Straight to the Point; Talking IUC - Your LifeStraight to the Point; Talking IUC Step-by-step guidance to addressing concerns with intrauterine contraception The Global INTRA Group

Straight to the Point; Talking IUCStep-by-step guidance to addressing concerns with intrauterine contraception

The Global INTRA Group is an independent panel of physicians with an expert interest in intrauterine contraception. Formation of the group and its ongoing work is supported and funded by Bayer AG.

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The INTRA group

INTRA group: Intrauterine coNtraception: Translating Research into Action

– A panel of independent physicians with expert interest in intrauterine contraception

– Purpose: To encourage more widespread use of intrauterine contraception (IUC) methods in a broad range of women through medical education

Formation of the INTRA group and its ongoing work is supported and funded by Bayer AG

Group members

Professor Carolina Vieira

Brazil

Professor Kai BühlingGermany

Dr Brian HauckCanada

Dr Josefina LiraMexico

Dr Pamela LotkeUSA

Dr Tina Peers UK

Professor Nikki ZiteUSA

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Difficult placement BleedingNo threads visible

Pain PerforationInfection

Introduction Despite the availability of an extensive range of contraceptive options, a high

number of pregnancies are unplanned1

Intrauterine contraception (IUC) is a highly effective method of contraception2,3

Regardless of parity, in 95% of women IUC can be placed easily and successfully,4-7 and the risk of complications is low7,8

However, concerns around placement and potential complications prevent some HCPs from recommending IUC9

The INTRA group provides step-by-step guidance to successfully manage these concerns, should they occur

This guidance is based on the best evidence available and good practice recommendations (where no evidence exists)

For help in addressing your particular concern, click on the appropriate icon

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Disclaimer: Please note that these statements and practical recommendations are based on the best evidence available and INTRA good practice recommendations (where no evidence exists)

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Perforation at time of placement (with sound)

• Stop the procedure• Monitor vital signs (blood pressure

and pulse rate) and level of discomfort until stable

• Offer new IUC placement with ultrasound guidance in 4 weeks10 (if patient still motivated to use IUC)

Ultrasound guidance• Confirm uterus position• Ensure no creation of

false passage• Can improve success and

placement accuracy11

Pain management• Consider local anaesthesia10,12,13

• For post-placement pain go to

Mechanical help• Adequate traction with tenaculum• Repositioning of tenaculum (to get round

‘kinks’ or ‘lip’ in cervical canal)• Use of dilators (small 5mm Denniston; Hegar

Cervical Dilators; Os finder or cytobrush)12,14

• Consider misoprostol prior to IUC placement (200 mcg 10 and 4 hours prior)14,15

IUC placement unsuccessful• For example, due to severe pain

• Counsel and reassure patient for another attempt at placement

• Discuss other methods of contraception until IUC placement10

Difficult placement

Pain

Additional information: • The recommendations included on this page should only be

considered for difficult placements. In the vast majority of women, IUC is placed with ease, regardless of age or parity4-6

References

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Perforation at time of placement (with sound)

• Stop the procedure• Monitor vital signs (blood pressure

and pulse rate) and level of discomfort until stable

• Offer new IUC placement with ultrasound guidance in 4 weeks10 (if patient still motivated to use IUC)

Ultrasound guidance• Confirm uterus position• Ensure no creation of

false passage• Can improve success and

placement accuracy11

Pain management• Consider local anaesthesia10,12,13

• For post-placement pain go to

Mechanical help• Adequate traction with tenaculum• Repositioning of tenaculum (to get round

‘kinks’ or ‘lip’ in cervical canal)• Use of dilators (small 5mm Denniston; Hegar

Cervical Dilators; Os finder or cytobrush)12,14

• Consider misoprostol prior to IUC placement (200 mcg 10 and 4 hours prior)14,15

IUC placement unsuccessful• For example, due to severe pain

• Counsel and reassure patient for another attempt at placement

• Discuss other methods of contraception until IUC placement10

Difficult placement

Pain

Additional information: • The recommendations included on this page should only be

considered for difficult placements. In the vast majority of women, IUC is placed with ease, regardless of age or parity4-6

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Additional information

In the vast majority of women, IUC is inserted with ease, regardless of parity4-6

Reference Countries Sample size Type of IUC

% of successful IUC placements

% of IUC placements rated as ‘easy’

