not prevent STI transmission.

Question 5

What are some advantages of using the copper IUD?

Answer 5

• reversible
• effective (failure rate 1/100 women years)
• safe
• no day to day pills
• can stay in place for 5 years
• no hormones.

Question 6

What are some side effects of the copper IUD?

Answer 6

• Breast tenderness
• Acne
• Spotting/light bleeding
• Headaches
• Nausea

IUDs DO NOT PROTECT PATIENT FROM STI’s

Question 7

What are 5x risks associated with the copper IUD?

Answer 7

1. Miscarriage rate increased if get pregnant.
   
   1. 25% if IUD removed, 50% if IUD remains.
   2. No teratogenic effect, PROM more likely.
2. Ectopic pregnancy decreases overall rate but increases risk of ectopic pregnancy by 5 times among those who do get pregnant.
3. Perforation: at time of insertion 1/1000 insertions
4. Infection post insertion associated with STIs. Most suitable for those in long-term relationship. Does not increase risk of PID/infertility for women in mutually monogamous relationships.
5. Expulsion of IUD occurs in 2-3%. Most common during 1st or 2nd period after insertion.

Question 8

What are some contraindications for Copper IUD?

Answer 8

Absolute C/I:

• pregnancy
• genital malignancy
• undiagnosed genital bleeding
• distorted uterine cavity or cavity >5.5cm.
• Wilson’s disease (a disorder of copper metabolism, characterized by copper deposition in multiple organs) (always mention Wilson’s disease even though they will most probably laugh at you)
• previous bacterial endocarditis
• severe PID

Stong C/I:

• active STI (gonococcal or chlamydial infection)
• PID

Question 9

What is the function and success rate of Mirena?

Answer 9

• Similar to the standard copper IUD but contains progestogen hormone: levonorgestrel.
• Functions:
  
  1. Inhibition of sperm function
  2. Inhibition of endometrial proliferation
  3. Alters cervical mucus
  4. Inhibits ovulation (approx 1/3 do not ovulate at all)
• 99.9% Success rate

Question 10

What are the advantages associated with using a Mirena?

Answer 10

Same as copper: reversible, effective (failure rate 1/100 women years), safe, no day to day pills, can stay in place for 5 years,

Effective treatment for menorrhagia

• Free for patients with menorrhagia but expensive if contraceptive alone
• qualification for funding required failed medical tx for HMB with Hb <120, Ferritin <40

Question 11

What are the disadvantages associated with using the Mirena?

Answer 11

• (same as copper IUD.) Miscarriage, exctopic pregnancy, perforation, infection, expulsion, doesnt prevent transmission of STIs
• Irregular bleeding and lower abdominal cramps common in first 3 months.
• Systemic dose 1/3rd of POP so low SEs.
• Cost $300+.$315 at Family Planning in 2009.
• Small risk of pelvic infection when IUD put in.

Question 12

What are Pre- and Post- IUD insertion measures are taken?

Answer 12

Pre-IUD visit:

• Endocervical swab for GC culture and Chlamydia
• Urethral swab if ELIZA test for Chlamydia.

Insertion: non-touch aseptic insertion technique used

Post-IUD visit: 6 week post insertion follow up.

• Expulsion 2-3%, Perforation 1/1000

Question 13

What are the functions of the Depo-Provera?

Answer 13

Function/MoA:

• Prevents ovulation/egg being released each month. (Suppresses ovulation at hypothalamo-pituitary level)
• Thickens cervical mucus
• Inhibits endometrial proliferation to inhibit implantation

Injection of progestogen into buttock every 12 weeks

• 4 week leeway (up to 16w)

Chance of getting pregnant: <1%, 1/100 women years

Question 14

What are the advantages of using Depo-Provera?

Answer 14

• Usually no periods – stops endometrial proliferation, so nothing to shed as period.
• One injection lasts 12 weeks
• Doesn’t interfere with sexual intercourse
• Useful for women who can’t take OCP.

Question 15

What are the disadvantages associated with using Depo-Provera?

Answer 15

• Irregular bleeding
• Weight change
• Mood changes
• Headache
• Reduction in libido
• Delay in fertility
  
  • For some women this is fairly immediate for others it may take longer – occasionally up to 18 months. Within 10 months of the last injection about 50% of women who have stopped it to conceive will be pregnant.
  • Needs to be discussed with women before starting on the injection
• No causal association between headache, mood changes and reduction in libido and the injection

Question 16

Does Depo-Provera have any effect on fertility long-term?

Answer 16

Some woman experience a delay in fertility after stopping the Depo-Provera:

• For some women this is fairly immediate for others it may take longer – occasionally up to 18 months.
• Within 10 months of the last injection about 50% of women who have stopped it to conceive will be pregnant.

They potential for delay in re-experiencing fertility needs to be discussed with women before starting on the injection

Question 17

What are the contraindications for starting Depo-Provera?

Answer 17

same as POP:

• Absolute C/I:
• pregnancy
• undisclosed genital bleeding
• Relative C/I: malabsorption, arterial disease, liver adenoma, severe liver disease

Question 18

When can you start the depo-provera?

Answer 18

• Immediately: if Menstruation day 1-5 = will provideiImmediate protection
• All other times: apply 7 day rule

Question 19

What follow-up regime occurs for depo-provera?

Answer 19

• 3 monthly
• Women who present late for repeat injection:
  
  • can have a further injection
  • but they need a pregnancy test ~3 weeks later to exclude an early pregnancy.

Question 20

What is the function of the Jadelle/Implant?

Answer 20

• Functions
  
  • Thickening mucus in cervix
  • May inhibit ovulation (ovaries from releasing egg)
• Progesterone released from 1 or 2 rods implanted under the skin of arm
  
  • Jadelle – 2 rods – releases levonorgestrel. $3 as script + cost of consultation and supplies to insert it.
  • Implanon – 1 rod – releases etonogestrel. Not effective if using enzyme inducing medication. Not subsidised - $240
• Failure rate
  
  • <1% for first 4 years
  • 1% in 5th year.

Question 21

What are the two types of implants?

Answer 21

Progesterone released from 1 or 2 rods implanted under the skin of arm

1. Jadelle – 2 rods – releases levonorgestrel.
   
   1. $3 script + cost of consultation + insertion equipment.
2. Implanon – 1 rod – releases etonogestrel.
   
   1. Not effective if using enzyme inducing medication.
   2. Not subsidised - $240

Question 22

What are the disadvantages of using Implanon instead of Jadelle?

Answer 22

1. Implanon is not effective if using enzyme inducing medication
2. Implanon isn’t subsidised ($240)

Question 23

What are the advantages of using a contraceptive implant?

Answer 23

• Lasts 3-5 years
• Useful for women who can’t take combined pill
• Useful for those who forget pills or injection appointments

Question 24

What are the disadvantages of using a contraceptive implant?

Answer 24

• Irregular bleeding. Often gets better with time.