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Contraceptive Conundrums: Your Questions Answered - Part 2

Jessica:
 
Good evening everyone, I will just take a couple of minutes to let everyone filter into the webinar before we officially get started. Okay, so everyone is still joining, but given it is 7 p.m. in my time zone, I think we will get started. So welcome to tonight’s webinar, which is Contraceptive Conundrums: Part 2, with your presenter Dr Amy Moten and myself, Jessica Fry as the facilitator. We would like to begin with an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past and present.
 
Those of you who were online last week would already be aware and familiar with the control panel, but if not, down the bottom of the screen there you will see if you hover over the bar at the bottom there, it has the raise your hand option which we will not be using tonight. So again, just any questions you have please send them through to the Q&A. And as you would already be aware, you have been placed on mute. So again, any questions you have, please send through to the Q&A and try not to use the chat if possible again because the Q&A is the best spot for us to pick up the questions.
 
So again your presenter for this evening is Dr Amy Moten and she is the Chair of the RACGP Specific Interest Group, Sexual Health Medicine Network. Dr Moten is the Coordinator of Medical Education at SHINE SA where she provides clinical training to doctors, nurses and midwives, and other health professionals. She is a passionate advocate for access to sexual and reproductive healthcare and prior to her time at SHINE SA, Amy trained and worked as a GP in Darwin, including at Family Planning NT. And as I mentioned, I am Jessica Fry, the NT representative for the RACGP SA and NT Faculty and your facilitator for this evening. So you will note that tonight you are not automatically allocated points. You will need to log these yourself via the Quick Log option within the My CPD Dashboard. So you just follow the prompts there on the screen and you get two points per hour. Okay?  And again, if you have any questions please feel free to contact me and I will assist you where I can.
 
And, that is all from me, so I am going hand over to Dr Moten. Thank you.
 
 
Amy:
 
Thank you very much, Jessica. Always forgetting to unmute my microphone for the first few seconds there. So welcome to Contraception Conundrums: Part 2. Now those of you that joined us last week would know that we focussed on oral contraception then and tonight we are going to be focussing on LARCS. A number of tonight’s slides are actually based on questions we have received since the last webinar, and thank you all for such fantastic questions. Someone has really made me go off and do my research, which is always good, because it makes me have a think about things as well. Now, we might not cover everyone’s questions. There were a number of sort of themes or repeated questions through the questions and in fact throughout the series of webinars and I have tried to focus on them and a couple of new ones. But we will have time for questions again at the end of this session. We will take some new ones and if we have time perhaps focus on some of the ones that related more to last week’s webinar. And just a reminder that the webinar is being recorded and the slides will all be available on the RACGP website including some or all of the links and tables that I show.
 
So what is LARC? LARC is long-acting reversible contraception and it is contraception that is administered less than monthly. And looking at this table here, we can see the licenced duration of use of the LARCs in Australia. So in Australia, we have a number of different IUDs. We have the TT380 IUD which you may hear referred to as the Copper T. There is more than one brand of that available in Australia but they are both licenced for 10 years of use. And then the other copper IUDs available in Australia, are the Load375 which I by habit still refer to as the Multiload which was an older name for it, but Load375 is the correct term, and then the TT380 short IUD. So both of these IUDs are licenced for five years of use because they have a slightly smaller amount of copper on them or a slightly different frame. We have two levonogestrel containing IUDs now in Australia, the 52 milligram levonogestrel and the 19.5 milligram levonogestrel, and these are both licenced for five years of use. Now later in the presentation I will talk a bit more about exceptions to these licence rules including use for other indications. And we also have the contraceptive implant which is licenced in Australia for use up to three years. Now, depot medroxyprogesterone acetate is what you might know as depot Ralovera or depot Provera. Now this is administered every 12 to 14 weeks under licenced use, and this is why it is considered to be a LARC, but it is often referred to as a second tier LARC, because it still requires administration on a frequent basis compared to any of the other LARCs, and it does in fact require a script every six months, because on the PBS you can only provide one repeat. So it is slightly less desirable as a LARC for that reason.
 
Now, why should we love a LARC? And I love my LARC is one of the images that FPAA uses for promoting LARCs. Well, when we look at studies of contraceptions, and in particular LARC one of the ones most commonly referred to is contraceptive CHOICE project which was a project in America where young people were given a choice of whatever type of contraception they wanted, whether it be a LARC, whether it be combined hormonal contraception and 75% chose the LARC. They had the highest satisfaction rates of their contraception if they chose the LARC, and people who chose a non-LARC method were 20 times more likely to have an unintended pregnancy than those who chose LARC. And continuation of the IUD and implant was much greater than the pill and the depot injection in this particular study.
 
So looking at this slide here, what we can see is that the non-LARCs, continuation rates at 12 months were only slightly over half and less than half at 24 months and for the LARCs, the continuation rates at 12 months were over 85% and still over three quarters of people who chose a LARC continued with that LARC at 24 months compared to less than half of the people who had chosen the pill, patch or ring. The other reason we love a LARC is its efficacy. And so this is the FPAA, Family Planning Alliance Australia How Effective is my Contraception card. And this is available on the FPAA website and also the websites of a number of the Family Planning organisations including SHINE SA. And what we see with the LARCs is that they are a set and forget method and they are greater than 99% effective. And if you were to compare what we call typical efficacy to perfect efficacy, there is not a lot of gaps in between what is perfect use and typical use because they are not user independent. They do not require taking a tablet every day or putting a condom on each time you have sex. And even then the second tier LARC or the injection used typically is around 96% because people do need to represent to a health professional every three months to get an injection, and you know, potentially there is a cost involved there, they have to maybe see someone every six months for a script. Again, there might be a gap there. And this is a really great tool for counselling your patients in terms of showing them the difference between the efficacies because a lot of people do want to know what is the most effective contraception as well as things like side effects.
 
This particular table here just shows the differences between the IUDs. So the levonogestrel IUD and the copper IUD. So in terms of the cost, I always talk to people about you know, what is PBS versus what is not PBS. So PBS listed medications can never be more than around 39 to 40 dollars because they are subsidised by the government, and they can be less than 10 dollars for people with Healthcare Cards. All the copper IUDs in Australia are considered to be medical devices, so they are not listed on the PBS and their cost varies between 80 and 120 dollars for the actual device, depending on where you buy it. Certainly Family Planning organisations are often able to provide it for the much lower cost. The levonogestrel IUD may thicken cervical mucus and affect sperm and oocyte motility. They cause endometrial atrophy and variable inhibition of ovulation in terms of their contraceptive mechanisms. The copper IUD works by being toxic to sperm and it also has an implant effect on the endometrium to prevent implantation of a fertilised egg. Both levonogestrel IUDs licenced in Australia last for five years and the copper IUD depending on the type is either five or 10 years. The levonogestrel IUD does reduce bleeding and certainly significantly so in the case of the 52 milligram which you all know is the Mirena IUD. Whereas the copper IUD can increase menstrual bleeding and pelvic pain. But the copper IUD does have the advantage of not having any hormonal side effects and giving people whatever their normal cycle would be. So it is often felt to be a lot more natural and also people who do not like unpredictable bleeding prefer the reliability. In terms of increased bleeding, it does increase by up to 50%, but for people already having light periods this is not necessarily a significant increase. Hormonal side effects can definitely occur with the levonogestrel IUDs and it can be quite startling how strongly people can develop hormonal side effects considering its low dose. The other benefits of the 52 milligram levonogestrel IUD or Mirena is it can be used for endometrial protection in menopause hormone treatment and it is also a treatment for heavy menstrual bleeding, whereas the copper IUD can be used as a highly effective and the most effective form of emergency contraception if inserted within five days of unprotected sex. And both of them are of greater than 99% efficacy which is not affected by typical use.
 
