Answering patients' questions on intrauterine contraception

Questions that GPs may need to answer from women considering having an IUS or IUD fitted, including the risks and benefits of intrauterine contraception, contraindications and the risk of ectopic pregnancy.

This article presents some of the questions that GPs are likely to encounter from patients considering using an IUD or IUS, and provides information that will enable GPs to field these questions successfully. Questions cover the effectiveness of the coil, its suitability for women in different circumstances, the process of coil fitting and what women can expect afterwards.

'I’m thinking about having a coil fitted, would it be a good contraception method for me?'

Increasing the uptake of copper coils (IUDs) and the progestogen-only IUS (Mirena, Jaydess), like other long-acting reversible contraception (LARC) methods including subdermal implants and injectable contraceptives, will reduce unintended pregnancies.

Fewer than 2 in 100 women over 5 years will have a pregnancy with a copper IUD (this figure is fewer than 1 in 100 women over 5 years for the IUS).1 IUDs, the IUS and implants are more cost effective than the injectable contraceptives.2 An IUD is a good choice of contraception for all women, especially if they have had children.

All LARC methods are suitable for nulliparous women, women who are breast feeding, women who have had termination of pregnancy (at the time of termination or later), women with BMI >30kg/m2, women with diabetes, women with contraindications to oestrogens, and women with migraine with or without aura.

'I’m 36 and I think I’m too old for the pill, should I have a coil instead?'

It is important for women to use effective contraception to prevent an unplanned pregnancy until after the menopause. When prescribing oral contraception, the clinician should be guided by UKMEC.3

Unless there is a medical contraindication to pill use such as cerebrovascular accident, VTE, migraine, obesity, or smoking, the combined pill can be used up until the age of 50 and the POP until 55 years.4,5 Women who are 35 and over and who smoke should be changed from the combined pill to a different method as the risks of using the combined hormonal method outweigh the benefits at this stage.

LARC methods such as IUD, IUS or implants, on the other hand, are more reliable than pills, because they do not need any day to day action and can last for several years. The IUD is a non-hormonal option and can last for 5 to 10 years. The IUS lasts for 5 years. Women should be advised that LARC methods can be as effective as sterilisation, and can be an alternative for women who do not want to be sterilised.2

'I’ve had unprotected intercourse. Can I have a coil fitted to prevent me becoming pregnant?'

Copper coils are a first line option for emergency contraception due to their lower failure rate as compared to emergency hormonal contraception. A copper coil can be inserted within 5 days of first episode of unprotected sexual intercourse or in case of multiple episodes, within 5 days of expected date of ovulation (that is, up to day 19 of a 28 day cycle). The hormonal IUS is contraindicated for EC use as it takes 7 days to become effective.

'What is the difference between the copper coil and Mirena?'

Copper-bearing IUDs work by blocking of fertilisation, copper being directly toxic to the sperm and also by blocking implantation as a back-up effect. Some women prefer this method as they do not wish to use any hormones.

The hormone-releasing IUS (Mirena, Jaydess) releases progesterone, which impairs the sperm penetrability of the cervical fluid, sometimes stops ovulation and has an anti-implantation effect. The added advantage is reducing periods and therefore the IUS can be an excellent choice for women with heavy, painful periods.1 It also offers endometrial protection and is therefore also licensed as part of HRT in older women.4

'I’ve got a new partner, can I have a coil fitted in spite of having an STI in the past?'

A careful sexual history will identify women at risk of an STI. Risk factors for STIs include unprotected sex, age under 25, multiple sexual partners, a new partner within last 3 months, past history of STIs, and use of drugs and alcohol. STI screening should be offered routinely to all women who are identified to be at risk of STI and asking for intrauterine contraception. Self- taken vulvo-vaginal swabs are the best option which can be tested for both chlamydia and gonorrhoea. If an STI is suspected, complete the treatment for the infection before inserting the IUD.

'I’ve had cancer, can I have the coil?'

