Guidelines 2016 – Intrauterine Contraceptive Devices
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION/MECHANISM OF ACTION
a. a sterile foreign body is placed in the uterus to prevent pregnancy. this is accomplished through several mechanisms:
1. a local sterile inflammatory response to the foreign body (i.e., iUd, iUCd) causes a change in the cellular makeup of the endometrium; with the copper devices, there is an effect on the endometrium of interfering with the enzyme systems, and with the progester- one device, there is an effect over time of a less well-developed endometrium.
2. a possible increase in the local production of prostaglandins that may increase endometrial activity
3. alteration in uterine and tubal transport
4. iUds (iUCds) probably exert an antifertility effect beyond the uterus and interfere with fertility before an ovum reaches the uterus.
5. alteration of cervical mucus, causing a barrier to sperm penetration (progesterone iUd)
6. possible ovulation suppression on the first year with levonorgestrel intrauterine system (lng iUs); Mirena releases 20 mcg/d of
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levonorgestrel, skyla releases 14 mcg/d levonorgestrel, and liletta releases 19 mcg/d of levonorgestrel
7. possible protective effect against endometrial cancer in obese women (treatment)
8. levonorgestrel-releasing iUd (iUCd) treatment for endometrial hyperplasia. some studies indicated it can protect the endome- trium in women with breast cancer treated with tamoxifen.
B. the exact mechanisms of action are not completely understood. one thing that has become clear is that the iUd (iUCd) does not act as an abortifacient.
C. different types of iUds (iUCds) use varying mechanisms of action to prevent pregnancy.
d. World health organization Category 3 (risks outweigh advantages for hiV-positive women)6: for hiV-positive women on antiretrovi- ral therapy, both copper-bearing and lng-releasing iUds can be used.
II. EFFECTIVENESS
a. theoretically: 92% to 99.9% effectiveness rate
B. User: 92% to 99% effectiveness rate. the range is close because the patient’s participation is low; therefore, there is little possibility of patient error.
III. CONTRAINDICATIONS
a. absolute contraindications
1. active pelvic infection (acute or subacute), including known or suspected gonorrhea or Chlamydia infection
2. Known or suspected pregnancy
3. recent or recurrent pelvic infection; postpartum endometritis; postabortion infection (past 3 months)
4. purulent cervicitis; untreated acute cervicitis or vaginitis
5. Undiagnosed genital bleeding
6. distorted uterine cavity (bicornuate; severely flexed)
7. history of ectopic pregnancy
8. allergy to copper (known or suspected) or diagnosed Wilson’s disease (paragard only); hypersensitivity to any part of Mirena, skyla, or liletta
9. abnormal pap smear, cervical or uterine malignancy, or prema- lignancy (endometrial hyperplasia, Cin, or cancer), unless used as therapy for endometrial hyperplasia
10. impaired responses to infection (diabetes, steroid treatment, immunocompromised patients)
11. presence of previously inserted iUd (iUCd)
12. genital actinomycosis
13. acute liver disease or liver tumor (Mirena/skyla/liletta)
14. Known or suspected breast cancer (Mirena/skyla/liletta)
15. Malignant gestational trophoblastic disease
16. Known pelvic tuberculosis
B. relative contraindications (benefits usually outweigh risks)
1. Multiple sexual partners or partner has multiple partners
2. emergency treatment difficult to obtain should complications occur; primarily a problem in very rural areas or developing countries
3. Cervical stenosis
4. impaired coagulation response (idiopathic thrombocytopenic purpura [itp], anticoagulant therapy, etc.)
5. Uterus sounding less than 6 cm or more than 10 cm
6. endometriosis
7. leiomyomata
8. endometrial polyps
9. severe dysmenorrhea (Mirena/skyla may be therapeutic)
10. heavy or prolonged menstrual bleeding without clinical anemia; consider oral iron or nutritional alterations to prevent with iUd (iUCd; Mirena/skyla may be therapeutic)
11. impaired ability to check for danger signals
12. inability to check for iUd (iUCd) string
13. Concerns for future fertility
14. history of pid (with subsequent intrauterine pregnancy, risk decreased)
IV. INSERTION TECHNIQUE
a. procedure
1. the woman is scheduled for appointment for insertion only dur- ing menses or within 7 days of onset of menses (Mirena/skyla) and after.
a. negative gonorrhea/Chlamydia testing
b. appropriate medical and menstrual history is obtained
2. patient should be instructed to eat before coming to an appointment
3. take oral analgesic or nonsteroidal anti-inflammatory 30 to 60 minutes before procedure
4. iUd (iUCd) consent form (see Appendix A) and minor surgical consent form must be reviewed and signed at the time of an iUd (iUCd) consultation and evaluation after discussion of
a. procedure
b. Mechanism of the device
c. side effects and complications
d. relationship to a woman’s needs
5. atropine 0.5 mg should be available at the time of insertion for severe vasovagal response
6. an anxious woman, or a woman for whom it is deemed necessary to perform a paracervical block and/or use intravenous atropine (to decrease likelihood of vasovagal reaction), should be referred to a gynecologist for insertion.