So I will start with a case study as I often like to do. We have an 18-year-old and she is interested in contraception. She is a nulliparous woman, with light, regular periods and no regular partners but has occasional partners. So the question is, when Tana comes in to a consultation, do you discuss LARC over the pill or as well as the pill? And I think most people listening would say yes, they would discuss LARC but really the question is do you discuss LARC in the context of Implanon only, or do you offer IUDs? And at this point, if this was a face to face presentation, I am sure there would be some people who would say, well no actually I am a little bit unsure about whether I should offer IUDs to people who are young and nulliparous and perhaps having a slightly higher risk of STIs, and I think this is really important to tease out, because there is absolutely no reason why Tana cannot have an IUD. Why do people worry about IUDs in young people? We know that IUDs are a safe and extremely effective long term contraceptive option. And they have been available since the 1960s. Many studies as we mentioned, the Choice study, demonstrated a high satisfaction rate and continuation methods, and modern IUDs are highly effective. But uptake in Australia and other western countries is significantly lower than many other countries. So for example, in 2011, the estimated use of IUD rates in Australia was about 3.2% compared to for example 35% in Vietnam and Egypt and 30% in China. And this is because of historical complications and well publicised complications of copper IUD.
 
So one of the most common concerns health professionals and patients have is that IUDs increase the risk of pelvic inflammatory disease, which we know can lead to all sorts of problems including infertility, chronic pain and potentially even untreated sepsis can occur and death. Now we like to talk about the legacy of the Dalkon shield which was one of the original IUDs and is often blamed for high rates of PID where it was inserted in the US, because it had what they call a sort of multifilament string and it was thought this particular string allowed infection to track up the string and into the uterus. Now, the reality is that probably at the time the Dalkon shield was kicking around in the 50s and 60s, is that all IUDs increased the risk of pelvic inflammatory disease, because people were not trained to insert them properly, they certainly were not given any idea about the need for aseptic technique in a lot of cases, and a lot of these devices were actually less effective and more prone to other complications. So what that has left us with is the idea that young, unmarried people are more likely to be exposed to sexually transmitted infections and that if they have a sexually transmitted infection, when they have an IUD in place, that they will be of higher risk of PID. The reality is that this PID is related to insertion process, the organism involved is not always a sexually transmitted infection. And in fact the rate at which you are likely to get pelvic inflammatory disease really relates to your risk of exposure to something like chlamydia and then we know that all people with chlamydia regardless of having an IUD have a certain percentage of transition into pelvic inflammatory disease. So when I say it is related to the insertion process, what I mean is we are actually introducing foreign objects into the uterus via the cervix and that we might be pushing all sorts of bacteria through, again not always STIs, they could be anaerobic bacteria, and a lot of PID regardless of whether it relates to IUD does not have an organism identified. So 70% of all IUD does not have an organism identified on swabs, even though it is pretty much confirmed by diagnosis.
 
So we should screen people who are wanting IUDs as per guidelines, whether that be the Australian guidelines, Sexually Transmitted Infection Guidelines or the RACGP Red Book which I will bring up there. So, the RACGP Red Book recommends all people under 30 who are sexually active should have an annual chlamydia screen. Certainly people with multiple partners in the last three months or new partners, should also be screened for STIs. There is no indication for screening people for bacterial vaginosis prior to an IUD insertion even though BV is increasingly implicated in PID. And, also the idea that sex workers would not be suitable for IUDs is probably completely false, in fact I think sex workers generally have the best knowledge about keeping themselves safe from STIs and are certainly aware of when they need to screen and seek treatment. Now if someone does develop a PID with an IUD in situ, if we treat as per the guidelines, again the Australian STI guidelines have a great protocol on treatment of PID, and we do not remove the IUD, we leave it in place. We review all people with PID at 48 to 72 hours, but if they are improving we leave the IUD in but if they are not improving then we might have consideration to taking it out.
 
So again looking at all the studies on IUDs, the overall rate of PID of 1.6 cases per one thousand woman-years of use. And two other retrospective cohorts showed PID occurred in less than 1% and @% of patients regardless of IUD type or age. So again, your background risk of having PID relates to your background risk of chlamydia and then the rates of chlamydia progressing to PID. The risk is elevated only for the 20 days following insertion. It is usually quoted at around one in 300 IUD insertions for up to 20 days, and following that, it returns to baseline for up to eight years post-insertion. And we always recommend that people not put anything in their vagina, so no sex, no tampons, no sex toys, no swimming, spas or baths for 24 to 48 hours after insertion because with it with a dilated the cervical os a little bit, and we have left a little track open for infection to go up into the uterus and reproductive system. But after about 48 hours, that is considered to be a very low risk. And in fact, there is some thought that the mucus plug that forms with the Mirena IUD is actually probably pretty protective against PID.
 
Now the other one we hear a lot is that you cannot have an IUD if you have not been pregnant. And I see a lot of young people whose mothers actually tell them this because that is what their mothers were told when their mothers were looking into contraception. So what we know if that if you look at the UK medical eligibility criteria, it is a category one, if someone is nulliparous, so never been pregnant and an age greater than 20. Category two if they are less than 20. So usually category two means maybe a second line option rather than a first line, but I personally consider this to be a bit of historical data again relating to historical concerns about young people. There is no lower limit at which you can put an IUD in. A lot of it will relate to how well a person will tolerate the procedure. Because if you look at uterine development, it does not relate to having been pregnant, it relates to puberty. The uterus lengthens and changes shape during puberty and once someone is menstruating, generally their uterus has reached a size at which it is safe to insert an IUD. So basically, in theory, anyone having periods should be able to have an IUD, but a very young person might not tolerate it well or they might need sedation. And honestly the age can range, you know, we will certainly insert IUDs in 16-year-olds at SHINE if they will be able to tolerate the speculum and obviously all the other criteria are met including the mature minor which relates to South Australian law.
 
The appearance of the cervix is not a good indicator for ease of insertion. So I often get people referred to me where someone has commented that they have done a speculum exam and they talk about things like a nulliparous os, meaning a tight pinhole os and a sort of long, round cervix. Now, this is no indicator of how easy it is going to be to measure the uterus and insert. In fact, the vast majority of resistance to inserting an IUD actually occurs at the inner os which is you know, usually about a centimetre inside the cervix and you cannot see it. So I never tell a patient looking at them that they might have a more difficult IUD insertion based on their cervical appearance, because it is absolutely not true. And what we often see is that people who are perimenopausal or have given birth vaginally, there is a little bit of cervical stenosis or scarring that can occur, and that can actually make it more difficult to have an IUD. So I am typically more worried about a perimenopausal person in terms of IUD insertion than I am about someone who has never been pregnant.
 
Discomfort during insertion is an individual variation. So overall studies do show that people may have more pain with insertion, or more self-reported pain if they are nulliparous, but what I have found in my personal practice is a highly motivated, not anxious, nulliparous person will tolerate the procedure extremely well and that the people who tolerate IUDs best of all are the ones who are having them inserted for heavy, painful periods, because they have a frame of reference and they are actually really fed up and really motivated. So they know what a really bad period cramp feels like. The IUD insertion probably feels like that, but instead of lasting for one or two days, it lasts for a minute to 30 seconds sometimes.
 
So looking at studies of insertion, so for example in this New Zealand study of almost one thousand insertions did find that nulliparity was a factor associated with abandoned insertions, and was also a factor in practitioner reported difficulty, but 80% of insertions in nulliparous women in this study were rated as easy by the inserting doctor. A Family Planning study found that also people who are nulliparous or no vaginal delivery, so they had had a Caesarean or a termination or miscarriage, were also more likely to have an abandoned procedure. But 88.8% had a successful IUD as outpatients, and again 80% was rated easy by the inserting doctor. And the experience of the inserting practitioner is a factor, and ideally all inserters should be doing at least 10 to 12 IUDs, but the more you have done early on, the more comfortable you are and the easier it is to assess whether you need to abandon the procedure or whether you can proceed with perhaps some acceptable dilatation or a cervical block, whatever it is that you like to use. And patient anxiety is a massive factor in both pain of IUD insertions and basically you know, what we would say leading to people wanting us to stop the procedure. And also previous experience of a speculum exam. So if someone comes into my room and the first thing they say is I am here for an IUD, but I really hate getting Pap smears and I hate the idea of speculums and you know, I just need to get it over with, I am already feeling that there are some red flags there, that this person is actually not going to tolerate the IUD as well as someone who is pretty relaxed about speculum exams.
 
