Intrauterine Devices

(IUDs)

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Fakultas Kedokteran Unand
 IUDs Around the World
100 million users worldwide

Yusrawati
Source: Treiman et al 1995. Seminar sehari S1 Kebidanan
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Fakultas Kedokteran Unand
 Types of Medicated IUDs
Copper-releasing: Progestin-releasing:
 Copper T 380A  Progestasert
 Nova T  LevoNova (LNG-20)
 Multiload 375  Mirena

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 Copper IUDs: Mechanisms of Action

Interfere with
reproductive process
Interfere with ability before ova reach
of sperm to pass uterine cavity
through uterine
cavity
Change
Thicken cervical endometrial
mucus lining

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 IUDs: Contraceptive Benefits
Highly effective (0.60.81 pregnancies per 100 women
during the first year of use for Copper T 380A)
Effective immediately
Long-term method (up to 10 years protection with
Copper T 380A)
Do not interfere with intercourse
Immediate return to fertility upon removal
Do not affect breastfeeding

1
Trussell et al 1998. Yusrawati
Seminar sehari S1 Kebidanan
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Fakultas Kedokteran Unand
 IUDs: Contraceptive Benefits continued
Few side effects
After followup visit, client needs to return to clinic
only if problems
No supplies needed by client
Can be provided by trained nonphysician
Inexpensive (Copper T 380A)

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 IUDs: Noncontraceptive Benefits
Decrease menstrual cramps (progestin-releasing only)
Decrease menstrual bleeding (progestin-releasing
only)
Decrease ectopic pregnancy (except Progestasert)

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 IUDs: Limitations
Pelvic examination required and screening for sexually
transmitted diseases (STDs) recommended before
insertion
Require trained provider for insertion and removal
Need to check for strings after menstrual period if
cramping, spotting or pain
Woman cannot stop use whenever she wants
(provider-dependent)

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Fakultas Kedokteran Unand
 IUDs: Limitations continued
Increase menstrual bleeding and cramping during the
first few months (copper-releasing only)
May be spontaneously expelled
Rarely (< 1/1000 cases), perforation of the uterus may
occur during insertion
Do not prevent all ectopic pregnancies (especially
Progestasert)
May increase risk of PID and subsequent infertility in
women at risk for STDs (e.g., HBV, HIV/AIDS)

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Fakultas Kedokteran Unand
 Who Can Use IUDs
Women of any reproductive age or parity who:
Want highly-effective, long-term contraception
Are breastfeeding
Are postpartum and not breastfeeding
Are postabortion
Are at low risk for STDs
Cannot remember to take a pill every day
Prefer not to use hormonal methods or should not use them
Are in need of emergency contraception

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 IUDs: Who Should Not Use
(WHO Class 4)

IUDs should not be used if woman:

 Is pregnant (known or suspected)
 Has unexplained vaginal bleeding until the cause is determined and any serious problems are treated
 Has current, recent PID

 Has acute purulent (pus-like) discharge

 Has distorted uterine cavity

 Has malignant trophoblast disease
 Has known pelvic TB
 Has genital tract cancer
 Has an active genital tract infection (e.g., vaginitis, cervicitis)

Yusrawati
Source: WHO 1996. Seminar sehari S1 Kebidanan
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Fakultas Kedokteran Unand
 IUDs: Common Side Effects
Copper-releasing:
Heavier menstrual bleeding
Irregular or heavy vaginal bleeding
Intermenstrual cramps
Increased menstrual cramping or pain
Vaginal discharge

Progestin-releasing:
Amenorrhea or very light menstrual bleeding/spotting

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 IUDs: Possible Other Problems
Missing strings
Slight increased risk of pelvic infection (up to 20 days
after insertion)
Perforation of the uterus (rare)
Spontaneous expulsion
Ectopic pregnancy
Spontaneous abortion
Partner complains about feeling strings

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 IUDs: Immediate Postplacental Insertion
Special training for providers
Prenatal counseling for clients
No additional risk of infection, bleeding or perforation
Convenient for client
Cost effective