There are few absolute contraindications to IUDs and the IUS, and these include undiagnosed vaginal bleeding, possible pregnancy, and hormone-dependent cancers in IUS users. Current and past history of breast cancer or endometrial cancer will need discussion with the cancer specialist.

'Do I have to be on my period to have my coil fitted?'

No, provided it is reasonably certain that the woman is not pregnant or at risk of pregnancy. Extra precautions will be required for 7 days after having an IUS fitted, whereas the IUD will be effective immediately post-insertion.

'Will it hurt having a coil fitted?'

Women are often deterred from using the coil because of fear of pain. Coil fitting is an uncomfortable procedure, but it does not require local cervical block. The risk factors for pain are nulliparity, no history of vaginal delivery, anxiety and lack of periods for some time. The insertion procedure can be made more comfortable by prior use of NSAIDs, topical lidocaine agents and misoprostol for cervical ripening. Good counselling and use of `vocal local’ is helpful in most cases.

'When is the best time to have the coil fitted after giving birth?'

Following childbirth, the risk of pregnancy starts from day 21, therefore it is recommended to use contraception from this time onwards. Coils can be inserted any time after four weeks following a vaginal or caesarean birth, although waiting until six weeks is recommended to lower the risk of expulsion.

'What is the risk of ectopic pregnancy with the coil?'

IUS and IUDs reduce the absolute risk of ectopic pregnancy when compared to using no contraception because they are such effective methods of contraception. However, if a pregnancy occurs with an IUD/IUS in situ,the relative risk of ectopic pregnancy is increased.

NICE recommends that IUD/IUS users should be informed that the overall risk of ectopic pregnancy is very low, at about 1 in 1000 at 5 years.2 The EURAS-IUD study reported an ectopic pregnancy rate for IUS of 0.02 per 100 woman-years and for the copper IUD a rate of 0.08 per 100 woman years.6

'Will I have regular periods with the IUS?'

Periods tend to change with the IUS. They can be frequent or longer post insertion for up to 3 to 6 months before they settle to a very acceptable light monthly period. In about 20 per cent of women periods may stop altogether, which is not harmful.1

'What are the chances that the coil might come out again?'

It has been estimated that expulsion of intrauterine contraception occurs in approximately 1 in 20 women, is most common in the first 3 months after insertion and often occurs during menstruation. There is some evidence to suggest that a past history of IUC expulsion increases the risk of future/subsequent expulsion.

'How soon will I become fertile again if I have my coil removed?'

There is no evidence that the IUD or IUS cause any delay in fertility after removal.

Case scenario

A perimenopausal patient aged 48 years who still needs contraception is asking for a coil. She does not like taking pills. She is also worried that fitting will hurt. How do you advise her?

It is very important to counsel patients before fitting the coil. Pain during coil insertion is one of the biggest worries. Counselling the patient on what to expect and how the pain can be treated is very important.

In exceptional circumstances, one can use local anaesthetic. IUS is still a suitable method of contraception for perimenopausal women. Only a tiny amount of progestogen enters the circulation, so progestogenic side effects are minimal. It can be useful as a part of HRT but in that case it is licensed for 4 years only.

  • Dr Farzana Siddiqui is a consultant in contraception and sexual health , Oldham Integrated Care Centre
  • Dr Anita Sharma is a GP in Oldham; clinical director for vascular care, Oldham CCG and NICE QSAC GP member

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References

  1. Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Intrauterine contraception. FSRH, April 2015 [updated Oct 2015]
  2. NICE. Long-acting reversible contraception, CG30. NICE, Oct 2005 [updated Sept 2014]
  3. Faculty of Sexual and Reproductive Healthcare. UK MEC 2016.
  4. Faculty of Sexual and Reproductive Healthcare Clinical Effectiveness Unit. Contraception for women aged over 40 years. July 2010.
  5. www.fsrh.org/faqs/at-what-age-should-women-stop-oral-contraception
  6. Heinemann K, Reed S, Moehner S, Minh T. (2015) Contraception 91: 4, 280-3.

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