Now the best pain relief is what we call “vocal local”, and that is having an assistant who is there not only to help the inserter, but to help relax the patient. So, in my experience in Family Planning organisations in Darwin and Adelaide, is that the nurse is the most important person in the procedure. And quite often that is the person the patient thanks when they leave the room, because that is the person who has got them through. So essentially that person is chatting to them, how has your day been? You know, are you doing anything this afternoon? What books do you like to read? What movies are you going to watch on the weekend? All of these things distract the patient and often make them laugh, and they can also keep an eye on the patient to see when they are becoming distressed, because often the inserter is focussing heavily on what they are doing down at the cervix basically and also I think the “vocal local” is probably more effective than any other intervention I have ever seen including using local anaesthetic on the cervix, or any kind of oral pain relief.
 
So that brings me to the next question that was asked, a couple of times in fact. We now have the two levonogestrel IUDs here in Australia since February or March this year. So Mirena or Kyleena. And I have heard a number of pronunciations, but I say Mirena and Kyleena, that is just my Australian accent. So, the Kyleena is also referred to as the mini-Mirena, basically meaning that it is a smaller version and a lower hormonal dose than the Mirena which we have had in Australia for many, many years. So looking at the indications. The Kyleena is indicated only for contraception. It is licenced for up to five years of use, as is the Mirena. But the Mirena also has the additional indications of treatment of heavy menstrual bleeding and endometrial protection with menopause hormone treatment. So the Kyleena is the 19.5 milligrams of levonogestrel, versus the 52 milligrams, and interestingly the cumulative failure rate which is the same at one year of use, which is 0.2% is almost, well it is double at five years. So, you know, 1.45% versus 0.71%. So at five years, the Kyleena IUD is slightly less than 99% effective. Now is that an issue for people? I think we just are going to have to wait and see. If you say to someone, which IUD do you want? If efficacy is the most important thing, then maybe the Mirena is the one for you versus the Kyleena. In terms of the amount of hormone released with the Kyleena, the average release per 24 hours is 12.6 micrograms versus 20 micrograms for the Mirena. And in terms of the bleeding pattern, 12% of people with a Kyleena will have amenorrhoea at one year, and 26% will have infrequent bleeding, so probably what we are talking about there is people having you know, months of not having a period and having spotting maybe for two to three months or longer. Now that compares to the Mirena at around 16% to 20% depending on the studies of amenorrhoea rates at one year, and over half will stop having a regular period, which is often a big plus for people.
 
In terms of the frame of the device, the Kyleena is slightly narrower in terms of its arms, but the length is not much shorter. So it is still indicated for the same length of uterus, which is typically six centimetres or more. The Mirena has wider arms, so 32 by 32 millimetres versus 28 by 30 millimetres. But really where the significant difference in terms of pain and ease of insertion is, is probably the millimetre diameter of the placement tube. So it is 3.8 millimetres versus 4.4 millimetres. So armed with information, how do we choose? Well there is a little bit more to think about. Most of the data around the Kyleena comes from the Scandinavian study, I think there were five different Scandinavian countries, of a number of healthy, nulliparous or parous people, so they did not discriminate in the study, but they were aged between 21 and 40. So what they found and I should point out, this study included the Kyleena, the Mirena and the Jaydess, but I am only going to report on the Mirena and the Kyleena because the Jaydess is not available in Australia. And the mean number of bleeding or spotting days decreased similarly over time, with the greatest reduction in the first 90 days. So basically, spotting is common with all IUDs in the first three to five months, but for both the Mirena and Kyleena, spotting decreased at about the same rates over time and mostly within the first three months. So by three months with an IUD is often broadly predictive of the bleeding you are going to have.
 
Where it was really interesting, that 93.5% insertions were rated as easy by the inserter compared to the Mirena at 86.2%. Having said that, 0.8% were rated as very difficult for Kyleena and that was two out of the entire study, versus 1.6% for the Mirena, so that was four out of the entire study. But it was you know, a double statistical increase. There was no statistically significant difference in hormonal side effects between the Kyleena and the Mirena, and this is really quite interesting because often people are choosing the lowest dose of hormone that they can get because they have had hormonal side effects. Since Kyleena has been available in Australia, I am hearing anecdotally by IUD inserters that people are reporting less side effects with the Kyleena, but that may be a placebo effect where people knowing they have a lower hormone dose leads them to think that they have less side effects. The reason I think there is probably not a lot of difference between the hormonal side effects is that the Mirena is a significantly lower dose than any other form of hormonal contraception, and if you are going to be sensitive to that dose of hormone, you are probably going to be sensitive to even the slightest drop of progestogen, so you will get that with the Mirena.
 
In terms of the pain of placement, and this was evaluated by the subject, around 72.2% reported no pain or mild pain with insertion of the Kyleena versus oh, I think I have mixed that up, that should say about 85%, yes close to 90% with the Mirena, none or mild. With the Kyleena, only 3.7% of people reported the Kyleena as having severe pain at placement versus Mirena 6.7%. So you are seeing a sort of doubling with the Mirena compared to the Kyleena. And yes, I am just looking at my producer notes, the none or mild for the Mirena should have said 87%, 87.9% not 57.9. Interestingly in the study there were no failed insertions. So all Mirena and Kyleena IUDs were successfully placed.
 
So again, where does that leave us? Well, I think in the end, it comes down to the patient’s preference. So, I like to give people all the information. Sometimes they will ask me well, what would you do? And I will often say well my priorities might be different to yours, I might want much better bleeding control and I am not that worried about the pain, versus well I am really a bit anxious about this insertion and I am happy to take some breakthrough bleeding versus pain, or I want no hormonal side effects in which case I am going to go with the copper IUD. It really is important to take the time and this can be difficult for GPs often with our 10 or 15 minute consultations and so even when I am seeing people every 15 minutes in general practice, if I know someone is coming in for an IUD assessment I will make it a 30 minute appointment to give me that time.
 
So differentiating between the IUDs, so bleeding reduction with any levonogestrel IUD is likely compared to no hormonal side effects with the copper IUDs. The pain of insertion is something that might be significant to people who are anxious and you know, we have seen a number of people take the Kyleena as an option, having no previous experience with an IUD just because it just sounds better because they like the idea of potentially less pain. Take the time to correct the myths, so things around IUDs not being good for young people, causing damage, causing problems with fertility, because in fact they are completely reversible once you take them out. And often again, you are dealing with a parent’s emotional or fears around IUDs or previously bad experiences. Always explain about the spotting which will decrease with time in most people and can be managed. One of the things I often laugh about with patients, but the size of the package of the IUD is actually quite significant. The Mirenas and the Kyleenas come in an enormous box and you know, people often look at that box and go what is going to go inside me? So, if you have a picture of the actual size of an IUD, I show people that and say, and this is going to come in an enormous box, but it is this little tiny thing which is going to go inside your body. Always use words like discomfort or cramps rather than pain, because if you tell people to expect pain they are more likely to experience pain, and so if you say, this is going to be a painful insertion, you are already setting them up for failure. Encourage them to take any non-steroidal anti-inflammatories prior to an insertion. This will not help with the pain of insertion, but it does help with cramping afterwards and probably reduces the risk of expulsion because of cramping post insertion. I also say to people, do not necessarily expect to have pain when you go home, but do not go for a jog or go to the gym because it might trigger some more cramping and it might even trigger your uterus to try and push that IUD out. Be well hydrated on the day and have had breakfast or lunch so that you are not having low sugar. It seems insignificant but do not be late. People who are rushing because they could not find a park or you know, they could not find the address are often hyperventilating and that increases the risk of them having a vasovagal reaction during the insertion or after. And a trial of speculum might indicate the need for sedation. So with the change in cervical screening guidelines, we are seeing a number of people under 25 who have never had a speculum exam and have no idea what to expect during the IUD process. You do not insist that people have a speculum exam or a bimanual prior to an IUD if they have had a previous speculum exam and have not indicated they have concerns around speculum exams. But if they have never had one, they really need to know what that feels like, because I have had some people book an IUD appointment, come in, turns out they have never had a speculum, as soon as the speculum goes in, they go no, this is not for me, and they have wasted their time and possibly bought an IUD that they have decided not to use. And if they cannot tolerate a speculum, this is an indication for referral under sedation which may need to be a private referral.
 
