Wendy Shen, MD, PhD Refresher Course for the Family Physician April 5, 2018 Coralville, Iowa

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1 Wendy Shen, MD, PhD Refresher Course for the Family Physician April 5, 2018 Coralville, Iowa

2 Objectives Distinguish the different types of IUDs Understand the mechanism of action and selection of candidates Recognize the related complications and management

3 Background and History Most commonly used reversible contraception worldwide History Gräfenberg's ring Dalkon Shield

4 Types of IUDS

5 IUD Utilization in US

7 Myths PID HIV and HPV Ectopic pregnancy Infertility

8 Types of IUDs Five IUDs available in US Copper IUD Levonorgestrel containing IUDs Mirena Liletta Kyleena Skyla

10 Mechanism of Action Inhibit sperm transport Spermicidal effects Ovicidal effects Inhibit implantation?

11 Copper and LNG-IUD Comparison Copper-IUD LNG-IUDs Efficacy 0.1% per year 0.8% per year Mechanism of Action Common Side Effects Copper impairs sperm motility Spermicidal Not abortifacient Heavier/longer periods Painful menstruation/sexual intercourse vaginitis Inhibit sperm penetration by causing profound cervical mucus change Not abortifacient Spotting/lighter periods Ovarian cysts Headache Acne Mood change

12 Copper IUD (ParaGard) Effective for 10 years Can be used for emergency contraception Benefits

13 Levonorgestrel Containing IUDs Skyla Kyleena Liletta Mirena

14 Levonorgestrel Containing IUDs Levonorgestrel dose Mirena (LNg 52/5) Liletta (LNg 52/4) Kyleena (LNg 19.5/5) 52 mg 52 mg 19.5mg 13.5mg Duration 5/7 years 5 years, likely 7 5 years 3 years Size 32 mm 32 mm 28 mm 28 mm Amenorrhea rate Non- Contraceptive benefits Up to 50% reduction in menorrhagia, anemia, dysmenorrhea, endometriosis-related pain, endometrial hyperplasia, PID and cervical cancer Skyla (LNg 14/3) 10% after one year

15 Candidate Selection

17 Eligibility Criteria for Contraceptive Use 1. No restriction (method can be used) 2. Advantages generally outweigh theoretical or proven risks 3. Theoretical or proven risks usually outweigh the advantages 4. Unacceptable health risk (method not to be used)

20 Condition Sub-condition Cu-IUD LNg IUD Anatomical abnormalities Distorted uterine cavity 4 4 Cervical Cancer Awaiting for treatment 4 4 Endometrial cancer 4 4 Breast Cancer Current 1 4 Past or no evidence of current disease for Gestational trophoblastic disease years Persistently elevated hcg or malignant disease 4 4 Cirrhosis Severe 1 3 Liver Tumors 1 3 PID Current 4 4 Postabortion Immediate postseptic abortion 4 4 postpartum Postpartum Sepsis 4 4 STIs Current purulent cervicitis or chlamydial infection or gonococcal infection 4 4 Ischemic heart disease Current and history of 1 3 SLE Severe thrombocytopenia 3 2 Positive antiphospholipid antibodies 1 3 Solid organ transplant complicated 3 3 Tuberculosis Pelvic 4 4 Unexplained vaginal bleeding 4 4

21 Special Considerations MRI Menopause Uterine artery embolization/endometrial ablation Removal for conception

22 Management of Common Side Effects Time of insertion Difficult insertion Cytotec? Pain with insertion Post insertion Irregular bleeding Actinomyces on pap smear

23 Levonorgestrel Containing IUDs Levonorgestrel dose Mirena (LNg 52/5) Liletta (LNg 52/4) Kyleena (LNg 19.5/5) Skyla (LNg 14/3) 52 mg 52 mg 19.5mg 13.5mg Duration 5/7 years 5 years, likely 7 5 years 3 years Size 32 mm 32 mm 28 mm 28 mm Amenorrhea rate Up to 50% 10% after one year Cost $992 $750 $992 $827 Non- Contraceptive benefits reduction in menorrhagia, anemia, dysmenorrhea, endometriosis-related pain, endometrial hyperplasia, PID and cervical cancer

24 Summary Two main types of IUDs: copper and LNg. Indicated for majority of the patients. Patient selection based on personal and insurance preferences when indicated for LNg IUDs

25 References regnancy/pdf/legal_summarychart_english_final_tag508.pdf

LONG-ACTING REVERSIBLE CONTRACEPTION. Summary Tables

LONG-ACTING REVERSIBLE CONTRACEPTION Summary Tables Bridging the Divide: A Project of the Jacobs Institute of Women s Health June 2016 Table 1. Summary of LARC Methods Available Years Since Effective Copper