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Fakultas Kedokteran Unand
 Immediate Postplacental IUD:
Spontaneous Expulsion Rates
14
12
10
Inexperienced
Rate per 100 8 Practitioners
Women 6 Experienced
Practitioners
4
2
0
1 6 12 18 24 30 36
Months After Insertion

Yusrawati
Source: Theiry, Vansehari
Seminar Kets and Van der Pas 1985.
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S1 Kebidanan Fakultas
 IUDs: Client Instructions
 The IUD is effective immediately.
 The IUD can come out of the uterus spontaneously, especially during the first few months.
 Bleeding or spotting may occur during first few days.
 Menstrual bleeding may change depending on type of IUD.
 The IUD may be removed any time you wish. However, it is safe and effective for (x number of years) when using the (type
of IUD).
 IUDs do not provide protection against STDs, (e.g., HBV, HIV/AIDS.)

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 IUDs: Client Instructions continued
Return for checkup after the first postinsertion menses,
4 to 6 weeks after insertion.
During the first month after insertion, check the strings
several times, particularly after your menstrual period.
Check strings after first month, only if you have:
cramping in the lower part of the abdomen,
spotting between periods or after intercourse, or
pain after intercourse (or if your partner experiences
discomfort during sex).

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 IUDs: General Information
Removal of the Copper T380A is necessary after 10
years but may be done sooner if you wish.
Return to your provider if you:
cannot feel the strings,
feel the hard part of the IUD,
expel the IUD, or
miss a period.
Use condoms if at risk for STDs.

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 Warning Signs for IUD Users

Contact healthcare provider or clinic if you develop any of the following problems:
 Delayed menstrual period with pregnancy symptoms (nausea, breast tenderness, etc.)
 Persistent or crampy lower abdominal pain, especially if accompanied by not feeling well, fever or chills
(symptoms suggest possible pelvic infection)
 Strings missing or the plastic tip of IUD can be felt when checking for strings
 Either you or your partner begin having sexual relations with more than one partner; IUDs do not protect
women from STDs (e.g., HBV, HIV/AIDS)

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 IUDs: Management of Vaginal Bleeding
Problems
Reassure client that menses generally are heavier with
an IUD and bleeding/spotting may occur between
periods, especially in first few months.
Evaluate for other cause(s) and treat if necessary.
If no other cause(s) found, treat with nonsteroidal anti-
inflammatory agent (NSAID, such as ibuprofen) for
57 days.
Counsel on options and consider IUD removal if client
requests.

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 IUDs: Management of Cramping and
Pain
Reassure client that cramping and menstrual pain
(dysmenorrhea) may occur with an IUD, especially in
first few months.
Evaluate for other cause(s) and treat if necessary.
If no other cause(s) found, consider treating with
acetaminophen or ibuprofen daily with onset of
menses.
Counsel on options and consider IUD removal if client
requests.

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 Management of Partner Complaints
About Feeling IUD String
Discuss client/couple's concerns, reassure it is not a
serious problem and requires treatment only if really
bothersome.
Check to be sure IUD is not partially expelled.
If IUD is in place, treatment options are:
cut string, or
remove IUD if client desires.

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 Management of Partner Complaints
About Feeling IUD String continued
When cutting the string:
Cut string so it does not protrude from cervical os.
Explain that IUD string now is located at opening of
cervical os, and she will not be able to feel it.
Note in record that string has been cut flush with the
cervix (important for followup and future removal).

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 IUDs: Indications for Removal
If the client desires
At the end of effective life of the IUD
TCu 380A = 10 years
If change in sexual practices (high risk behavior),
consider adding barrier method (condoms) or removal.
If treated for STD or documented pelvic infection.
Menopause

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Fakultas Kedokteran Unand
 IUDs: Common Medical Barriers to
Service Delivery
Insertion only during menses
Age restrictions (young and old)
Parity criteria (less than 2 living children)
Marital status/spousal consent requirements
Inappropriate "contraindications" (immediate
postpartum, valvular heart disease)
Process hurdles (too many pre- or followup visits)
Who can provide (physicians only)
Provider bias (provider does not recommend)

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 MOKASIH

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