Dr Lara Roeske: Hello everyone, welcome to ‘Crisis averted – Emergency contraception and IUDs: A general practice case study’.
We acknowledge the traditional owners of all the lands on which we are meeting today we pay our respects to their elders past present and emerging we extend that respect to all Aboriginal and Torres Strait Islander people present at this meeting
I'm Dr Lara Roeske, Chair RACGP Specific Interests.
I'd like to introduce our presenters:
Dr Amy Moten, Chair RACGP Specific Interests Sexual Health Medicine, Coordinator Medical Education Shine South Australia and member of the Family Planning Alliance Australia Medical Advisory Committee
I'd also like to introduce Dr Sara Whitburn who is a GP lactation consultant, Medical Educator with Family Planning Victoria and RACGP Specific Interests Sexual Health Medicine Member.
I will now hand over to Dr Amy Moten and Dr Sara Whitburn
Dr Amy Moten: Before we start I'd just like to address the terminology that we'll be using when we're talking about intrauterine contraception because it can be confusing with terms such as intrauterine system or intrauterine contraceptive device being interchangeable with IUDs.
For the purpose of this presentation the terms we will be using IUD for intrauterine device which covers both the levonorgestrel and the copper IUDs so LNG refers to the intrauterine device releasing levonorgestrel and CuIUD refers to the type of into intrauterine device containing copper.
We'd like to start with a case study.
We have Aisha who is a 24-year-old who presents to your consulting rooms are asking for emergency contraception. She's been using condoms with her relationship of the past six months but last night realised the condom had come off during sex. She's understandably quite anxious.
What's the most effective emergency contraception you can give her? When we're talking about emergency contraceptive we're talking about a method to reduce the risk of pregnancy after unprotected sexual intercourse.
This can be due to contraceptive failure such as the condom broke or a missed pill, it can be followed following on from sexual assault or it could be because someone wasn't on contraception at the time they had unprotected sex.
We know that emergency contraception doesn't cause disruption to an established pregnancy and therefore doesn't cause an abortion but some forms of emergency contraception may prevent a fertilized egg from implanting. We no longer refer to emergency contraception as the ‘morning-after pill’ there are more than oral methods of emergency contraception and also, depending on the type of emergency contraception, it may be safely used up to five days following unprotected sexual intercourse.
There are three main methods in Australia, but we do know that oral emergency contraception should be taken as soon as possible after unprotected sex to prevent or delay ovulation. We also know that it's very hard for some people to predict the time that they are ovulating even if they're having a regular cycle, so emergency contraception should be used by anyone who doesn't wish to become pregnant following unprotected sex regardless of the timing of their cycle.
It is also important to be aware that there are no age limits to using emergency contraception. If someone is at risk of unintended pregnancy whether they are at the lower or the upper end of reproductive age they should be given access to it.
As I mentioned there are three methods available in Australia and these are the methods that are also mainly used overseas. Non-hormonal emergency contraception is the copper IUD and hormonal contraception is either levonorgestrel ECP or ulipristal acetate ECP.
I just like to talk about copper IUD as a form of emergency contraceptive before we move on to the hormonal methods. Now the copper IUD works by interfering with sperm movement. It inhibits fertilisation by direct toxicity to sperm and it may also prevent implantation of a fertilised ovum. It is important to be aware if someone would consider that having a fertilised ovum that they would not wish to disrupt a pregnancy and would consider that to be a form of abortion this is not a suitable method for them. If the copper IUD is inserted within 120 hours following unprotected sex or up to five days of earliest predicted ovulation, whichever is later, it is in fact the most effective form of emergency contraception. It is as effective at day one as day five and so when we have a patient like a Aisha it's great that she has presented within 24 hours of unprotected sex because that gives us a couple of days to potentially facilitate an IUD insertion for her method of emergency contraception.
We do know that it's not appropriate to use a copper IUD for emergency contraception if there has been a chance of unintended pregnancy earlier in the cycle because of the potential effect it can have on an ongoing pregnancy. So the copper IUD should not be inserted after day 12 of the normal menstrual cycle, if there has been earlier unprotected sex in the cycle.
Access to copper IUDs can be limited by cost. The device itself costs between $90 to $120 depending on which pharmacy or warehouse you access it from. Individual inserters may charge a gap of anywhere from $50 to a couple of hundred dollars and that is entirely dependent on the inserter.