So I will move onto depot because there was quite an interesting question around the use of the depot or DMPA, medoroxyprogesterone acetate, which is a progestogen only long acting reversible contraceptive, but it often gets ignored in the rush to promote IUDs and implants. But it is still a very effective and useful contraception. So as mentioned, its typical use is slightly less than its perfect use because it relates to the timing of the injection and making sure you do not miss out, and like all progestogens, it thickens the cervical mucus, but this one is also very, very high dose of progestogen, completely suppresses ovulation and it quite a high suppressant of oestradiol itself. Typically given in day one to five, but can be quick started at any time where you can either reasonably exclude pregnancy or organise a follow up pregnancy test.
 
Its only real contraindication is breast cancer, past or present. Because it is a high dose of progestogen, and one of the progestogens that we used in the original studies which showed a lot of thromboembolism it is often considered that the benefits outweigh, sorry the risks outweigh the benefits where there is a history of cardiovascular disease or multiple risk factors for arterial disease. So in this case, it is a medical eligibility criteria 3. Also liver tumours and cirrhosis and of course any unexplained vaginal bleeding. But people with a previous history of VTE or migraine with aura may actually use depot, as it is a MEC2.
 
Now depot is the LARC that does impair return to fertility, and so certainly there is a delay in return to fertility following discontinuation, but not for long term reduction in fertility. And certainly the delay in return probably relates to the length of use, so if someone has had to depot injections, they probably will return pretty quickly, but if they have been on it for years, it can take some time and the mean time of return to previous menstrual pattern is eight months after their last depot. So you can reassure people that 78% of people wishing to conceive will conceive within 12 months and fertility is considered to return to normal by 18 months. But when people are trying to conceive immediately, and they have not been informed of this, it can cause a lot of distress, so I have had a few people come to see me and say, well I stopped my depot six months ago and I still have not had a period. Now there is nothing I can do at that point to induce ovulation. It just has to work its way out of their system. But if say that person was 36 or 37, they have now got to wait potentially another year to try and conceive with all the corresponding declining fertility, so every time I do a depot review, I ask them what is their future plan for fertility, and when they start to tell me that they are thinking of conceiving in the next 12 months, then I start to say, well I think we really need to stop your depot now and use something else.
 
I mentioned that the depot was licenced for use at that 12 to 14 weeks, and that is in the MIMS, so that is the Australian indication, it is actually I think 13 weeks in the UK. It is certainly okay to give it greater than 14 weeks if they have not had any unprotected sex since that 14 weeks when it was due, but they will need to be advised to use condoms or abstain for another seven days, and if it is more than 14, and they have had unprotected sex there is probably a low risk of pregnancy if it is a couple of weeks late, but we consider this to be a quick start of contraception so again you need to discuss the chance that they might be pregnant and the need that they have for follow pregnancy testing at four weeks.
 
The other big question I hear about and was one of the questions for tonight’s presentation was the risk of bone density and depot, and depot is the only hormonal contraception that has this effect, again because it is the only one which is also completely suppresses oestradiol. And there are definitely reductions in bone mineral density of the hip and spine in people who use it over two years, and it does increase over four years. After this you know, it probably stabilises but what is the most important thing to remember is, there is no evidence of increased fracture risk in people who use depot. So people regain most of their bone mineral density after they stop, and the risk of osteoporosis and minimal trauma fractures is around the 60s and 70s, which is typically you know, 20 years after they stopped their depot. Or at least 10 years after they have stopped their depot. But we do not recommend it necessarily as a first line so it can be used in young people who are still putting on their bone stores and people over 45 who are approaching menopause if other methods are intolerable or unacceptable. And I recommend that people be assessed for osteoporosis for new users and every two years. Now, this does not mean I do not recommend any kind of blood test or bone density levels, but really that you should just have this discussion around risk factors including smoking, alcohol, family history, dairy intake and exercise, and if anyone is concerned when you discuss this, think about changing them to something else. And we do not recommend depot beyond the age of 50 for this reason, as well as some potential cardiovascular risk factors.
 
Weight gain is variable if you look at the studies. But there is certainly a causal association possible with some studies finding an average weight gain of 2% to 6%. And weight gain is more likely in certain groups, in particular people under 18 with already baseline BMI of over 30, so these people are the ones that tend to do worse in terms of weight gain, and some studies have shown that early weight gain is more significant, so if people have gained greater than 5% of body weight which is around 20% to 25% depending on the study, these people are the ones that continue to gain further weight. So a weight gain of more than 5% early on, think about discontinuing the depot injection.
 
There were also a number of questions around LARC and mood. So, in particular the Implanon, someone asked the question, they had seen a study that it was a major cause of depression in teens and premenopausal people. And a couple of people were asking you know, do we need to remove the LARCs if they develop mood disorder? Now, I cannot comment on the presentation that someone else has seen because I have not seen the evidence, so the evidence I am aware of and what I could find doing a literature review mainly centred on a Danish study that was published in 2016 which linked all hormonal contraception to depression, although interestingly, Implanon was not included in that particular study. So they found an association between first time use of antidepressant and hormonal contraception, but people who had never used contraception had a 1.7 per hundred women-years risk of starting antidepressants for the first time compared to 2.2 per hundred women-years who had previously used or were using contraception, and that equated to an additional one in 200 prescriptions of antidepressants for the first time. It was an observational study and no causal link was found, and what we advise with previous or new depression is not contraindication but the possibility should be advised and patients should be encouraged to return for review if symptoms develop. So again, looking at a few different studies there is some support for mood-related side effects of hormonal contraception, most commonly in people with a history of depression. And we know that hormones affect neurotransmitters, so this should not be a surprise. But some people may experience beneficial effects of hormonal contraception use, specifically on premenstrual mood symptoms, and also if they are having heavy painful periods, people with endometriosis who are missing school, work, are going to have a more positive mental outcome from treating that pain and bleeding than potentially they are likely to get depression from their hormonal contraception. And as far as I guess adolescents and perimenopausal people, unintended pregnancy and untreated menopausal symptoms are going to be associated with poorer health outcomes overall than potentially any sort of hormones. If you can, if someone is reporting these symptoms or you are worried about their risk, consider a copper IUD. And one of the questions was you know, I would hate to remove a LARC if I was not sure if someone’s depression was caused by their LARC. I will say in the end sometimes that is what you have to do if only to prove to yourself and the patient and postpartum depression is particularly problematic, because a lot of people are given Implanon as their postpartum medication and then they are depressed and really the only way to tease that out is to remove the Implanon and some of these people are having quite significant symptoms including suicidal thoughts. So if you can, try and get them to have the copper IUD before you take the Implanon out, but it is not always possible.
 
So there are a couple of questions about IUDs and pregnancies, and so someone asked why do we need to remove IUDs if someone is pregnant? So there is very strong evidence to support the fact that people who become pregnant with an IUD in situ are at greater risk of adverse pregnancy outcomes including spontaneous abortion, particularly second trimester septic abortion and pre-term delivery and chorioamnionitis. From limited evidence, it does appear that removing the IUD early in the pregnancy helps improve the outcomes, but it does not completely eliminate the risks of these outcomes later in pregnancy.
 
