• a reduction in the risk of unintended pregnancy in women who are not breastfeeding
• providing new mothers with a LARC method.
Myth #3: Antibiotics and NSAIDs should be administered
This myth arose from concerns about PID and insertion-related pain. However, a Cochrane Database review found no benefit for prophylactic use of antibiotics prior to insertion of the copper or LNG-IUS devices to prevent PID.8
In fact, data indicate that the incidence of PID is low among women who are appropriate candidates for an IUD. Similarly, Allen and colleagues found that nonsteroidal anti-inflammatory drugs (NSAIDs) did not ameliorate symptoms of cramping during or immediately after insertion of an IUD.9
Myth #4: IUD insertion is difficult
In reality, both the copper IUD and Mirena are easy to insert. In addition, the smaller LNG-IUS (Skyla) comes more completely preloaded in its inserter. In a published Phase 2 trial comparing Mirena with two smaller, lower-dose levonorgestrel-releasing devices, with the lowest-dose product corresponding to the marketed Skyla product, all 738 women given Mirena or the smaller devices experienced successful placement, with 98.5% of placements achieved on the first attempt.10
Various studies have been conducted to evaluate methods to ease insertion, including use of intracervical lidocaine, vaginal and/or oral administration of misoprostol (Cytotec), and vaginal estrogen creams. None was found to be effective in controlled trials. (See the sidebar, “Data-driven tactics for reducing pain on IUD insertion,” by Jennifer Gunter, MD, on page 28.) In the small percentage of women in whom it is difficult to pass a uterine sound through the external and internal os, cervical dilators may be beneficial. Gentle, progressive dilation can be accomplished easily with minimal discomfort to the patient, easing IUD insertion dramatically.
If a clinician does not insert IUDs on a frequent basis, it is prudent to look over the insertion procedure prior to the patient’s arrival. The procedure then can be reviewed with the patient as part of informed consent, which should be documented in the chart.
No steps in the recommended insertion procedure should be omitted, and charting should reflect each step:
1. Perform a bimanual exam
2. Document the appearance of the vagina and cervix
3. Use betadine or another cleansing solution on the cervical portio
4. Apply the tenaculum to the cervix (anterior lip if the uterus is anteverted, posterior lip if it is retroverted)
5. Sound the uterus to determine the optimal depth of IUD insertion. (The recommended uterine depth is 6 to 10 cm. A smaller uterus increases the likelihood of perforation, pain, and expulsion.)
6. Insert the IUD (and document the ease or difficulty of insertion)
7. Trim the string to an appropriate length
8. Assess the patient’s condition after insertion
9. Schedule a return visit in 4 weeks.
Related Article Let’s increase our use of IUDs and improve contraceptive effectiveness in this country Robert L. Barbieri, MD
Myth #5: Perforation is common
Uterine perforation occurs in approximately 1 in every 1,000 insertions.11 If perforation occurs with a copper IUD, remove the device to prevent the formation of intraperitoneal adhesions.12 The LNG-IUS devices do not produce this reaction, although most experts agree that they should be removed when a perforation occurs.13
Anecdotal evidence suggests that perforation may be more common among breastfeeding women, but this finding is far from definitive.
How to select an IUD for a patient: 3 case studies
CASE 1: Heavy bleeding and signs of endometriosis
Amelia, a 26-year-old nulliparous white woman, visits your office for routine examination and asks about her contraceptive options. She has no notable medical history. She has a body mass index (BMI) of 20.2 kg/m2 and exercises regularly. Menarche occurred at age 13. Her menstrual cycles are regular but are getting heavier; she now “soaks” a tampon every hour. She also complains that her cramps are more difficult to manage. She takes ibuprofen 600 mg every 6 hours during the days of heaviest bleeding and cramping, but that approach doesn’t seem to be effective lately. She is in a stable sexual relationship with her boyfriend of 2 years, now her fiancé. They have been using condoms consistently as contraception but don’t plan to start a family for a “few years.” Amelia reports that their sex life is good, although she has been experiencing pain with deep penetration for about 6 months.
Examination reveals a clear cervix and nontender uterus, although the uterus is retroverted. Palpation of the ovaries indicates that they are normal. Her main complaints: dysmenorrhea and heavy menstrual bleeding.
What contraceptive would you suggest?