I would just like to point through the imagery we have on the screen there so you can see the copper IUDs available in Australia are the copper T and the copper multiload. They are equally as effective as emergency contraception, so either is a suitable choice and either is more than 99% effective as an emergency contraception.
Now there are some advantages and disadvantages to the copper IUD.
The biggest advantage is that it is the most effective form of emergency contraception. It provides ongoing contraception so if someone has been unsure ongoing contraceptive options inserting the copper IUD as emergency contraception can buy them time to change to another form of contraception or they could continue with that for the lifespan of the IUD. The other advantage is it's not an oral absorption pathway so it's not affected by medication interactions and it's not affected by gastrointestinal problems such as inflammatory bowel disease. Of course there are some disadvantages, and the main one is barriers to access. In order to access a copper IUD as an emergency contraceptive the patient needs to be able to afford both the device and the potential cost of insertion, and you need to have access to an IUD inserter. You need, in fact, to be aware that it's a potential option for emergency contraception and you need to access them within five days of unprotected sex.
There are some contraindications to IUDs in general and some potential complications that do require careful counselling. We will cover those contraindications and complications later in the webinar. I'd now like to pass over to Sara to talk a bit more about the emergency contraceptive pill.
Dr Sara Whitburn: Thank you very much, Amy.
The emergency contraceptive pill.
Both forms of the hormonal pills act by disrupting or delaying ovulation by up to five days. The greatest risk is if unprotected sexual intercourse has occurred within 72 hours of ovulation, but as many of you may know there is difficulty in estimating timing of ovulation for each individual patient. That means that there should be a very low threshold for offering emergency contraception.
The emergency contraception pill has no effect once ovulation has occurred and it is not a type of abortion pill.
The first type I am going to talk about is the levonorgestrel emergency contraceptive pill. These pills contain 1.5 milligrams of levonorgestrel and it works as a progesterone analogue. It prevents or delays ovulation by interfering with follicular development in the ovary, but it is not effective once the luteinizing hormone surge has commenced. There is no evidence of harm to a developing fetus if the emergency contraceptive pill is taken and the patient is already pregnant. The cost of the levonorgestrel pill is about $15 to $30 dollars and it can either be provided as one 1.5 milligram tablet or you can take two levonorgestrel 750 microgram tablets together and they're both taken stat.
There is another form of putting the dose together which is if you use 30 micrograms of levonorgestrel as Microlut you could take two doses of 25 tablets so that is two doses of 25 tablets all together 12 hours apart. This is not evidence-based and I don't think it's particularly a patient preferred model but it is another option if that is all you have available,
The levonorgestrel emergency contraceptive pill is the most effective the sooner it is taken post unprotected sexual intercourse so in our case as Amy mentioned it's great that she's there in the first 24 hours to think about inserting a copper IUD but it is also good that she's presented early if she decides to choose the levonorgestrel emergency contraceptive pill and this is licensed up to 72 hours.
The other type of emergency contraceptive pill that's available in Australia is ulipristal acetate. This is a progesterone receptor modulator it contains 30 milligrams of ulipristal acetate and it blocks the effect of the body's progesterone and so inhibits or delays ovulation. It is unlikely to affect the implantation of a fertilised egg but it is more effective than levonorgestrel emergency contraceptive pill. It can delay the luteinizing hormone peak once the surge has started and it costs a little bit more costs around $45.
So Amy I will hand back to you to talk about a more historical method – the Yupze method.
Dr Amy Moten: The reason we've left this slide in is we have had some pre-questions from registrants asking about access to emergency contraceptive perhaps in regional and remote areas.
As Sara mentioned, one option is to use multiple tablets of the progesterone-only pill, Microlut, but it may be that all someone has available is some packets of their combined oral contraceptive pill. Now this method does also involve two doses 12 hours apart containing at least 10 micrograms of ethinylestradiol (EE) and 500 micrograms of levonorgestrel so that would typically be about five tablets of a low-dose pill, a 20 microgram pill containing 100 micrograms of levonorgestrel and it's taken 12 hours apart and given with an antiemetic. The reason for that is that the very high dose of oestrogen that people received during this method is likely to cause nausea and vomiting so it is a last-line method of emergency contraception but it is a possibility if all other emergency contraceptive methods are unavailable.