Marions L, et al. 20114

Sweden 224 nulliparous women

LNG-IUS 20 97.4% 72%

Gemzell-Danielsson K, et al. 201216

Thirty-seven centres in Finland, Sweden, Norway, Hungary and UK

738 parous and nulliparous women

LNG-IUS 20LNG-IUS 12LNG-IUS 16

99.5% 94.0% (LNG-IUS12/ LNG-IUS16)

86.2% (LNG-IUS 20)

Harvey C, et al. 201217

Australia and New Zealand

996 parous and nulliparous women

Cu-IUD 95% 90%

Bahamondes MV, et al. 20116

Brazil 159 nulliparous women

LNG-IUS 20 99.4% 81%

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References

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• Perform a speculum examination• Use a cytobrush to retrieve threads

Able to confirm IUC – threads located with cytobrush

Unable to confirm IUC – threads not located with cytobrush

Provide reassurance

Positive pregnancy test

Malpositioned IUC

Negative pregnancy test

Position at the fundus

Unable to confirm IUC with ultrasound

Check for pregnancy

No immediate access to

ultrasound

Routine careImmediate access to ultrasound

Able to confirm presence and positioning of IUC with

ultrasound

IUC visualised (pelvis or abdomen)

Recommend surgical management

IUC not visualised

Assume expulsion

Provide contraceptive counselling

• Schedule ultrasound• Counsel on other contraceptive

options and consider emergency contraception if indicated

• Abdominal/pelvic X-ray (or schedule if asymptomatic)

• Counsel on other contraceptive options and consider emergency contraception if indicated

Counselling points:

• IUC removal may be requested by the patient at any time

• If patient requests IUC removal, a cytobrush or IUS hook may be used

• Counsel on other contraceptive options

No threads visible

References

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Counselling points:

• IUC removal may be requested at any time• If patient requests IUC removal: use

cytobrush, palpation, IUS hook and packing forceps


No threads visible

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• Perform a speculum examination• Use a cytobrush to retrieve threads

• Able to confirm IUC – threads located with cytobrush

• Unable to confirm IUC – threads not located with cytobrush

• Provide reassurance


Nonfundal location


Position at the fundus

Unable to confirm IUC with ultrasound

Check for pregnancy

No immediate access to

ultrasound

Routine care

Immediate access to ultrasoundAble to confirm presence and positioning of IUC with

ultrasound

IUC visualised (pelvis or abdomen)

Recommend surgical management

IUC not visualised

Assume expulsion

Provide contraceptive counselling

• Schedule ultrasound• Counsel on other contraceptive

options and consider emergency contraception if indicated

• Abdominal/pelvic X-ray (or schedule if asymptomatic)

• Counsel on other contraceptive options and consider emergency contraception if indicated


Additional informationCLOSE

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Using a cytobrush A cytobrush can be used during difficult placement to retrieve threads

When IUC threads are noted to be missing, the first step in management is the use of a cervical cytology brush to sweep the threads from the endocervix

This procedure alone is frequently effective and can be performed regardless of pregnancy status and whether the patient wishes to continue with the IUC or not

In addition, a colposcope and/or endocervical speculum may be used to improve visualisation of IUC threads in the cervical canal

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Obtain ultrasound

Able to confirm intrauterine pregnancy

Able to confirm position of IUC in uterus

Counsel on pregnancy options

Continue pregnancy

Remove IUC if threads

visible

If patient declines removal, counsel on possible adverse

outcomes such as miscarriage and pre-term birth

Termination of pregnancy (TOP)

Intrauterine pregnancy confirmed

Remove IUC at time of TOP

• Evaluate the possibility of ectopic pregnancy • Manage according to local guidelines

Unable to confirm intrauterine pregnancy


Pregnancy of unknown

location suspected

Ectopic pregnancy confirmed

Refer to local guidelines

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CLOSENonfundal location of IUC

(identified or confirmed using ultrasound)

• Detailed counselling: expectant management vs removal19

• Retention of low-lying IUC is associated with lower pregnancy rates than removal20

Asymptomatic

• Partial expulsion; remove IUC19


Symptomatic (pain and/or abnormal discharge or bleeding or dyspareunia)

• Detailed counselling: expectant management vs removal19

• Retention of low-lying IUC is associated with lower pregnancy rates than removal20

