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Canadian Contraception Consensus (Part 3 of 4): Chapter 7 – Intrauterine Contraception

Published:February 24, 2016DOI:https://doi.org/10.1016/j.jogc.2015.12.002

      Abstract

      Objective

      To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.

      Outcomes

      Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada.

      Evidence

      Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

      Values

      The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

      Chapter 7: Intrauterine Contraception

      Summary Statements
      • 1.
        Intrauterine contraceptives are as effective as permanent contraception methods. (II-2)
      • 2.
        The use of levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg by patients taking tamoxifen is not associated with recurrence of breast cancer. (I)
      • 3.
        Intrauterine contraceptives have a number of noncontraceptive benefits. The levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg significantly decreases menstrual blood loss (I) and dysmenorrhea. (II-2) Both the copper intrauterine device and the LNG-IUS significantly decrease the risk of endometrial cancer. (II-2)
      • 4.
        The risk of uterine perforation decreases with inserter experience but is higher in postpartum and breastfeeding women. (II-2)
      • 5.
        The risk of pelvic inflammatory disease (PID) is increased slightly in the first month after intrauterine contraceptive (IUC) insertion, but the absolute risk is low. Exposure to sexually transmitted infections and not the IUC itself is responsible for PID occurring after the first month of use. (II-2)
      • 6.
        Nulliparity is not associated with an increased risk of intrauterine contraceptive expulsion. (II-2)
      • 7.
        Ectopic pregnancy with an intrauterine contraceptive (IUC) is rare, but when a pregnancy occurs with an IUC in situ, it is an ectopic pregnancy in 15% to 50% of the cases. (II-2)
      • 8.
        In women who conceive with an intrauterine contraceptive (IUC) in place, early IUC removal improves outcomes but does not entirely eliminate risks. (II-2)
      • 9.
        Intrauterine contraceptives do not increase the risk of infertility. (II-2)
      • 10.
        Immediate insertion of an intrauterine contraceptive (10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher continuation rate compared with insertion at 6 weeks postpartum. (I)
      • 11.
        Immediate insertion of an intrauterine contraceptive (IUC; 10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher risk of expulsion. (I) The benefit of inserting an IUC immediately postpartum or post-Caesarean section outweighs the disadvantages of increased risk of perforation and expulsion. (II-C)
      • 12.
        Insertion of an intrauterine contraceptive in breastfeeding women is associated with a higher risk of uterine perforation in the first postpartum year. (II-2)
      • 13.
        Immediate insertion of an intrauterine contraceptive (IUC) post-abortion significantly reduces the risk of repeat abortion (II-2) and increases IUC continuation rates at 6 months. (I)
      • 14.
        Antibiotic prophylaxis for intrauterine contraceptive insertion does not significantly reduce postinsertion pelvic infection. (I)
      Recommendations
      • 1.
        Health care professionals should be careful not to restrict access to intrauterine contraceptives (IUC) owing to theoretical or unproven risks. (III-A) Health care professionals should offer IUCs as a first-line method of contraception to both nulliparous and multiparous women. (II-2A)
      • 2.
        In women seeking intrauterine contraception (IUC) and presenting with heavy menstrual bleeding and/or dysmenorrhea, health care professionals should consider the use of the levonorgestrel intrauterine system 52 mg over other IUCs. (I-A)
      • 3.
        Patients with breast cancer taking tamoxifen may consider a levonorgestrel-releasing intrauterine system 52 mg after consultation with their oncologist. (I-A)
      • 4.
        Women requesting a levonorgestrel-releasing intrauterine system or a copper-intrauterine device should be counseled regarding changes in bleeding patterns, sexually transmitted infection risk, and duration of use. (III-A)
      • 5.
        A health care professional should be reasonably certain that the woman is not pregnant prior to inserting an intrauterine contraceptive at any time during the menstrual cycle. (III-A)
      • 6.
        Health care providers should consider inserting an intrauterine contraceptive immediately after an induced abortion rather than waiting for an interval insertion. (I-B)
      • 7.
        In women who conceive with an intrauterine contraceptive (IUC) in place, the diagnosis of ectopic pregnancy should be excluded as arly as possible. (II-2A) Once an ectopic pregnancy has been excluded, the IUC should be removed without an invasive procedure. The IUC may be removed at the time of a surgical termination. (II-2B)
      • 8.
        In the case of pelvic inflammatory disease, it is not necessary to remove the intrauterine contraceptive unless there is no clinical improvement after 48 to 72 hours of appropriate antibiotic treatment. (II-2B)
      • 9.
        Routine antibiotic prophylaxis for intrauterine contraceptive (IUC) insertion is not indicated. (I-B) Health care providers should perform sexually transmitted infection (STI) testing in women at high risk of STI at the time of IUC insertion. If the test is positive for chlamydia and/or gonorrhea, the woman should be appropriately treated postinsertion and the IUC can remain in situ. (II-2B)
      • 10.
        Unscheduled bleeding in intrauterine contraception users, when persistent or associated with pelvic pain, should be investigated to rule out infection, pregnancy, gynecological pathology, expulsion or malposition. (III-A)

      Key Words

      Abbreviations:

      BMD (bone mineral density), BMI (body mass index), CDC (Centers for Disease Control and Prevention), CHC (combined hormonal contraception), COC (combined oral contraceptives), Cu-IUD (copper intrauterine device), DMPA (depot medroxyprogesterone acetate), EC (emergency contraception), ENG (etonorgestrel), FSH (follicle-stimulating hormone), HIV (human immunodeficiency virus), HMB (heavy menstrual bleeding), IM (intramuscular), IUC (intrauterine contraceptives), IUD (intrauterine device), LARC (long-acting reversible contraceptive), LEEP (loop electrosurgical excision procedure), LNG (levonorgestrel), LNG-EC (LNG emergency contraception), LNG-IUS (levonorgestrel-releasing intrauterine system), NNRTI (nucleoside/nucleotide reverse transcriptase inhibitors), NSAIDs (non-steroidal anti-inflammatory drugs), PID (pelvic inflammatory disease), POP (progestin–only pills), RCT (randomized controlled trials), SARC (short-acting reversible contraceptive), STI (sexually transmitted infection), UPA-EC (ulipristal acetate-EC), UPI (unprotected intercourse), VTE (venous thromboembolic disease), WHO (The World Health Organization)
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