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Long-acting reversible contraceptives in nulliparous women

Case report

Ms BD (aged 39 years para gravid, non-smoker, BMI 29. No meds, no allergies, PHx focal migraine) attended the clinic requesting contraception.

She complained of heavy monthly menstrual bleeds and was not keen on hormonal contraception, as she had had problems with mood changes and weight gain on the pill. We discussed all options available and although she had been keen on the copper IUCD, we discussed that it may make her periods heavier. She had had a normal transvaginal pelvic ultrasound with her GP within the past year.

She opted to try the Jaydess, as she was not happy with the idea of no periods with either the Mirena or the implant. She was given a prescription for the Jaydess, Cytotec to be inserted pv three hours before the procedure, and mefenamic acid 500mg to be taken PO one hour beforehand.

She returned for fitting during her menstrual bleed. She complained of momentary discomfort at the time of fitting and slight cramping for a day following the procedure. She had some spotting for a few weeks following the insertion but then reported light monthly bleeds thereafter.

Discussion

Many women nowadays delay starting a family until a later age due to career and lifestyle choices. They may therefore be sexually active for many years before their first pregnancy and require a safe, convenient, effective and reversible method of contraception.

Traditionally, the oral contraceptive pill would be the first choice for most nulliparous women and would be the method recommended as a first line by most doctors. However, for a lot of women, the pill can be problematic, with having to remember daily tablets.

Also there are many women for whom the combined oral contraceptive pill is contraindicated, for example, in those who get focal migraine, those with a family history of clotting disorders, etc. In those women, one of the long-acting reversible contraceptives (LARCs) would be a better option.

The UK NICE guidelines define LARCs as contraceptive methods that require administration less than once per cycle. LARCs available in Ireland include levonorgestrel (LNG) intrauterine systems (IUS) (Mirena and Jaydess), the intrauterine contraceptive device (IUCD), the subdermal implant (Implanon) and the progestogen-only injection (Depo-Provera).

For nulliparous women, LARCs are:

1. Highly effective.

2. There is no need for daily, weekly or even monthly administration (‘fit and forget’).

3. Rapidly reversible.

4. Cost effective.

5. Have potential non-contraceptive benefits (eg, reduced menstrual bleeding).

6. Can be inserted quickly in most women.

Intrauterine contraceptives

The Mirena and the Jaydess, when placed in the uterine cavity, provide a continuous release of LNG. The Mirena contains 52mg of LNG, which is released over five years, and the Jaydess contains 13.5mg of LNG and is licensed for three years as a contraceptive.

The Jaydess may be easier to fit in nulliparous women due to its size, but both can be used. The IUS is inserted up to day seven of the menstrual cycle but can be inserted up to any stage of the cycle if a pregnancy can be excluded.

Screening for STIs is recommended. An endocervical swab can be taken at the time of insertion to screen for chlamydia and gonorrhoea. Beneficial effects of the Mirena include reduced pain associated with primary dysmenorrhoea, endometriosis and adenomyosis. As the Mirena reduces menstrual blood loss, it can be used in the management of heavy menstrual bleeding (where a pathological cause has been excluded).

Most women experience amenorrhoea, although some still have regular light bleeds and some occasional irregular bleeds. The hormonal side-effects including acne, breast tenderness, and headaches are common in the first three months after insertion, but most often settle with time. If this is explained to the woman beforehand, she is more likely to persist with the Mirena.

The Jaydess is much lower in hormones so more women do still have a regular monthly bleed, although lighter than with their normal period. Some women would prefer to get regular monthly bleeds so may opt for the Jaydess over the Mirena for that reason. Also, the systemic side-effects are reduced in the Jaydess due to the lower amount of hormone released.

Although some women report weight gain with the IUS, there is no significant evidence to support a causal association.

There has not been shown to be any effect on bone mineral density or any link with breast cancer.

The rebate of perforation (two per 1,000 insertions), however, is approximately six times higher in breast-feeding women, so it is advisable to fit the IUS four months postnatally in lactating women.

The risk of expulsion is low and there is no increased risk of expulsion in nulliparous over multiparous. Some studies have shown a higher risk of expulsion in parous women than in nulliparous.

Pelvic inflammatory disease in women using the IUS is less than 1 per cent, which is the same as in women using the oral contraceptive pill.

IUCDs

IUCDs are non-hormonal and vary in size and shape, consisting of copper and plastic. Devices containing 380mm2 of copper are considered more effective than those containing 300mm2. The 380mm IUCDs are generally recommended for 10 years use, while those with 300mm for five years.