So when prescribing the emergency contraceptive kit depending on the type is actually pretty similar we know that if someone vomits a dose fairly soon after taking it then it's not going to have been absorbed and so you should repeat the dose if vomiting occurs with three hours of taking either the levonorgestrel or the ECP.
There are no real medical contraindications to either ulipristal or levonorgestrel. Though, of course, a true allergy or hypersensitivity to either those components would be very very rare.
Product information and guidelines often refer to severe liver disease as being a potential issue with either of these medications. But the reality is an ongoing unintended pregnancy is going to cause much more problems to a person with severe hepatic impairment than a single dose of the emergency contraceptive pill. So I think we need to use careful consideration in not prescribing in those circumstances
Ulipristal acetate also potentially does have an additional contraindication in severe asthma controlled oral steroids and this is because it has an antiglucocorticoid effect. But again, it's not considered a true contraindication if the risk of ongoing unintended pregnancy would present a greater risk to the person than having a single dose of the emergency contraceptive pill.
The side effects of both UPA and LNG appear to be very similar. They include headache dizziness and abdominal pain and, unsurprisingly because we are acting to delay ovulation, menstrual disturbance is common. Most people should experience bleeding or their normal period within seven days of when they expected it and certainly if their next period was more than seven days of expected time we would strongly suggest that they have a follow-up the pregnancy test.
There are some additional issues with the oral contraceptive emergency contraceptive pill that are not related to the copper IUD. Because they are taken orally and systemically absorbed they can be affected by the same liver enzyme inducers that can affect other forms of oestrogen and progesterone containing contraception.
So a client who is taking a liver enzyme inducer such as an antiepileptic medication or certain HIV antiretrovirals needs to be advised that both forms of the emergency contraceptive pill may be less effective if these liver enzyme drugs are being taken and if they've been taken within 28 days of taking the ECP.
Ulipristal acetate is predominantly metabolised by these cytochrome p450 enzymes and is specifically not recommended to be used as an emergency contraceptive pill within 28 days of a liver enzyme inducer.
A double-dose of levonorgestrel ECP can be used in the instance that someone is taking one of these medications it is an off license indication and the efficacy is uncertain but it is considered better than taking a single dose of levonorgestrel or UPA. Now in this instance this would be another indication where copper IUD would be a first-line emergency contraceptive because it will not be affected at all by these liver enzyme inducers.
Body weight is another area where there have been theoretical concerns around effectiveness of the emergency contraceptive pill.
Studies have shown that the leavener gestural ECP could be less effective in people with a body weight greater than 70 kilos or a BMI greater than 26. In this instance UPA would be the recommended emergency contraceptive pill but if that was not available or advisable then a double dose of levonorgestrel can be offered and again the efficacy is uncertain but it is considered better than not offering it at all.
With ulipristal acetate the BMI cut-off tent seems to be around 30 or more. Some studies which showed a three-times increase rate of pregnancy in people with a BMI over 30 in clinical trials of UPA ECP compared to people with a BMI of less than 25. For UPA the efficacy threshold appears to be about 85 to 88 kilos. The UK Faculty of Sexual Reproductive Health, the guidelines we follow here in Australia, do say that for people with a weight greater than 85 kilos or a BMI of 30 it is unknown whether a single dose of UPA or a double dose of levonorgestrel is more effective. They have tended to err on the side of caution that UPA is generally more effective overall and should be a first-line in this instance.
So no hand back to Sara to talk about the effect of ECP and contraception.
Dr Sara Whitburn: Thank you Amy.
We did get questions before before the webinar and one of the questions was about can we use emergency contraception and other contraception at the same time or how do they impact on each other.
As we've already mentioned the copper IUD can be ongoing contraception, so that works very well, but when you're thinking about the emergency contraceptive pill the main concern is really with UPA. That if you're taking a progesterone containing contraception within five days of using UPA it may actually reduce the effectiveness of that. So the faculty that we've mentioned, of Sexual Reproductive Health in the UK has actually recommended waiting at least five days before restarting the regular contraceptive. As well as the progesterone only contraception such as progesterone-only pills and implants and the levonorgestrel IUD it also includes the vaginal ring. So there is a delay between having emergency contraception and then ongoing contraception.
The other thing to consider that UPA may be less effective if the contraception that's been missed, the previously used contraception, was progesterone-only and so it may be less effective if somebody was on progesterone-only in the preceding seven days. It may you want to consider that, once again, this is sort of suggesting that if you can arrange access to a copper IUD that does help with some of these situations.
