IUDs and the Nulliparous Patient

Developed in collaboration

Learning Objectives

Upon completion, participants should be able to:

• Examine new evidence and recommendations

regarding the use of IUDs for nulliparous women,

including teenagers

• Review evidence about the use of analgesic

medication and cervical preparation before

IUD insertion

23-Year-Old Woman—Gravida 0

• Has been on oral

contraceptives, but was

recently diagnosed with

migraine with aura

• Wonders what method

would be right for her

Classic Visual Scotomata

New York Headache blog. www.nyheadache.com/blog/when-does-migraine-aura-occur.

US Medical Eligibility Criteria

Curtis KM, et al. MMWR Recomm Rep. 2016;65:1-103.

Summary Chart of US Medical Eligibility Criteria for Contraceptive Use

1 No restriction for the use of the contraceptive method for a woman with the

corresponding medical condition on the previous slide

2 Advantages of using the method generally outweigh the theoretical or proven

risks

3 Theoretical or proven risks of the method usually outweigh the advantages—or

no other methods that are available or acceptable to the woman with the

corresponding medical condition on the previous slide

4 Unacceptable health risk if the contraceptive method is used by a

woman with the corresponding medical condition on the previous slide

US Medical Eligibility Criteria: Categories

Curtis KM, et al. MMWR Recomm Rep. 2016;65:1-103.

IUD Contraindications (MEC Cat 4)

• Pregnancy

• Undiagnosed vaginal bleeding

• Uterine anomaly or distortion

• Active cervical, breast (LNG only), or endometrial

cancer

• Infected uterus

Curtis KM, et al. MMWR Recomm Rep. 2016;65:1-103.

LARC• Contraceptive implant

– Etonogestrel implant

• IUDs:– Levonorgestrel 52 mg IUD, effective for 5 years

– Levonorgestrel 52 mg IUD, effective for 3 years

– Levonorgestrel 19.5 mg IUD, effective for 5 years

– Levonorgestrel 13.5 mg IUD, effective for 3 years

– Copper IUD, effective for 10 years

Curtis KM, et al. N Engl J Med. 2017;376:461-8; prescribing information.

Effectiveness of Each Method

Guttmacher Institute. www.guttmacher.org/fact-sheet/contraceptive-use-united-states.

Method Perfect Use Typical Use

Implant 0.05 0.05

Vasectomy 0.10 0.15

IUD—LNG 0.20 0.20

IUD—copper 0.60 0.80

Tubal sterilization 0.50 0.50

Injectable 0.20 6

Pill 0.30 9

Ring 0.30 9

Patch 0.30 9

Additional Safety Considerations for

Nulliparous Patients

• Primary side effects of IUDs and contraceptive implants are

changes in bleeding patterns

– Vulvovaginitis, abdominal/pelvic pain, acne/seborrhea, ovarian cyst,

breast pain, and headache may occur

• Serious adverse effects of IUDs include infection, expulsion,

perforation, pelvic infection, and increased risk of pregnancy

loss if pregnancy occurs

Curtis KM, et al. N Engl J Med. 2017;376:461-8; prescribing information.

Contraceptive Choice and Continuation Rates

• When allowed to choose:

– 75% of women pick a LARC method

• Rate of continuation:

– 86% of women continue LARC at 1 year compared

with 55% of non-LARC methods

Peipert JF, et al. Obstet Gynecol. 2012;120:1291-7; Peipert JF, et al. Obstet Gynecol. 2011;117:1105-13.

Let’s Say Our Patient Was a 15 Year Old

• Updated AAP recommendations

• September 2014: “The first-line contraceptive

choice for adolescents who choose not to be

abstinent is a LARC”

– Teen pregnancy prevention policy statement

– Confirms safety of LARC for teens

American Academy of Pediatrics Committee on Adolescence. Pediatrics. 2014;134:e1244-56.

Should You Premedicate?

VOL. 128, NO. 3, SEPTEMBER 2016 OBSTETRICS & GYNECOLOGY e69

Clinical Challenges of Long-Acting Reversible

Contraceptive Methods

A B S T R A C T : Long-acting reversible contraceptive methods are the most effective reversible contraceptives

and have an excellent safety record. Although uncommon, possible long-acting reversible contraceptive complica-

tions should be included in the informed consent process. Obstetrician–gynecologists and other gynecologic care

providers should understand the diagnosis and management of common clinical challenges. The American College

of Obstetricians and Gynecologists recommends the algorithms included in this document for management of the

most common clinical challenges.