In terms of removing an IUD, and do not do this at all if you are anxious about it, please refer them on, but it should be possible to safely remove an IUD in the first trimester if the strings are visible. There is no need for prophylactic antibiotics and if you do need an instrumental procedure to remove due to missing strings, then you would need ultrasound guidance and antibiotic cover, and this would be something done by a specialist in hospital. But certainly in that first trimester, if you can take the strings, I would advise the patient that it is possible that removing the IUD will cause a miscarriage but it is probably more possible that leaving it in will cause a miscarriage. If it is in the second trimester, it may be possible to remove an IUD if the strings are visible and the ultrasound indicates that removal will not disrupt the placenta and membranes, but again, this would be done in hospital with the ability to take someone to theatre if they started to have a second trimester miscarriage.
 
There was another question about IUDs and ectopic pregnancy. And yes, it is actually true that the absolute risk of ectopic pregnancy in all IUD users is low, particularly the levonogestrel, but if pregnancy occurs the relative likelihood of the pregnancy being ectopic is actually increased, and we are not really sure what the mechanisms are there, whether it is to do with inflammation of the fallopian tubes due to the IUD being in place, whether this is both levonogestrel and the copper IUD, because copper IUD numbers overall are a bit lower. But the reality is, the overall rates of pregnancy of non-IUD users is higher, and therefore the rate of ectopic pregnancy is higher. So for example, the recent studies on Kyleena said that the incidence of ectopic pregnancy is 0.2 per hundred women-years, but in women not using any contraception, the rate of ectopic pregnancy is 0.3 to 0.5 per hundred women-years, because they are more likely to be pregnant overall and therefore have a percentage of ectopic pregnancy. But because of this risk, someone who does have a pregnancy with an IUD in situ should have an urgent scan to locate the pregnancy and confirm it is not ectopic.
 
And then another question which is a bit of a common theme throughout the series and with the last presentation and I have showed this slide before, but as I said it is a common question. Management of troublesome bleeding on LARC. And this is the downloadable fact sheet that you can get from FPAA or any Family Planning website, but this is breaking it down into a few different slides. So it is really important to counsel people about expected bleeding patterns, and first of all emphasising that all bleeding is likely to improve with time, but that we can help manage it proactively. And with the Implanon, about one in five people will stop having a period, three out of five will either have lighter regular bleeding or infrequent irregular bleeding, and one out of five will have frequent or more prolonged bleeding, so either spotting all the time, a couple of weeks every month, or having periods that last two weeks. But that approximately half with frequent or prolonged bleeding will improve after three months and another 50% of people will improve from three months to six months.
 
With the hormonal IUD, again frequent spotting or bleeding in the first three to five months, and the copper IUD spotting again around that time frame, and that most people with hormonal IUD get lighter periods or they may stop or become infrequent. With the depot, around half of people will have no periods and usually that will occur by the second injection, around one in six will have infrequent irregular bleeding and a third will have frequent or prolonged bleeding. Amenorrhoea is likely to increase over time and while depot is not an indication for heavy menstrual bleeding, I have used it successfully in some people with heavy menstrual bleeding who had, you know, they could not tolerate any of the other treatments, could not have the pill for various reasons, did not want an IUD or had had one before and did not like it. So it is occasionally useful in heavy menstrual bleeding because it does suppress ovulation and so completely. And make sure you let people know there are things you can do for the bleeding. So, I will say to people, do not wait for three months, come back in a month if it is bothering you, come back in a week if it is bothering you. There are things we can do. We need to make sure we have excluded other causes, are they pregnant? Chlamydia in particular is a big cause of breakthrough bleeding. Are they starting their enzyme inducing medications that has affected their implant? And do they have any vaginal, cervical or uterine pathology? So I would say, we should not be doing co-testing people within three months of starting a hormone or contraception, it is not indicated because that bleeding is unlikely to be suspicious for cervical cancer, because there is another reason for it. But certainly if someone starts to breakthrough bleed after a year of no bleeding on their LARC, then I would be a little bit more worried. Make sure they know that their contraception is working as contraception, it is just not working as bleeding control, and make sure that we can manage them medically. We can take the implant or the IUD out at any time and the depot can be stopped.
 
So if someone has no contraindications to the combined oral contraceptive pill, this pretty much always fixes the problem. Take it continuously or cyclically, I usually think cyclically is easiest for three months, or you can give them a five day course of an NSAID or tranexamic acid, but this really only works for heavy cyclical bleeding because it is only recommended for five days at a time.
 
There is less evidence for these second line options, but certainly if someone cannot tolerate a pill, then you could add in some progestogen, norethisterone 5 mg three times a day works very well, but lots and lots of progestogenic side effects. Lower evidence for the levonogestrel progestogen only minipill, the 31 microgram twice a day for 20 days. Certainly if someone has come to their fourth year of their hormonal IUD or their third year of their implant, removing it and replacing it early can be beneficial, or shortening the interval between the depot injections from 12 to 10 weeks.
 
And then we also had a lot of questions about LARC at menopause and I think this is something that is not well taught in I guess our training and when do we stop and change over? And the guidelines can be confusing because they have changed in the last five years, and then they have changed again with COVID, which is even more confusing. So we know that fertility declines significantly after the age of 37, and the age at 45 it is approximately 1% each month. I always say to people who want to get pregnant over 45, it is likely to be difficult, but if they do not want to get pregnant over 45, they can be that one in 100 or one in the million at 50 or 51. So, using contraception should relate to how badly you do not want to get pregnant. So less than one in 100 people conceive over 50, and we think that at 55 all natural fertility has declined. Certainly people who are older, over 45 or over 50, they do have increased risk of foetal abnormality, miscarriage and premature delivery. And we recommend that people stop depot and the combined hormonal contraceptives at age 50, and that all contraception can be stopped at age 55.
 
So, this is a question that was repeated and I have showed this table before but I think it is worth reviewing. This is the off licence, off label recommendations for IUD removal when inserted over the age of 40. So any of the copper IUDs available in Australia, the Copper T, the Load375 or short Copper T, if they are inserted over the age of 40, then they can be retained until one year after the last period that occurs over the age of 50. If they are under the age of 50, then we wait two years before removing it, because again, we are extremely conservative in risk of pregnancy. Now, previous advice about the 52 milligram Mirena was that if it was inserted over 45 it could be left in for seven years for contraception at which time it needed to be removed or replaced. What we now say is that we think it is actually still reliable contraception if it is inserted from the age of 45 up until the age of 55 if being used for contraception or if it is used for heavy menstrual bleeding if they remain amenorrhoeic, we know it is controlling their symptoms. So again, this is off label but well supported by national and international guidelines, the UK Faculty of Sexual and Reproductive Health and FPAA.
 
What do we do if someone is not over the age of 50 and their Mirena is in place, how do we determine menopause is the question. This is the one indication for checking FSH levels in people over 45. So if they are over 50, they have had a Mirena in situ, and they are not having a period, we do a serum FSH and if it is over 30, then we leave the IUD in for another year, again just bearing in mind the premenopausal fluctuations of FSH and then we remove the IUD. If they have got them to 55, we take it out anyway, we do not really need to worry about the FSH levels. This is not an indication for the 19.5 milligram Kyleena IUD. That is removed and replaced at five years regardless of age. And with the 52 milligram levonogestrel used for endometrial protection in menopause hormone therapy, must be replaced every five years, again regardless of age because if it has only been studied for endometrial protection up to five years of use.
 
In terms of IUD and menopause hormone therapy, this was a question that came through about what is the risk of systemic versus local progestogen? Now there are not a lot of studies done on the IUD as part of menopause hormone treatment and breast cancer. A lot of studies just say it is safe for endometrial protection, but not really any data around breast cancer risk as part of MHT. So the consistent data on postmenopausal MHT is that the addition of any progestogen to oestrogen does increase the risk of breast cancer diagnosis compared with oestrogen alone, which is actually a completely foreign concept to what I was taught in medical school, which is that all breast cancer is oestrogen. So what we think is that oestrogen does not initiate or promote breast cancer on its own, it is when progestogen is exposed to oestrogen stimulated breast tissue that there is an increase in the diagnosis of breast cancer. So, oestrogen alone transdermal MHT does not increase the risk of breast cancer, but adding in some of the other progestogens does.
 