Just a reminder that levonorgestrel emergency contraception (not the Mirena) and UPA should not be both be taken in the same cycle. So you can't use the two different types of emergency contraceptive pill.
The other consideration with UPA is breastfeeding. There is a lack of studies of UPA in breastfeeding women and so national guidelines tend to follow the manufacturer recommendations in that we should be expressing and discarding breast milk for seven days after a dose of UPA. As can imagine, that would really impact on a patient’s supply. If you look at LactMed, or some of the other breastfeeding medicine online apps or guidelines, it does suggest that there's low transfer into breast milk and that the peak concentration reaches between one to three hours, but other studies have said that it can take up to four to five days to get 93% clearance. Some of the guidelines, and the World Health Organisation is one of them, recommend expressing and discarding for 24 hours but that is based on only a small amount of data. Here in Australia we still recommend that you need to have that break of seven days so I would consider using another option, either the levonorgestrel emergency contraception or the copper IUD.
Summing this all up is really important when we're prescribing the emergency contraceptive pill to take a very good history as that's going to help us decide what type of emergency contraceptive pill we can offer, it at all. In the history it's very important to ask the patient when was the last menstrual period, the timing of unprotected sexual intercourse and whether there's been any previous unprotected sexual intercourse. Has there been any history of contraception failure including broken or slipped condoms or any contact between the penis and the vagina without a condom. You do actually have to ask specific questions to get a good idea of risk because sometimes what we mean about using condoms or not using condoms is different between patient and practitioner. Also taking a very clear history of any missed pills and types of pills.
I've mentioned already that you want to think about the risk of pre-existing pregnancy – so has there been any change in the last menstrual period, did it come at expected time? Is there any other unprotected sexual intercourse that hasn't had emergency contraception or anything else that might make you think that there's already a pre-existing pregnancy and, of course like any prescribing, we want to consider allergies or medical conditions and any use of other liver enzyme inducing medications.
As I've mentioned, breastfeeding is very important to decide if you're going to use levonorgestrel or UPA . Does this person have ongoing contraceptive needs? What contraception were they using? Do we have to have that break with UPA or are we going to provide an ongoing contraceptive with the copper IUD? We need to know about the current risks for STIs and HIV by taking a good sexual health history and we need to think about somebody's weight and height for their BMI. Also thinking about pregnancy tests on the day and any ongoing pregnancy tests if we're concerned about previous episodes of unprotected sexual intercourse so that brings me to follow up.
I’ve mentioned that it's important to think about STI risk and pregnancy risk, so it may be needing a test of cure or a test of reinfection if we're concerned about STIs. If we decide to ‘quick start’ a hormone or restart hormonal contraception and there's a need to exclude pregnancy down the track that also needs a good recall system. If someone is having repeat use of emergency contraception of the pill type then we need to make sure that we follow up – have they had a bleed when we expected, do they need a pregnancy test and what's their ongoing contraceptive need. Same again if the menses is more than seven days late.
There's also routine follow-up if we decide to use copper IUD as the emergency contraception. We want to make sure that the patient is managing their IUD well and also excluding pregnancy again. I think if anyone is high risk either for pregnancy, or you're concerned about high risk from a follow-up point of view, then it's very important to have good clear contact details and how you're going to recall this patient to exclude pregnancy.
To sum up the what we've said about emergency contraception before we get on to our case.
So the key points in emergency contraception is that copper IUDs are the most effective form of emergency contraception. If emergency contraceptive pills do not provide ongoing contraception UPA is more effective than levonorgestrel but it does reduce the ability to continue or ‘quick start’ hormonal contraception.
An emergency contraception choice depends on a variety of factors including patient factors, practitioner factors and access.
Dr Amy Moten: Sarah so we go back to Aisha.
Aisha is very much interested in a copper IUD as the most effective form of emergency contraception but she is interested in learning more about the levonorgestrel IUD in case she wants to change over later. It is sometimes the case that people will have a copper IUD for their emergency contraception and then change to the levonorgestrel IUD so we should have a table coming up in a moment which looks at the differences between the two.
We've already talked about the cost of the copper IUD and the reason for a substantial cost difference is the copper IUD is not a PBS item so it can be purchased without a script. It's actually not a bad idea, if you're a regular IUD inserter, to have a spare copper T and copper multiload in your rooms.