• Remove IUC if symptoms remain troublesome and/or persist beyond 3 months and counsel on other contraceptive options

• Partial expulsion; remove IUC19



IUC stem above internal os19

IUC stem below internal os: IUC within cervical canal19

IUC stem below internal os: IUC within cervical canal19

IUC stem above internal os19

Counselling points:

• If patient desires IUC replacement, consider use of ultrasound

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Additional information: • Over 90% of low lying IUCs can move

upwards within 60-90 days of placement. Endometrial changes during menstrual cycle are a factor18,21,22

References

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• Less than 3-6 months after IUC placement and symptoms* absent10,24,27

• Reassure about bleeding patterns10,24

• Offer options to manage bleeding if bothersome:

– Nonsteroidal anti-inflammatories (NSAIDs) can be considered with LNG-IUS and Cu-IUD24,27-30

– Combined oral contraceptives (COC) can be considered with LNG-IUS24 **

– Tranexamic acid (500 mg) can be considered with Cu-IUD (N.B. studies show lack of efficacy with LNG-IUS)27,29-31

If bleeding continues to be bothersome:• Counsel on other contraceptive options• Remove IUC if requested

• Less than 3-6 months after IUC placement and symptoms* present10,23,24,27 OR

• More than 3-6 months after IUC placement with persistent bleeding or failed medication treatment or new symptom or bleeding pattern10,24,27

• Pregnancy test • Gynaecological examination

Treat accordingly

Nonfundal location


Gynaecological examination normal

Ultrasound

Normal ultrasound Abnormal ultrasound

Gynaecological examination abnormal (e.g. infection, cervical lesion)

BleedingFrequent and/or prolonged and/or heavy



*Symptoms: pelvic pain, dyspareunia, abnormal vaginal discharge, heavy bleeding, postcoital bleeding10,11,24,27

**Please note, this statement reflects current clinical practice which includes off-label use.

Counselling point:

• Before placement, counsel on the expected bleeding pattern associated with IUC use10,23-26

References

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Post-insertion (same day) Post-insertion (>1 day)

Mild pain Moderate/severe pain No apparent cause Infection

Check position of IUC with ultrasound

Nonfundal location

• Reassure• Offer symptomatic

relief/analgesia• Follow-up

Please see INTRA Hints and Tips slide set at

www.your-life.com/HCP

Gynaecological examination Gynaecological examination

Pain

No apparent cause

Perforation

Threads visible

Pregnancy test


Ultrasound

PerforationNonfundal

locationNo apparent

cause

• Reassure• Start NSAIDs/heat• Follow-up

Uterine abnormalities

Treat accordingly

No threads visible



https://www.your-life.com/HCP/

References

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Insertion day Later >1 day

Mild pain Moderate/severe pain No apparent cause Infection

Check position of IUC with ultrasound

Nonfundal location

• Reassure• Offer symptomatic

relief/analgesia• Follow-up

Please see INTRA Hints and Tips slide set

Gynecological exam Gynecological exam

Pain

No apparent cause

Perforation

Threads visible

Pregnancy test


Ultrasound

PerforationNonfundal

locationNo apparent

cause

• Reassure• Start NSAIDs/heat• Follow-up

Uterine abnormalities

• Treat accordingly

No threads visible



For the vast majority of women, pain with IUC placement is mild to moderate, regardless of parity32-34

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Reference Countries Sample (characteristic and size)

Type of IUC Pain at IUC insertion


36 European countries

304 nulliparous and parous adolescents

LNG-IUS 8µg/day

20.5% none, 34.3% mild, 34.3% moderate and 10.9% severe

Hall AM & Kutler BA. 201633

US 109 nulliparous women

88 LNG-IUS 20µg/day and 21 Cu-IUD (T380A)

23% mild pain; 35% moderate pain and 42% severe pain

Hubacher D et al, 200634

Chile 2019 nulliparous and parous women (randomised: 1008 to placebo and 1008 to ibuprofen group)

Cu-IUD (T380A) Placebo group – 81.8% none or mild, 13.4% moderate and 4.9% severe

Ibuprofen group – 84.7% none or mild, 12.6% moderate and 4.0% severe


References

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Infection

Asymptomatic

Reassure

Symptomatic

Swab positive for • Chlamydia trachomatis• Neisseria gonorrhoeae

Swab negative • No clinical features of

pelvic inflammatory disease (PID)