In all of the literature, micronised progestogen appears to the safest form of progestogen based on this literature review, and it has no increased breast cancer risk up to five years and probably beyond that. Now the use of the levonogestrel IUD does appear to reduce systemic side effects and so that has been extrapolated to say that because the breast tissue is exposed to less progestogen that it would be safer than another form of oral or topical progestogen, but there is no evidence really to support that. So if someone wants the safest form of MHT and they cannot tolerate micronised progestogen and I have had a few people who cannot tolerate the side effects, then in theory the levonogestrel IUD would be the next safest one, but I cannot provide evidence to support that. And I do tell patients that. I tell them this is the theory but there is not any evidence to support that.
 
In terms of hormone and overall cancers, so contraception and MHT, there was a recent Lancet study that showed younger people starting MHT before the age of 45 had a higher breast cancer risk, but we have to understand that if they are going through menopause before 45, they are actually having a lower risk than their same aged controls who are still having natural hormones. So if the menopause hormone therapy restores their cancer risk to what it would be if they had not gone through early menopause. Overall risk of premature morbidity and mortality for people who go through early menopause is quite high due to things like cardiovascular disease and fractures which lead to complications. And other studies show hormonal contraception reduces lifetime cancer rates because it leads to lower ovarian cancer and endometrial cancer and possibly colorectal cancer.
 
So again when it comes to menopause hormone treatment you can reassure your patients that their overall risk of breast cancer is you know, might be slightly increased by their MHT but compared to other risk factors it is either comparable or less and that it is safe to use specific types of progestogen in particular. Now this is the Australian Menopause Society’s equivalent dose of MHT, so you can see one of the recommendations for progestogen supplements with something that is oestrogen only, so the transdermal topical oestrogen for example, and again the Mirena is licenced for five years for low and medium use oestrogen, but interestingly there is no evidence to support the Mirena for use in the very high doses, so the 75 to 100 micrograms of oestradiol patches are actually needing an oral dose of progestogen to counteract the risk of endometrial cancers. So just to be aware, Mirena is licenced for low to medium dose of oestrogen.
 
So I think we have covered the recommendations around menopause hormone treatment and also use of Mirena at menopause, so I am just going to throw another spanner into the works and talk about pre-COVID recommendations for IUDs. So as mentioned, current guidelines support the extended use of Mirena, inserted age greater than 45, but the UK Faculty of Sexual Reproductive Use does support the change over of a 52 milligram levonogestrel IUD without additional precautions when the IUD is between five and seven years post insertion if it was inserted under the age of 45. So that is not something we would recommend to patients, but if someone presents, but if someone presents to your clinic and their IUD has been in place for five and a half years, you can replace it without insisting on three weeks of no unprotected sex. Obviously would you want a negative pregnancy test on the spot, and they would need a follow up test at least three weeks after the last unprotected sex. It is not ideal, but it is considered to be safe to do because the risk of pregnancy of up to seven years with a 52 milligram levonogestrel IUD is considered quite low. And this of course does not apply to the Kyleena or if being used for menopause hormone treatment. And RANZCOG has also come out to support the extended use of the 52 milligram levonogestrel IUD up to six years.
 
Now I think I will pause there and not go into any more COVID recommendations, because I think that may muddy the water, just to say again that the use of IUDs around menopause in those extended use recommendations so, at 40 years for copper IUDs, safe to leave till 55 and at 45 years for the Mirena IUD safe to leave to the age of 55. If you have to you can replace an IUD that was inserted under the age of 45 between five and seven years with the additional precautions of a pregnancy test at the time and follow up at least three weeks later. And again, just making the patient aware that if they are pregnant with an IUD in place that they need to have it removed and that removal may cause complications with the ongoing pregnancy as in terms of a miscarriage. But it will certainly cause problems if it is not removed in a lot of cases.
 
So, what I will do there, again I will just have a look and see, there was a question that I did not have a slide for but I would like to address before Jess starts asking some of the newer questions, and I think it is important to be aware about training for the LARC. So I believe in most States and Territories, the only LARC training is available via Family Planning organisations. Here in South Australia, we have had one really highly motivated GP who has been providing RACGP accredited IUD training for many years by the name Meredith Frearson, and we have also been piloting a train the trainer IUD program because the biggest problem with IUD training is if it is done by someone like Family Planning, we actually have to provide clinics for patients, whereas if you can have a trainer come into your practice, you can organise the patients yourself and again the numbers of I guess, IUD insertions you have to do for Family Planning is typically seven or eight, whereas if it is in your own practice, often a lot of trainers are comfortable with you doing four or five which is a lot easier to accommodate, and certainly for insurance reasons it is  really important to have IUD training, depending on your insurer, even if you trained overseas or trained in hospital or under an O&G placement.
 
 
Jessica:
 
Okay, Amy. We are going at the same time. Okay, so we have got a few questions here that have come through. And as per usual, if you have any questions and you have not already submitted any, please do so. Now is the time. So, and again, we are not using the raise your hand this evening, so just pop any questions you have through to the chat. Sorry, not the chat box, the Question and Answer box. So the first question is, is Mirena effective for seven years if it is inserted in the late 40s?
 
 
Amy:
 
Yes. So if it is inserted at the age of 45, the previous recommendation did say it was effective for up to seven years. But in fact we now say it is effective up to the age of 55 if it is inserted at 45 years or more. If it is inserted under 45, then it is effective for up to seven years if you follow the UK Faculty guidelines. But we do not recommend that to patients, we do not let them know that basically because we do not want them coming in even later. But yes, we think it is effective up to seven years regardless of age of insertion.
 
 
Jessica:
 
Okay. So we have got a Darwin-related question here. Are the copper coil shorts still available? I cannot seem to get any in Darwin.
 
 
Amy:
 
Yes, and they have always been the hardest ones to get. And I am glad that was a Darwin question, because I know we used to have to order them in about six weeks in advance when I worked at Family Planning. Because IUDs are medical devices, you can actually purchase them from the company that makes them without a script. So if you are a regular inserter of IUDs it might be worth contacting, there are two companies, there is Medical Industries and you can contact their pharmaceutical rep directly and organise to keep some stock and have at least one short copper IUD in place, because if you measure someone under seven centimetres and you have got the copper IUDs, the short copper is licenced for use in under seven, the standard is over seven centimetres and you can actually just switch them out and you could also often do what we do, which is provide them at a lower cost if you can sort of purchase a batch of them. You know, we buy a batch of 10 Copper Ts at a time, and that is why we can charge about 80 or 90 dollars versus some pharmacies charging 120. But yes if you can order them in in advance, or have a relationship with a local pharmacy and ask them to keep one in stock for you, and know to send the patient directly to that pharmacy, that is a really useful thing.
 
 
Jessica:
 
Do we currently know about the risk of ectopic pregnancy with IUDs, please?
 
 
Amy:
 
Yes. Yes, so what I mentioned in one of the slides is that yes, absolutely if someone has an IUD in place for probably inflammatory reasons, they have a higher risk of ectopic pregnancy if they were to get pregnant, but they have a lower risk overall of ectopic pregnancy compared to someone who is not using an IUD, because the rates of pregnancy overall are higher in people who are not using IUDs. So if someone is pregnant with an IUD in place, they are more likely to have I think it is about a three to six times increased risk of ectopic pregnancy, but overall rates of ectopic pregnancy are higher in non-users of IUDs.
 
 
Jessica:
 
It is interesting that Kyleena has a lower dose of progestogen than Mirena and also risk of PV bleeding is lower. Is it due to different types of progestogen content?
 