The levonorgestrel IUD is a PBS device, which means that if you have Medicare and you have a health care card it will cost usually no more than nine dollars. If you don't have a health care card but still have Medicare then it's around $40. Now the mechanism of action we've we've also covered with the copper that it's toxic to sperm and does have that little bit of an extra inflammatory effect on the endometrium to prevent implantation. This can lead to alterations in the menstrual cycle.
The main mechanism of action of the levonorgestrel IUD is that it thickens cervical mucus to prevent sperm and eggs from transitioning through the cervix, sperm certainly. And it also has an effect on the endometrium where it causes atrophy, so thinning the lining of the uterus. The levonorgestrel is released into the surrounding reproductive system and it has a variable effect on ovulation, so only about 30% of people will stop ovulating. Seventy percent will still have a regular ovulation, regardless of whether or not they are having a period. The levonorgestrel IUD is licensed for five years contraceptive cover with the copper IUD it depends on the type – so the multiload is licensed to five years and the copper-T is licensed to ten years. This just relates to the slightly different amounts of copper on the actual device and of the different effects on the endometrium is the reason we see these differences in bleeding patterns.
So you can see on the graph that the effect on bleeding in the levonorgestrel IUD is to significantly reduce bleeding and it is often used for the treatment of heavy menstrual bleeding for that reason. Because of the inflammatory effect of the copper IUD it can increase menstrual bleeding and pelvic pain. However, I would say that this is probably something that is over emphasised when people are talking about the types of IUDs and that many people who don't have a particularly heavy or painful menstrual cycle are quite easily able to tolerate the slight increase in bleeding and pelvic pain that they may get with a copper IUD.
Both IUDs can cause increased bleeding and spotting in the first three to five months and what happens after that five or six month mark is often broadly predictive of what will happen for the remainder of the lifespan of the IUD, but people can see significant improvement in the early stages. What we see is around 20% of people are amenorrheic with the levonorgestrel IUD at 12 months. Whereas people with a copper IUD will typically go to have whatever natural regular cycle they would have had without the IUD.
Now of course the big advantage of the copper IUD is it contains no hormones and therefore it doesn't cause hormonal side effects and this is very well tolerated by people who've had issues with previous hormonal contraception. The Mirena IUD is the lowest dose of hormone as far as hormonal contraception goes but people can still get hormonal side effects and these can actually cause significant issues.
The other benefits to the levonorgestrel IUD is that it can be used as endometrial protection as part of your hormone replacement therapy or menopause hormone treatment. As we mentioned the copper IUD is a highly effective emergency contraceptive. As far as contraceptive efficacy goes they're both greater than 99% effective. There are slight differences the levonorgestrel IUD is 99.9% effective the copper IUDs around 99.5% effective. This just relates to the copper IUD being slightly more position dependent inside the uterus than the levonorgestrel IUD
We will just to move on to some of the disadvantages or concerns that people have around IUDs. There are what we call expected adverse outcomes or side effects. These are well known and well studied but with careful counselling and consent most people tend to tolerate these very well when they do happen and they are quite rare overall.
We know that there's a slightly increased risk of infection at the time of insertion it's less than 1 in 300 insertions and it only lasts for 20 days and after insertion at which time the person goes back to their background risk of pelvic infection. So it relates to the process of insertion and the fact that we're introducing something through the vagina and cervix into the uterus. It's usually completely treatable with antibiotics and doesn't require removal of the IUD.
We know that IUDs can be expelled – they can be expelled partially where they come down into the cervical canal or they can be expelled fully into the vagina and outside of the body and this happens in five percent post-insertion. It is most likely to happen within the first three cycles after insertion and within the first 12 months after insertion at which time it's considered to be a lot rarer.
The most intimidating potential complication for clients and possibly clinicians is the risk of perforation, of the IUD partially or completely going through the wall of the uterus. We do reassure our clients this is actually quite rare, it occurs in less than 2.3 per thousand insertions and that's an old figure, which is probably higher than current perforation rates. We know the biggest risk factors this is just had a baby so being in the first nine months postpartum and breastfeeding. Breastfeeding alone confers a risk of perforation that is about six times higher than someone who is not breastfeeding, but it's still a low risk overall. It has been mentioned previously that cesarean section or multiple cesarean sections might be an increase risk for perforation but this is not being shown in any of the studies around IUDs and perforation, so IUD insertion should not be delayed for someone who's just had a cesarean section.