7. insertion under sterile technique
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a. perform bimanual examination to determine uterine position and size; insert warmed speculum
b. Cleanse the vagina, cervix, and endocervical canal with iodine solution (unless allergic to iodine).
c. Xylocaine gel or hurricane spray could be used to decrease discomfort of tenaculum.
d. Use tenaculum to straighten the uterine body and cervical canal
e. sound the uterus (depth less than 6 cm or more than 10 cm is a contraindication)
f. insert specific iUd (iUCd) as instructed by manufacturer
g. spasm of the internal cervical os may occur; it is usually relieved by simply waiting. never force entry of the sound or applicator.
h. after insertion, observe the patient for weakness, pallor, diaphoresis, either bradycardia or tachycardia, hypotension, and syncope, which may occur (check Bp several times follow- ing insertion).
i. if patient has mild cramping, the following may be used.
i. nonaspirin analgesic 650 mg every 4 hours, or
ii. a prostaglandin inhibitor (nonsteroidal anti-inflammatory drug [nsaid]) such as Motrin 400 mg orally four times a day
j. explain to patient that the iUd (iUCd) is effective immediately. in some settings, it is recommended that the patient abstain from intercourse for 1 day because of the disruption of the cer- vical mucus barrier.
k. instruct patient to check for presence of iUd (iUCd) string postmenstruation or after unusual cramping prior to relying on device for continued contraception effect.
l. follow up with appointment in 6 weeks to 3 months is recom- mended; at that time, be sure that the woman can feel the iUd (iUCd) strings.
V. COMPLICATIONS FOLLOWING INSERTION AND WHAT TO DO ABOUT THEM
a. immediate, severe vasovagal response
1. notify physician
2. place patient in shock position
3. Monitor pulse and Bp until stable
4. administer oxygen as needed
5. atropine 0.4 mg sc or im may be administered if appropriate
B. severe immediate cramping: remove iUd (iUCd)
C. excessive pain or bleeding is often a sign of perforation (fundal); con- sult physician for management
d. side effects or later complications
1. two or more missed periods: recommend a serum pregnancy test (e.g., paragard). With Mirena/liletta, irregular, little, or no bleeding is normal. Missed menses: 2 of 10 women have no men- ses after 1 year of Mirena; amenorrhea is less common with skyla.
pregnancy is rare, but when this happens, there is a 50% chance of miscarriage. if iUd (iUCd) is removed, this drops to 25%.
2. pregnancy occurring while iUd (iUCd) is in place: it is now rec- ommended that, because of the risk of infection, the iUd (iUCd) should be removed at the time of diagnosis whether the pregnancy is continued or terminated. there should be consultation with a gynecologist prior to removal of the iUd (iUCd) by the gynecolo- gist or nurse practitioner.
3. if breakthrough bleeding is related to iUd (iUCd), use the follow- ing guidelines for removal.
a. Bleeding is associated with endometritis.
b. the hematocrit falls 5 points.
c. there is a hematocrit of 30% to 32% or lower.
d. the iUd (iUCd) is partially expelled.
e. the patient wants the iUd (iUCd) removed.
4. Cramping and pelvic pain
a. rule out ectopic pregnancy
i. obtain a serum pregnancy test
ii. Consider ultrasound and surgical consult (physician consult)
b. pain or cramping caused by or associated with
i. partial expulsion of iUd (iUCd)
a) remove iUd (iUCd)
ii. pid (a long-standing, foul-smelling discharge in an iUd [iUCd] wearer presumed to be pid until proven otherwise)
a) no evidence suggests removal of iUd (iUCd) with treatment
b) treat infection per Centers for disease Control and prevention (CdC) guidelines
c) Consult a physician if no response to treatment
iii. spontaneous abortion
5. Migraine headache
a. first time or focal migraine with asymmetrical vision loss or other symptoms of transient cerebral ischemia, consult with a physician
6. expulsion
a. objective findings when the cervix is visualized
i. the iUd (iUCd) is seen at the cervical os or in the vagina.
ii. the iUd (iUCd) string is lengthened (partial expulsion).
iii. the iUd (iUCd) string is absent (complete expulsion).
iv. the iUd (iUCd) cannot be located using various methods of probing (consult physician).
v. the iUd (iUCd) is absent on ultrasound of abdomen.
b. removal and reinsertion of iUd (iUCd)
i. if partial expulsion occurs, iUd (iUCd) should be removed. iUd (iUCd) may be reinserted immediately if there is no infection or possibility of pregnancy, or with the next menses.
ii. if completely expelled, a new iUd (iUCd) may be reinserted as outlined previously.
7. lost iUd (iUCd) strings
a. referrals for locating iUd (iUCd) include
i. exploration of canal with gentle probing; if not found, then
ii. Ultrasound
iii. flat plate of abdomen, or
iv. hysterosalpingogram
8. difficulty in removing iUd (iUCd). the following techniques may help in the removal of iUd (iUCd):
a. remove only during menses
b. employ gentle, steady traction; remove iUd (iUCd) slowly. if iUd (iUCd) does not come out easily, physician consult is in order.
c. if iUd (iUCd) strings are not visible, nurse practitioner may probe for them in the cervical canal with narrow forceps.
9. Uterine perforation (fundal or cervical), embedding of the iUd (iUCd)
a. objective findings include
i. absence of iUd (iUCd) string
ii. inability to withdraw iUd (iUCd) if string is still present
iii. demonstration of displaced iUd (iUCd) by ultrasound, hysteroscopy, or x-ray
b. if perforation or embedding is suspected, referral to physician is in order
c. reinforcement of education that multiple partners increase the risk of infection, including hiV infection
VI. FOLLOW-UP
a. pelvic examination and pap smear per asCCp guidelines with removal and reinsertion as the particular iUd (iUCd) requires (Mirena: 5 years; skyla: 3 years; liletta: 3 years; paragard t 380a: 10 years)
B. as needed for any of previously mentioned complications with physi- cian consultation as necessary
Appendix A may be photocopied for your patients as an informational handout as well as a consent form for using an IUD (IUCD).
See Bibliographies.
Websites: www.paragard.com; www.mirena.com; www.asccp.org; www
.lilettahcp.com