 
Amy:
 
Yes. So actually, so the Kyleena has the lower dose of progestogen. It is the same progestogen, so it is levonogestrel, it does not have lower rates of POV bleeding, it has higher rates. So basically the spotting for the first three to five months is the same, but people are more likely to become amenorrhoeic with the Mirena with the slightly higher dose of levonogestrel, and less likely to become completely amenorrhoeic with the Kyleena and it is for this reason that the Kyleena has no indication for heavy menstrual bleeding. It is purely a contraceptive. Where it is most likely to be useful is going to in nulliparous people because we know that again the pain of insertion is certainly reported as less, but also probably the post uterine irritability. When you have never had something in your uterus and you have got a slightly smaller IUD then you are much more likely to get less pain and cramping in those sort of months after insertion.
 
 
Jessica:
 
What is the ideal timing for an IUD insertion? When is it going to be effective?
 
 
Amy:
 
Yes, that is also interesting because it does depend on the type of IUD. So copper IUDs have an immediate effect because they are toxic to sperm the minute the sperm comes into the reproductive tract and we actually say you can safely insert a copper IUD at day 12 of a normal menstrual cycle because we think that ovulation, the earliest it can occur is day seven, and then you have got that five extra days of emergency contraceptive effect. So, a copper IUD that is inserted when there is no risk of pregnancy is immediately effective or inserted up to day 12. With the Mirena IUD and indeed the Kyleena, inserted day one to five or one to seven is the licenced indication, and it is immediately effective again based on that, but if it is inserted at any time outside of the cycle, seven days of condoms or alternative contraception before it is effective. And that also includes if you are changing from another contraception. So if for example you have got an Implanon and you put a copper IUD in, you can take the Implanon out on the same day, but if it is a Mirena or a Kyleena, then you need to take the Implanon out seven days later so that the full effect of the mucus plug and the endometrial atrophy are working with the Mirena and the Kyleena IUD.
 
 
Jessica:
 
Some patients come for DMPA at less than 12 weeks. How early can we use it?
 
 
Amy:
 
Well we can certainly give it anywhere from 10 weeks and often people are spotting earlier than 12 weeks which is often the case, so they go for 10 or 11 weeks and then they start to spot, then we give it a bit early. But we do not recommend giving it earlier than 10 weeks because you are probably going to get a cumulative dose of progestogen if you are giving it earlier than 10 weeks every time.
 
 
Jessica:
 
Regarding depot, in the situation it is overdue and the patient has had UPSI, you inject and do a pregnancy test at four weeks. Is that right? What is the risk to the pregnancy?
 
 
Amy:
 
Yes, and so for those of you not familiar with UPSI, it is unprotected sexual intercourse. So in that case, if it is over 14 weeks, it is probably, well it is the same as quick starting. So we say that depot is suitable for quick starting someone who is potentially having unprotected sex and not using any form of hormonal contraception. In the studies, there has not been any real evidence of any effect on an ongoing pregnancy or a foetus. They used to talk about, they called it virilisation of a female foetus but the reality is, that that has not been borne out in any real studies. So yes, if someone is pregnant with depot, there is no effect on the foetus or the ongoing pregnancy. They will have to wait for the depot to get out of their system and we do the follow up pregnancy test in a week, mainly because they are, you know, their bleeding patterns could be altered by the depot and we do not want them to find out they are pregnant at three months instead of one month and it be too late for certain types of termination if that is what they want to do.
 
 
Jessica:
 
Okay, so we have got a question about Mirena and Kyleena. Just to clarify the mini Mirena and Kyleena is not indicated in postmenopausal women on HRT even after the age of 55? At what stage, age do you stop using the Mirena in postmenopausal women who remain on low dose HRT? What is the evidence with regards to breast cancer in postmenopausal women who are on low dose oestrogen and the Mirena versus Prometrium?
 
 
Amy:
 
Yes, so the first point, definitely Kyleena is not indicated for HRT. It has not been studied for that benefit and it does not matter how far after menopause they are, because if you are giving oestrogen in theory they are not menopausal. They have got the same risk of cancer and endometrial hyperplasia as they have at any age. In terms of how long to continue it for, it really depends on the length of symptoms, so you know around 20% of people will continue to have menopausal symptoms more than 10 years after menopause, and I have got patients in their 80s who have seriously severe hot flushes when they try and stop their menopause hormone treatment. So, in theory a Mirena you could replace every five years for as long as you like. Most gynaecologists and inserters would at that point say maybe they should try a different form of progestogen just because of the worries how well they tolerate the actual speculum exams if they are having vaginal atrophy, but in theory they could have a Mirena every five years until they die basically, along with their MHT. Any form of MHT can be continued as long as there are big gaps in the MHT, so I think you know, I talked a bit before about the idea that the risk of cardiovascular disease is if you have breaks from oestrogen and then you lose that cardiovascular protection and arteries start to harden and block with cholesterol plaques. But if you stay on your MHT from the age of 55 to 85, you have no increased risk of cardiovascular disease. So I guess again, Kyleena is never indicated for menopause hormone treatment. Mirena has to be replaced every five years, and there is no specific upper limit to age or length of time being on MHT as long as it is started within about five years of menopause ideally and under the age of 60 and no big gaps in your MHT.
 
 
Jessica:
 
If the Implanon is inserted at 50 years old, is there evidence showing that it is still effective to be left in for more than three years?
 
 
Amy:
 
Yes, not specifically at age 50. So again, these studies have not actually been done. So the recommendation would be that Implanon be replaced every three years regardless of age. Now I understand your point which is again that background fertility is going to be extremely low in someone over the age of 50, but the recommendations would say at three years. Now, there is some recommendations particularly out of the UK Faculty around extending Implanon to four years for anyone of any age, and they have shown that pregnancy rates at four years are comparable to three years and in fact because of COVID they have made recommendations that you can leave Implanon to four years, but those studies were based on smallish numbers so you know, each study I think was no more than 300 or 400 people. So that would be one where you would have to have a very thorough discussion with the patient and what would be their background risk of pregnancy and what would be their concerns if an unintended pregnancy was disastrous for them, then you know, if you can safely replace it at three years, do that.
 
 
Jessica:
 
So we have to postpone insertion of IUD if swab positive for BV or thrush? Or is it only for the STI?
 
 
Amy:
 
Yes, typically it is only for the STIs. Thrush is not an issue at all with IUD insertions. You can offer treatment bearing in mind they should not be putting anything in their vagina for the first 48 hours. BV, if they test positive, we often like to get them started on the treatment but it is probably best to have them on the treatment around the time of insertion because we know that the recurrent rates of BV are actually quite high, so if you were to treat them say three weeks before the insertion, they might conceivably have it back by the time you put in the IUD. But as long as they start the first day of treatment for BV, then definitely I would say on the day of insertion, if they are having the first day, that is fine, and that is often the most practical thing, they come in and you give them the script on the day. As you say, for STIs like chlamydia or gonorrhoea, ideally we like them to be treated at least a week before chlamydia, and with the gonorrhoea we like them to have a test at two weeks post treatment before we will insert the IUD.
 
 
Jessica:
 
Okay, so we have got a long question here. Thanks for a fabulous presentation as usual. When timing the insertion of the LNG IUD the guidelines emphasise how important it is to exclude pregnancy prior to insertion. My understanding is that this is because of the conundrum faced if someone is later found to be pregnant with an IUD in situ and wants to continue that pregnancy for the reasons you mentioned before, higher risk of miscarriage, poor pregnancy outcomes et cetera. However if the patient is aware of this risk and still wants an LNG IUD inserted, is it reasonable to go ahead with the insertion and document their acceptance of their risk, e.g. if they said they would like to have a termination anyway.
 