The other disadvantages can relate to cost and access as we've mentioned – so buying the IUD paying, the gap appointment, finding access to inserers and potentially being referred to insert as if your own GP is not an inserter. And then, of course, there's this sort of natural fear and anxiety which can relate to something which is a minor medical procedure but is a little more intimidating than potentially having a prescription for the pill or even a contraceptive implant insertion.
There are a few relative contraindications. Of course, undiagnosed abnormal vaginal bleeding is a contraindication to any form of contraception and it should be fully investigated, by having done so it might be that you are using the levonorgestrel IUD as treatment for abnormal vaginal bleeding or heavy menstrual bleeding. If someone has a current sexually transmitted infection such as chlamydia or a pelvic inflammatory disease then we would need to complete the treatment before inserting the IUD. But we don't always recommend screening for STIS prior to the insertion anymore. If someone was found to have an STI at a swab taken at insertion or shortly afterwards we would treat them as per the normal protocol and only remove the IUD if they weren't improving.
Breast cancer and liver disease are contraindications for all forms of progesterone, so contraindications for the levonorgestrel IUD. Thrombocytopenia is a contraindication for the copper IUD only, theoretical risk of increased bleeding. And any distortion to the uterine cavity which could impact on the actual insertion process itself is a contraindication for both forms of IUD, and this can include a bicornuate uterus or fibroids in distorting the uterine cavity.
Aisha is very keen on having an IUD but she's heard it might not be possible because she hasn't had any children, and she's also heard there's a high rate of pelvic infection with IUDs particularly in young people.
Now the reality is that while these are common beliefs and they do cause barriers to insertion they're actually not really an issue. Never having given birth vaginally does not make the insertion process any more difficult, and while it might be a little bit more uncomfortable for someone who has no experience of that kind of pain it's certainly well tolerated and well accepted in young people. There are a number of studies showing that the IUD is a very accepted option for people under 30 and it is well tolerated and they are more likely to continue with their IUD than they are with their combined oral contraceptive pill.
In relation to the increased risk of pelvic inflammatory disease, this again relates to the risk at insertion and within 20 days of insertion. Once those 20 days have passed then the person has no more risk being young and having an IUD than someone who is older and having an IUD. Their risk of PID relates to their background risk of exposure to things like chlamydia which cause pelvic inflammatory disease.
So Aisha is very keen on having her IUD and because she presented earlier we actually had a couple of days to organize her insertion it was inserted within five days giving her greater than 99% efficacy. She had a follow-up pregnancy test and it was negative and now she has ongoing contraception. So this is a win for Aisha.
I would just like to hand back to Sara for the final case.
Dr Sara Whitburn: Thank you we're going to move on to Louise now.
Louise is a 51 year-old woman and she has a levonorgestrel IUD and this was inserted when she was 45. She's been a amenorrheic now for the last four years and she comes to you asking when can she have her IUD removed.
This is often a question I think we get asked about is how do we use IUDs at the end of patients reproductive lives? The current guidelines the Faculty of Sexual Reproductive Health say is that if you have a copper IUD that's inserted when someone is equal to 40 or older than 40 then that can be retained for one year after their last menstrual period if they are over 50 but two years if they're under 50. That's to allow for the natural drop of fertility around the time of the menopause. This is off-licence use but, as I said, it is supported by the faculty's guidelines.
It can be either of the copper IUDs that's another point to know – prior to 40 the multiload is licensed for five years and the copper T for 10 years, but at the forty years that changes and the copper on both of them is is adequate to provide good contraception until somebody is either had their last period over 50 or two years under 50.
For the levonorgestrel IUD if the IUD is inserted at 45 or older it can actually remain in situ until that person is fifty-five if we're using it for contraception or heavy menstrual bleeding only – not if we're using it for endometrial protection. I'll talk about that point in a moment. Once again it's an off-license use and, once again, it's supported by faculty guidelines. However, if somebody would like to have it removed before 55 or there are any concerns about the diagnosis of menopause if the patient is over fifty years, has a levonorgestrel IUD and is amenorrheic then we can check FSH levels. And if a serum FSH is equal to or greater than 30 international units then they do need to keep the levonorgestrel for one more year, but once they get to that year it can be removed without further blood tests. So we can either leave it to 55 and just remove it without the blood tests, or we could have one blood test and then wait for in a further year just to allow for any ovulation that might occur as somebody's moving from the perimenopause into the menopause. That one year makes sure that we've covered that time.