Follow your local antibiotic policy

• IUC removal is not routinely required nor recommended in PID10,19,35

• Removal should be considered if there is no response to treatment (after 48 – 72 hours)10,19,35

• If a woman requires IUC removal, it should be done after antibiotics have been initiated to prevent bacterial spread19,35

Swab positive• No features of PID

Clinical features of PID:35

• Pelvic or abdominal pain plus at least one of the following:

– cervical motion tenderness or

– uterine tenderness or – adnexal tenderness

References

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Infection

Asymptomatic

Reassure

Symptomatic

Swab positive for • Chlamydia trachomatis• Neisseria gonorrhoeae

Swab negative • No clinical features of

pelvic inflammatory disease (PID)

Follow your local antibiotic policy

• IUC removal is not routinely required nor recommended in PID10,20,36

• Removal should be considered if there is no response to treatment (after 48 – 72 hours)10,20,36

• If a woman requires IUC removal, it should be done after antibiotics have been initiated to prevent bacterial spread20,36

Swab positive• No features of PID

Clinical features of PID:36

• Pelvic or abdominal pain plus at least one of the following:

– cervical motion tenderness or

– uterine tenderness or – adnexal tenderness• Fever (>38oC) in

moderate to severe disease

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Studies involving women of various ages, parity and risk of sexually transmitted infection (STI) show that the risk of pelvic inflammatory disease (PID) with IUC use is low (<1%)7,36,37

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Reference Countries Sample (characteristic and size)

Type of IUC

Incidence of PID (%)

Sufrin CB, et al. 201236 USA 57,728 women, aged 14 to 49 years

LNG-IUS 0.54

Birgisson NE, et al. 201537

USA (CHOICE Study population)

7,611 women, aged 14 to 45 years, interested in reversible contraception

Cu-IUD LNG-IUS

0.46


Argentina, Canada, Chile, Finland, France, Hungary, Mexico, Netherlands, Norway, Sweden and USA

2,884 women, aged 18 to 35 years, requesting contraception and considered suitable for IUC insertion

LNG-IUS 8 LNG-IUS 13

0.42

References

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Suspected perforation

Perforation with the sound

Unable to confirm positionAble to confirm positionMonitor vital signs (blood pressure and pulse rate) and level of discomfort

until stable10

• Offer new IUC placement after 4 weeks (if patient still motivated to use IUC)10

• Discuss alternative contraceptive method until IUC placement10

• Consider ultrasound guidance for placement of another IUC11

• Consider expulsion• Consider diagnostic hysteroscopy

or laparoscopy to confirm expulsion

• Consider laparoscopic or hysteroscopic removal10,18,19,38

• If patient is still motivated to use IUC: – Consider placement during removal under direct laparoscopic

guidance19

– Or offer new IUC placement after 4 weeks10: Discuss alternative contraceptive method until IUC placement10

Consider ultrasound guidance for placement11

Threads visible:• Remove immediatelyNo IUC

placement attempt

Threads not visible:• Confirm position with pelvic ultrasound

or abdominal/pelvic X-ray10,19,23

Perforation with the IUC

Counselling point:

• Counsel regarding other contraceptive options• Provide guidance about interim

contraception options whilst awaiting confirmation of IUC position10

References

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Suspected perforation

Perforation with the sound

Unable to confirm positionAble to confirm positionMonitor vital signs (blood pressure and pulse rate) and level of discomfort

until stable10

• Offer new IUC placement after 4 weeks (if patient still motivated to use IUC)10

• Discuss alternative contraceptive method until IUC placement10

• Consider ultrasound guidance for placement of another IUC11

• Consider expulsion• Consider diagnostic hysteroscopy

or laparoscopy to confirm expulsion

• Consider laparoscopic or hysteroscopic removal10,18,19,38

• If patient is still motivated to use IUC: – Consider placement during removal under direct laparoscopic

guidance19

– Or offer new IUC placement after 4 weeks10: Discuss alternative contraceptive method until IUC placement10

Consider ultrasound guidance for placement11

Threads visible:• Remove immediatelyNo IUC

placement attempt

Threads not visible:• Confirm position with pelvic ultrasound

or abdominal/pelvic X-ray10,19,23

Perforation with the IUC

Counselling point:

• Counsel regarding other contraceptive options• Provide guidance about interim

contraception options whilst awaiting confirmation of IUC position10

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None of the perforations resulted in serious sequelae, such as bowel or bladder injury, septicemia or peritonitis8


The EURAS-IUD study shows a low risk of uterine perforation with IUC within the total patient population, incidence of perforation was ~~1/1,000 placements8

Breastfeeding and time since last delivery are independent risk factors for uterine perforation, irrespective of type of IUC placed8

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Uterine perforation incidence per 1000 placements for the entire study cohort (parous women, n=60,213)1

Breastfeeding status

Time since last delivery Yes No Relative risk (95% CI)

≤36 weeks 5.6 (3.9–7.9) 1.7 (0.8–3.1) 3.3 (1.6–6.7)

>36 weeks 1.6 (0.0–9.1) 0.7 (0.5–1.1) 2.2 (0.3–16.3)

Relative risk (95% CI) 3.4 (0.5–24.8) 2.3 (1.1–4.7)

*Relative risk in 2017 re-analysis (95% Cl)2 2.9 (0.4-21.4) 1.9 (0.8-4.8)

* A re-analysis, looking only at complete perforations, found slightly reduced risk estimates2

References

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References1. Sedgh G, et al. Intended and unintended pregnancies worldwide in 2012 and recent trends. Stud Fam Plann 2014;45(3):301–14. 2. Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397−404.3. Heinemann K, et al. Comparative contraceptive effectiveness of levonorgestrel-releasing and copper intrauterine devices: the European Active

Surveillance Study for Intrauterine Devices. Contraception 2015;91:280–283.4. Marions L, et al. Use of the levonorgestrel releasing-intrauterine system in nulliparous women – a non-interventional study in Sweden. Eur J

Contracep Reprod Health Care 2011;16:126–34.5. Suhonen S, et al. Clinical performance of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: a

comparative study. Contraception 2004;69:407–412.6. Bahamondes MV, et al. Ease of insertion and clinical performance of the levonorgestrel-releasing intrauterine system in nulligravidas.

Contraception 2011;84:e11–16.7. Gemzell-Danielsson K, et al. The effect of age, parity and body mass index on the efficacy, safety, placement and user satisfaction

associated with two low-dose levonorgestrel intrauterine contraceptive systems; subgroup analysis of data from a phase III trial. PLoS ONE 2015;10(9):e0135309.

8. Heinemann K, et al. Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the European Active Surveillance Study on Intrauterine Devices. Contraception 2015;91(4):274–9.

9. Black K, et al. A review of barriers and myths preventing the more widespread use of intrauterine contraception in nulliparous women. Eur J Contracept Reprod Health Care 2012;17:340–350.

10. Faculty of Sexual & Reproductive Healthcare. Intrauterine Contraception. FSRH, 2015. London. Available at: https://www.fsrh.org/standards-and-guidance/documents/ceuguidanceintrauterinecontraception/ Last accessed: October 2017

11. Elsedeek MS. Comparison between the traditional non-guided and a novel ultrasound-guided technique for office fitting of intrauterine contraceptive devices. Int J Gynaecol Obstet 2016;133(3):338-41.

12. Dermish A, et al. Evaluation of an intervention designed to improve the management of difficult IUD insertions by advanced practice clinicians. Contraception 2016;93(6):533–8.

13. Lopez LM, et al. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Ver 2015;(7):CD007373.14. Zapata LB, et al. Medications to ease intrauterine device insertion: a systematic review. Contraception 2016; 94(6):739–759.15. Bahamondes MV, et al. Effect of vaginal administration of misoprostol before intrauterine contraceptive insertion following previous insertion

failure: a double blind RCT. Hum Reprod 2015;30(8):1861–6.16. Gemzell-Danielsson K, et al. A randomized, phase II study describing the efficacy, bleeding profile, and safety of two low-dose levonorgestrel-

releasing intrauterine contraceptive systems and Mirena. Fertil Steril 2012;97:616–22.17. Harvey C, et al. Ease of intrauterine contraceptive device insertion in family planning settings. Aust NZ J Obstet Gynaecol 2012;52(6):534–9.18. Golightly E & Gebbie AE. Low-lying or malpositioned intrauterine devices and systems. J Fam Plann Reprod Health Care 2014;40(2):108–12.19. ACOG. Committee Opinion No 672: Clinical Challenges of Long-Acting Reversible Contraceptive Methods. Obstet Gynecol

2016;128(3):e69–77.

