First Things First
What does LARC stand for?
Long Acting Reversible Contraceptives
how long is the copper IUD effective for
officially 10 years, shown to be effective up to 12 years
Should you screen for STIs prior to placing an IUD?
Bonus: If you do, should you delay IUD insertion?
yes if no routine screening done OR patient is at increased risk of STIs
BONUS: No!!!
Contraindication: current purulent cervicitis or known chlamydia or gonorrhea
What is the mechanism of action for nexplanon?
primarily suppression of ovulation, possibly additional protection from thickening in cervical mucous
What increases risk of IUD expulsion?
- post placental placement
- parous patients
- adolescence
Name the LARCs
Copper IUD
Levonorgestrel IUD (low dose vs higher dose)
Etonogestrel implant
Name a reason cited in the paper for early discontinuation of copper IUD
- heavy bleeding, dysmenorrhea (set expectations)
Name 3 possible side effects
- amenorrhea or lighter menses
- headaches, nausea, breast tenderness, mood changes, ovarian cyst formation
How long is nexplanon effective for?
FDA approved for 3 years, data to support 4 and even 5 years
- some question whether this data can apply to obese patients
Should you remove an IUD if a patient becomes pregnant with one in place?
it depends - yes if strings visible (shared decision making)
- consider if IUD is below pregnancy, and of course if pregnancy is desired
Name 3 barriers to LARCs
- in person visit
- procedural placement - pain, bleeding
- training required
- requiring a patient to be menstruating to place an IUD (outdated practice)
- two visit protocols
the inhibition of sperm migration and viability (HOSTILE ENVIRONMENT)
Mechanism of action?
profound change in amount and viscosity of cervical mucous - impermeable to sperm
Name 3 side effects of the implant
- irregular bleeding
- GI upset
- headaches
- breast pain
- vaginitis
- ? weight gain
Name three times you can safely place an IUD
- post placental
- post first trimester aspiration
- post Med Ab
- post second tri D&E
- "interval" - anytime during the menstrual cycle if pregnancy can be reasonably excluded
Name your favorite LARC and why
:)
How long is back up contraception recommended for after placement?
no backup required as it is effective immediately (i.e. why it can be used as an emergency contraceptive)
Name two indications for LNG-IUD
- desire for contraception
- heavy menstrual bleeding
- endometrial hyperplasia
When does MEC category change from 2 to 1 for postpartum nexplanon placement and why?
30 days postpartum, theoretical risk of effect on milk production and infant growth and development
- systematic review showed no negative effect!
Name two procedures you can do with an IUD in place
- EMB
- colpo
- cervical excision
- ECC
Name two ways to be reasonably certain a patient is not pregnant
- within 4 weeks postpartum
- within 7 days of FDLMP with normal menses
- has not had intercourse since FDLMP
- currently and consistently using a reliable method of contraception
- within 7 days of induced or spontaneous Ab
- fully or nearly fully breastfeeding (>85% of feeds), amenorrheic, and < 8 months postpartum
Describe two benefits of using copper IUD as emergency contraception
- effective up to 5 days following unprotected intercourse
- effect not modified by BMI
A 49 year old patient presents to your office. She had her Mirena placed at age 45 after the delivery of her last child. She has been amenorrheic on it and is wondering when it should be removed
- can remove at its expiration date, no indication or compelling reason to remove prior to this
how long following a medication abortion can you insert a nexplanon
A patient presents to triage with fever, hypotension, foul-smelling discharge. LMP 13 weeks ago. on US you see missed abortion measuring 10 weeks. She desires LARC following her D&E, what is a good option for her?
Implant! IUD contraindicated following septic abortion