The advice is different if the levonorgestrel IUD is being used as part of menopause hormone therapy or endometrial protection. To provide adequate endometrial protection then it needs to be replaced every five years and so that would depend on how long that person is using menopausal hormone therapy it can't stay for those up to ten years as it would be if we were using it for contraception.
So that's the end of our cases and our presentation today but we have had some questions already sent in and I'm sure there might be some questions that have come in through the webinar today.
I'm just going to hand to Amy because there was one question that we want to talk about and Amy that's about if there's a loss of strings, we can't fell the strings, however the IUD might be seen on the ultrasound and I'll hand back to you to talk about that more.
Dr Amy Moten: Thank you Sara.
So this is a fairly common presentation in in general practice where you might be doing a cervical screening test and the person has told you they have an IUD but you can't see the strings. Just in the first instance there, what you can do is very gently with a cervix brush, that you use for cervical screening, try and just pop that just a little bit inside the under cervical os and gently try and tease off to flick out the strings. And if you can do that that's great you don't need any further action.
Obviously if you you can't find the strings and and you've done the right thing, which is send someone off to have an ultrasound to confirm the IUDs in situ, and it is in fact in place, it becomes a little less clear. If the IUD is in place then basically you can be fairly sure that someone or someone is contraceptively covered and they will continue to be contraceptively covered. With a Mirena IUD if they're having an amenorrheic bleeding pattern then you can also be very well reassured by that and you can tell the patient they can be reassured that as long as they are continuing not to have a period that the Mirena is in place and it is working contraceptively. If they do develop any unusual bleeding, increased bleeding then they should use other precautions such as condoms or not have sex and get a repeat ultrasound.
It's a little bit less clear with the copper IUD because the copper IUD is very position-dependent in in its efficacy of action. And if someone is having a period every month then it is possible for the IUD to move and if they can't check their strings and they may not be aware that that's happened. While it's unlikely to have a complete expulsion that someone hasn't noticed, it is possible to have a partial expulsion. Again that might present with an increase in bleeding outside of the regular cycle, but if I did have someone with missing strings and a copper IUD I would offer them the choice of removal and replacement so that they could go back to having strings that they can check on a regular basis and be reassured. That would be the patient's decision to make after giving them all that information.
I think we had one more question that we really thought was important to cover which was the choice of which copper IUD regarding both emergency contraception and also ongoing contraception.
I'll just hand that one back to Sara.
Dr Sara Whitburn: Thank you.
Yes we had a question about how do we choose the length or the type of copper IUD depending on size of uterus. I guess it's a good time to talk about, if you are an inserter, the uterine cavity length and and how that helps us decide. Most of the time we were working in a length of seven centimetres to 10 centimetres. It really does depend a little bit on which device you're using. I guess I just like to say that if you do measure the uterus below six centimetres or above ten centimetres, then the risk of perforation or the risk of malposition is much higher. Some of the guidelines say if you measure below six or above ten then you should get an ultrasound to confirm the size of the uterus or perhaps refer to have that done in a in a specialist way.
I guess working in community with the levonorgestrel IUD the manufacturer doesn't actually recommend a uterine cervical length, but between seven and ten centimetres would, I think, be quite effective for the Mirena.
For the copper IUD you can insert that from anywhere that it's equal to seven centimetres to 10 centimetres. For the standard copper T that's the same, but there is a copper T short and that can be quite useful if you measure between six and seven centimetres. So it can be useful to have the different sizes in your rooms. We did mention that before that you can buy these from medical suppliers, some chemists will also order them in and so some practitioners will choose to have those already in their clinic. Then once they've done a sounding and decided on the measurement then they have a short or a standard and they're able to make that decision on the day. But otherwise the levonorgestrel, the copper T standard and the load copper load or multi load all work well within seven to ten centimetres.
Dr Lara Roeske: Sara and Amy, we do have four questions from the participants.
I might throw the first question to you Amy. In regards to emergency contraception in a case of sexual assault should should we refer or not?