IUCDs with the longest duration of use are recommended, as they reduce the risk of infection, perforation and expulsion. Pregnancy rates are between 0.1 per cent and 1 per cent after the first year.

The copper IUCD can be used as emergency contraception if fitted within 120 hours of unprotected sex.

The use of the copper IUCD can be associated with heavier menstrual bleeding in some women. So in women with heavy periods, the IUS may be the preferred option.

The fitting times for the IUCD are the same as for the IUS.

Pregnancy rates are low with the IUCD and IUS but if a pregnancy occurs, an ectopic should be considered and screened for using pelvic ultrasound.

In all women attending for intrauterine contraception, discussion beforehand should include risks, side-effects, etc, of the procedure, and afterwards. Many doctors recommend an analgesic (eg, mefenamic acid 500mg) taken one hour before, and Cytotec (misoprostol 200mg) inserted high in the vagina three hours before the procedure.

Implant

The implant available in Ireland is the Implanon NXT. It is an extremely safe and reliable form of contraception, with a failure rate of less than one per 1,000 implants.

Implanon is a radiopaque progesterone-containing flexible rod, which is pre-loaded in a sterile applicator. Each rod contains 68mg of etonogestrel, which is released slowly over three years. The implant is inserted subdermally in the inner upper aspect of the non-dominant arm, approximately 8-10cm above the medial epicondyle of the humerus, using a local anaesthetic (lignocaine). It is inserted between day one and five of the menstrual bleed, without the need for further contraception following insertion.

There is no upper age limit for the use of the implant.

Undesirable side-effects may include menstrual changes, headaches and acne. Around 20 per cent of women develop amenorrhoea, while 20 per cent report frequent or prolonged menstrual bleeding. Bleeding problems are the most common reason for patients discontinuing the implant.

Prolonged bleeding can be managed in some women using the combined oral contraceptive (COC), providing it is not contraindicated. The COC can be given for three months, either cyclically or continuously, without a pill-free interval. For women in whom the COC is contraindicated, the progesterone-only pill can be used. Both practices are outside product license.

Although some women report weight gain and mood or libido changes, there is no evidence of a causal association. There is also no evidence of an adverse effect on bone mineral density with the use of the implant.

If a woman requires a second implant at the end of three years, a new one can be inserted following the removal of the first in the same incision. To avoid insertion into a thickened scar, the second implant should be inserted along a fresh track.

The contraceptive effect of the implant may be reduced by enzyme-inducing drugs, eg, anti-epileptic drugs or antibiotics, eg, rifampicin and antiretroviral therapy.

There is no restriction on the use of the implant in obese women (BMI >30).

Progestogen-only injectable

The progestogen-only injection (Depo-Provera) works mainly by inhibiting ovulation. It is considered a LARC but after discontinuation, there may be a delay of 12-to-18 months in the return of fertility, whereas with other LARCs it is immediately reversible.

Depo-Provera contains 150mg of medroxyprogesterone acetate (DMPA) in a pre-filled 1ml syringe and is administered at 12-week intervals intramuscularly into the gluteal muscle. The failure rate is approximately 0.2 per cent in the first year. The majority of DMPA users become amenorrhoeic with time. DMPA may be used to reduce pain associated with endometriosis. It is also a contraceptive option for women with sickle cell disease and may reduce the severity of sickle crisis pain.

DMPA may be associated with a small loss of bone mineral density, which is mainly reversed on discontinuation of the Depo. However, DEXA screening is recommended after two years of continued use. It is also not advisable in women under 18 years of age (who have not yet obtained peak bone mass) or in perimenopausal women where additional bone loss will occur, without consideration of other methods.

Side-effects include altered bleeding patterns (amenorrhoea, infrequent bleeding, spotting and prolonged bleeding) and are common, though may settle with time. Forty-seven per cent of women are amenorrhoeic at one year of use.

Use of DMPA can cause weight gain, especially in women under 18 years of age and in those with a BMI >30. Women who gain more than 5 per cent of their baseline weight in the first six months of use are likely to continue to gain weight. Other possible side-effects include acne, reduced libido, mood swings, depression, hot flushes and vaginitis.

The efficacy of DMPA is not reduced with concomitant use of enzyme-inducing drugs.

DMPA is given intramuscularly within the first five days of the menstrual cycle, without the need for additional contraception. Repeat injections should be given at 12-week intervals and not given later than 13 weeks.

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