Recom m endat ions

The American College of Obstetricians and Gynecologists makes the following recommendations:

• Routine misoprostol before intrauterine device (IUD) insertion in nulliparous women is not recom-mended, although it may be considered with difficult insertions.

• When IUD strings are not visualized, pregnancy should be excluded and a backup method of con-traception and emergency oral contraceptives (if appropriate) should be recommended until the IUD is confirmed to be properly located in the endometrial cavity.

• Management of the nonfundal IUD varies depending on the position of the device and the patient’s symp-toms. An IUD located within the cervix is partially expelled; given the increased risk of complete expul-sion, the IUD should be removed (and replaced if the patient desires). If the woman is asymptomatic and the IUD is above the internal os, removal of the IUD is more likely to lead to pregnancy than IUD retention.

• If a woman becomes pregnant with an IUD in place, the IUD should be removed if strings are visible or if the IUD is within the cervix.

• Whenever an implant is not palpable, pregnancy should be excluded and the woman should be coun-seled to use a backup method of contraception until the presence of the implant is confirmed; emergency oral contraceptives, if appropriate, should be recom-mended.

• When the implant is not palpable, removal should not be attempted until implant location is deter-mined.

The use of long-acting reversible contraception (LARC) has increased in recent years, from 2.4% of all women using contraception in 2002 (1) to 11.6% in 2013 (2). Intrauterine device complications, including uterine perforation and pelvic inflammatory disease, occur in less than 1% of women regardless of age or IUD type. Similarly, implant complications, including hematoma formation, unrecognized noninsertion, and deep inser-tion leading to removal difficulties, are uncommon (3). As LARC use increases, however, the absolute number

C O M M IT T EE O PIN IO NNumber 672 • September 2016

Committee on Gynecologic Practice

Long-Acting Reversible Contraception Work GroupThis Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Gynecologic

Practice and the Long-Acting Reversible Contraceptive Expert Work Group in collaboration with committee member David L.

Eisenberg, MD, and Expert Work Group members Nichole Tyson, MD and Eve Espey, MD.

This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should

not be construed as dictating an exclusive course of treatment or procedure to be followed.

The American College of Obstetricians and GynecologistsWOMEN’S HEALTH CARE PHYSICIANS

Copyright ª by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.

Unauthorized reproduction of this article is prohibited.

*Off-label use†2% lidocaine gel had no effect on pain.

ACOG Committee on Gynecologic Practice Long-Acting Reversible Contraception Work Group. Committee opinion no. 672. 2016; Lopez LM, et al. Cochrane Database Sys Rev.

2015;CD007373.

• “Routine misoprostol* before IUD insertion in nulliparous women is not

recommended, although it may be considered with difficult insertions”

• Some lidocaine formulations†, naproxen, and tramadol had some impact on pain

Should You Use a Smaller IUD?

• Adolescents tolerate IUD

placement well

• Continuation rates are high

• More evidence is needed to

determine whether a smaller

IUD is associated with less pain

at insertion

American Academy of Pediatrics Committee on Adolescence. Pediatrics. 2014;134:e1244-56.

28 mm

T-body

Drug reservoir

Silver ring

30 mm

Removal

threads

Summary

• LARC contraception should be offered as a first-line method due to

high typical use efficacy

• LARC should be offered as a first-line method for teenagers in an

effort to reduce unintended pregnancy rates

• IUDs can be used in a variety of medical conditions without

contraindication

• Cervical preparation for nulliparous patients is unnecessary

• Evidence about the benefits of smaller IUDs in nulliparous patients is

not robust, and more research is needed to guide clinical practice

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evaluation, attestation, and post-test.

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Unless otherwise indicated, photographed subjects who appear within the

content of this activity or on artwork associated with this activity are models;

they are not actual patients or doctors.

Abbreviations/Acronyms IUDs and the Nulliparous Patient AAP = American Academy of Pediatrics CDC = Centers for Disease Control and Prevention IUD = intrauterine device LARC = long-acting reversible contraceptive LNG = levonorgestrel MEC = Medical Eligibility Criteria STD = sexually transmitted disease US = United States