Dr Amy Moten: That's a very good question and it is, I guess, a very complex answer. If someone presents to you reporting sexual assault, the first and most important thing is to check their safety – are they emotionally safe and physically safe? And the second thing is is to determine what they want from you. Not everyone who discloses sexual assault wants anything other than check-up and emergency contraception. They may say I'm not going to report it, I don't want any special counselling, I just want you to examine me, check me for STIs and give me the most effective form of emergency contraception you can offer. So if you think that they might benefit from the copper IUD and you can access it then absolutely. In certain states and territories the sexual assault centres will have better access to that then you might in your general practice. If you give them the option of would you like to go and see someone at a specialised sexual assault centre, again, if they think that that's that might be useful for them. But there is no reason that you can't offer them the basics. You obviously can't offer them a forensic check but, as I mentioned, that maybe not what they want, they may just want the emergency contraception and the STI protection. So absolutely you can manage that.
Dr Lara Roeske: Thank you Amy and now, certainly a common question for you Sara.
A common question from my patient does the levonorgestrel cause weight gain?
Dr Sara Whitburn: That's a very good question as well.
So the actual studies that looked at weight gain, because it's over a five-year period and because it's multifactorial it wasn't able to say that weight gain was specifically from their levonorgestrel IUD.
I tend to counsel that some people will report weight gain and that I do take the patient's experience, which is very important. But there's no good data that says that it definitely causes weight gain, and I talk more about keeping an eye on their mindful eating, keeping a healthy lifestyle and that the door is open to talk about any side effect concerns they might have, but that there's no good data to say that it will definitely cause weight gain.
Dr Lara Roeske: Thank you Sara.
In relation to the table referring to the end of reproductive-life care and IUDs we've got two questions and and they are the last two questions.
The first question revolves around the timing of and the need for any sort of repeat FSH test, so we're asking here do we need a repeat FSH after six weeks? Amy can you help with that?
Dr Amy Moten: Absolutely!
So that was the old guidelines that you would do two FSH levels, six-weeks apart, and they both had to be over 30 but the current guidelines suggest that that's unnecessary. That if you have a single FSH level over 30 in someone who is over 50 that you can safely remove the IUD in 12 month’s time, giving that extra 12 months to make absolutely certain that they've passed any risk of ovulation or pregnancy.
Dr Lara Roeske: Thank you, and Amy I'll just stay with you now as we go on to the second question relating to this stage of women's lives.
If a woman has a levonorgestrel IUD, is over 50 and has an FSH that's greater than 30, do you need to wait one year after the FSH level is done before removing the IUD.
Dr Amy Moten: The answer is yes.
If, you want to be completely risk-averse being aware that in perimenopause in the early stages of perimenopause the FSH might be increasing up to around 30 but there is still the occasional breakthrough ovulation. If you remove the IUD early, it's incredibly rare, but the the risk of having that pregnancy in terms of the impact on that person's life would be quite disastrous, I imagine.
So we say we do have to wait for that 12 months after that single FSH and then we can safely remove your IUD.
Dr Lara Roeske: Thank you that's very helpful Amy. Now I've got one final question I can see here, I'll just check back with both of you are there any other questions that you receive prior to the webinar that you feel that you'd like to raise or address at this stage before we come to the final question.
Dr Sara Whitburn: No I think that with the two that particularly stood out to us that we thought were very common and helpful questions we've addressed, so very happy to hear from someone who's watching right now.
Dr Lara Roeske: Thank you Sarah, I'll just check with you Amy.
Dr Amy Moten: I agree with Sara.
Dr Lara Roeske: Our final question is – does phentermine affect the efficacy of hormonal contraceptives? I'm not sure if either Sarah or Amy would like to respond to that?
Dr Amy Moten: As far as I'm aware, phentermine is not on the list of medications which interact with hormonal contraception or the emergency contraceptive pill. I did just review that list prior to this webinar, so I'm going to say no. But I would also say that if you do go to the UK Faculty of Sexual and Reproductive Health information guidelines, they do have some very helpful charts and tables where you can have a look at the individual liver enzyme inducers and non-liver enzyme inducers which also have an impact on hormonal contraception and emergency contraception.
Dr Lara Roeske: Thank you Amy and thank you Sarah. We are now going to shortly conclude this webinar.
I just would like to thank everybody for their attendance and I'd also like to thank our sponsor the Victorian Government which has provided the resource ‘General practitioners supporting women's sexual and reproductive health’ and this is available for download in the documents section of this webinar. Thank you to all.