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References

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20. Braaten KP, et al. Malpositioned intrauterine contraceptive devices: risk factors, outcomes, and future pregnancies. Obstet Gynecol 2011;118:1014–20.

21. Faundes D, et al. T-shaped IUDs accommodate in their position during the first 3 months after insertion. Contraception 2000;62:165–8. 22. Morales-Rosello J. Spontaneous upward movement of lowly placed T-shaped IUDs. Contraception 2005;72:430–1. 23. Black A, et al. Canadian Contraception Consensus (Part 3 of 4): Chapter 7 – Intrauterine Contraception. J Obstet Gynaecol Can 2016;38(2):182–

222.24. Faculty of Sexual & Reproductive Healthcare. Problematic Bleeding with Hormonal Contraception. FSRH, 2015. London. Available at: https://

www.fsrh.org/standards-and-guidance/documents/ceuguidanceproblematicbleedinghormonalcontraception/ Last accessed: October 201725. Modesto W, et al. A randomized clinical trial of the effect of intensive versus non-intensive counselling on discontinuation rates due to bleeding

disturbances of three long-acting reversible contraceptives. Hum Reprod 2014;29(7):1393–9.26. Diedrich JT, et al. Association of short-term bleeding and cramping patterns with long-acting reversible contraceptive method satisfaction. Am J

Obstet Gynecol 2015 Jan;212(1):50.e1-8.27. World Health Organization. Selected practice recommendations for contraceptive use – 3rd ed. WHO Document Production Services, 2016,

Geneva, Switzerland. Available at: http://www.who.int/reproductivehealth/publications/family_planning/SPR-3/en/ Last accessed: October 201728. Madden T, et al. Naproxen or estradiol for bleeding and spotting with the levonorgestrel intrauterine system: a randomized controlled trial. Am

J Obstet Gynecol 2012;206(2):129.e1–8.29. Godfrey EM, et al. Treatment of bleeding irregularities in women with copper-containing IUDs: a systematic review. Contraception

2013;87(5):549–66.30. Friedlander E, Kaneshiro B. Therapeutic Options for Unscheduled Bleeding Associated with Long-Acting Reversible Contraception. Obstet

Gynecol Clin North Am 2015;42(4):593–603.31. Sordal T, et al. Management of initial bleeding or spotting after levonorgestrel-releasing intrauterine system placement: a randomized controlled

trial. Obstet Gynecol 2013;121:934–41.32. Gemzell-Danielsson K, et al. A Phase III, single-arm study of LNG-IUS 8, a low-dose levonorgestrel intrauterine contraceptive system (total

content 13.5 mg) in postmenarcheal adolescents. Contraception 2016 Feb 9. pii: S0010-7824(16)00036–6.33. Hall AM & Kutler BA. Intrauterine contraception in nulliparous women: a prospective survey. J Fam Plann Reprod Health Care 2016;42(1):36-42.34. Hubacher D, et al. Pain from copper intrauterine device insertion: randomized trial of prophylactic ibuprofen. Am J Obstet Gynecol

2006;195(5):1272–7.35. Centers for Disease Control and Prevention 2015 STD Treatment Guidelines. Pelvic Inflammatory Disease. Available at: http://www.cdc.gov/std/

tg2015/pid.htm Last accessed: 12th April 2016.36. Sufrin CB, et al. Neisseria gonorrhea and Chlamydia trachomatis screening at intrauterine device insertion and pelvic inflammatory disease.

Obstet Gynecol 2012;120(6):1314–21.37. Birgisson NE. et al. Positive Testing for Neisseria gonorrhea and Chlamydia trachomatis and the Risk of Pelvic Inflammatory Disease in IUD Users.

J Womens Health (Larchmt) 2015;24(5):354–9. 38. Kaislasuo J, et al. Uterine perforation caused by intrauterine devices: clinical course and treatment.

Hum Reprod 2013;28(6):1546–51.

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Documents

Straight to the Point; Talking IUC - Your LifeStraight to the Point; Talking IUC Step-by-step guidance to addressing concerns with intrauterine contraception The Global INTRA Group