 
Amy:
 
Yes, and that is a really nuanced question because everyone who is an inserter I guess has a different threshold. So yes, the risk is of course if you quick start that they have an issue with the pregnancy and it, look it is possible that someone who might be very clear prior to insertion that they would have a termination when they find themselves pregnant have an emotional reaction and actually want to continue the pregnancy. So there is I guess always the risk that people will change their mind. I think if yes, you had someone who was at high risk of unintended pregnancy, if you made them delay, I think again you have to have a different threshold. If you are sending someone away for three weeks and during that time they are potentially going to have unprotected sex, then it might be better to insert on the day. But as you say, the most important thing is to have a detailed discussion about that risk, and document every single step of that and your reason for putting it in. I think you know the best way around that is again a thorough discussion prior to the insertion if you can. If you have the ability to do the assessment and it is not you know, the same sort of insertion which is becoming increasingly common, then you can really emphasise how comfortable you would be for these reasons inserting, but yes, while it is generally not recommended to quick start an IUD I think there are always going to be circumstances where you have to make an exception. Another one you know, might be you have to think about what is your ability to follow them up? So on the one hand you might want to do someone’s IUD because you know that they are not likely to attend another appointment. On the other hand you do not want to do the IUD because they are not likely to do a follow up pregnancy test and again, potentially have those complications. So yes, I guess the answer is yes, you could do it. I think you would be supported by the majority of experts in the field, but I think you really have to be careful about who you do it for and documenting it thoroughly.
 
 
Jessica:
 
Could you please repeat the name of the doctor who trains for IUD insertion in SA and any other organisation in South Australia?
 
 
Amy:
 
So, Meredith Frearson does do IUD training but she typically only does it through SAPMEA Organisation. SHINE SA does IUD training. At the moment, I think there are a couple of other IUD trainers but I do not actually have their names at hand. But certainly if you are interested in IUD training, yes, the SHINE SA website does have a section on that.
 
 
Jessica:
 
Do we have to advise patients to not have unprotected sex for certain days before removing the IUD?
 
 
Amy:
 
Yes, and it is because of how long the sperm lives in the reproductive system. So, basically we know that sperm can live for at least five days, it is possibly up to seven days and certainly if there is no other barrier method involved and someone has had unprotected sex in the last seven days, there is a theoretical risk that they could get pregnant with the removal of any type of IUD, so either hormonal or copper IUD. So, we do typically recommend no unprotected sex for seven days. Now having said that, often you do not even know why someone is coming in to see you and they turn up and you say when was the last time you had unprotected sex? Oh, three nights ago. So then you say, well how badly do you not want to get pregnant? You know are you having the IUD removed because you are thinking about getting pregnant in six months, but it would not be a disaster, then we can take it out today. If it is an unacceptable risk, maybe we need to get you back in seven days or the other alternative is to offer them emergency contraception bearing in mind that that is not 100% effective. So ideally if you have forewarning, then seven days of no unprotected sex before removal of any IUD.
 
 
Jessica:
 
Regarding postpartum IUD insertion, when is the ideal period for insertion and why?
 
 
Amy:
 
Again it very much depends on the IUD. So, the recommendations for the copper IUD is actually that it can be inserted within 48 hours postpartum. Now this is not very common and it is actually something that we are just starting to have here in South Australia, so there is the O&G Department at the Lyell McEwin Hospital here in Adelaide is actually doing immediate postpartum IUD insertions. After 48 hours and before four to six weeks, there is an increased risk of expulsion and also you can worry about the uterus involuting, so the Mirena IUD and the Kyleena actually both say insertion after six weeks postpartum or when the uterus has finished involuting. And the copper again at four weeks postpartum can be inserted but most inserters are most comfortable with inserting it around six weeks postpartum. So if you do happen to be working with you know for example on a postnatal ward, it is a good idea to have a conversation with your patients about some other form of contraception prior to their IUD because it is unlikely that they are going to get an IUD insertion before six weeks. And the risk of perforation is higher in the immediate postpartum period, but up to 36 weeks postpartum.
 
 
Jessica:
 
So just regarding the training again, is it acceptable to have IUD training in a hospital or is it essential to have it with SHINE SA?
 
 
Amy:
 
Yes, it again depends on your insurer. So a lot of the insurers will say that someone must have undergone appropriate IUD training and that is often considered by at least two of the insurers to be either Family Planning or RACGP accredited training. And there are not a lot of RACGP accredited training, that would be again, Meredith has had her program accredited. And it is frustrating and I totally understand if you have done a Diploma at RANZCOG and have been doing you know, IUDs all the time in hospital, even if you have done a six month rotation, it is not that again, you are considered to be inferior to having done training with SHINE or Family Planning Welfare NT or any other FPOs, it is just that your insurer often will not accept it. So sometimes I do recommend people check and shop around with their insurer if they can find an insurer that will accept their previous experience then switch to that insurer if you are otherwise confident in your competency for IUDs.
 
 
Jessica:
 
So Mirena could be in situ for nearly 10 years without replacement if inserted post 45 years old?
 
 
Amy:
 
Yes, absolutely. And while all IUDs have to be removed at some point, the actual devices themselves are pretty safe to leave in for those time frames. So we know there is even in China for example, there is a ringless IUD which is basically just left in until menopause. So yes, there does not seem to be any harm or complications. There is no increase in scarring or adhesions. Obviously in some people who are under 50, you know if they left it in forever, they would start to bleed again if it was the Mirena and the copper wears out in terms of the contraceptive effect in terms of the copper, but the actual device itself is not causing any problems for up to 10 years.
 
 
Jessica:
 
What is the ease of insertion of the copper IUD compared to the Mirena and the tolerability of the copper IUD compared to the Mirena?
 
 
Amy:
 
Yes, it is a good question because I think it depends on the individual’s response. So, again as an inserter, there are some people who are just really easy insertions because it has nothing to do with pregnancy, age, it is just they are a bit more relaxed, they have done their research, they have had previous issues, they are motivated. And then also it comes down to what they want out of their contraception. So, someone who has had a lot of hormonal side effects and really hates the idea of hormones or you know, wants something natural, is much more likely to put up with a bit of increased bleeding than someone who just wants you know, a nice light period or no periods at all. And so what we are seeing, certainly since I started inserting is an increased number of copper IUDs for that reason, that people are doing their research, they want something that is non-hormonal and they do not mind if there period is two or three days heavier or it lasts a few extra days. In terms of devices, the Kyleena in my experience, the ones that I have done were easier than the Mirenas, including one failed Mirena insertion that I happened to have a spare Kyleena that I could use. With the copper IUDs, I would probably say that the Multiload is easier to insert than the copper IUD because the tube that it is in is a bit more flexible, but do I think there is much of a difference between coppers overall and Mirenas? Probably not. Generally if I had concerns about someone who was nulliparous, my choice would be a Kyleena or a hormonal IUD Multiload for a copper IUD, but it really would be ideal to have both in the room so that when you sound the uterus and measure and feel everything, that is really the first time you get that real indication of how the IUD insertion is going to go.
 
 
Jessica:
 
So just going back to the postpartum IUD insertion as you mentioned, is there any difference for women who have an LSCS versus vaginal birth?
 
 
Amy:
 
Yes, we used to think so and what we used to say was that we would not do IUDs under 12 weeks postpartum for LUSCSC which is lower uterine segment Caesarean section. And in fact I just happened to be looking at the product information for the copper IUDs and they actually still say you should not insert under 12 weeks with Caesarean. But they did a large meta-analysis a few years ago, the EURAS study if you want to look that up, and what they found was the main factors in perforation of the uterus with an IUD insertion was breast feeding. So breast feeding was a six-fold risk in perforation. Being up to 36 weeks postpartum which is almost the entire length of your pregnancy which is surprising, but yes up to 36 weeks. If you are breast feeding and up to 36 weeks postpartum there was a cumulative effect. There was no increased risk of perforation with a Caesarean section, and the other biggest risk factor for perforation was the number of insertions per year the inserter was doing. So there was a higher rate of perforation with people who do less than 50 insertions versus people doing over 50 insertions, which is you know really interesting and a little scary for some inserters who are maybe not doing as many as that. But that realistically, it is still less than two per thousand insertions overall for all people having an IUD. So I would not delay an IUD insertion beyond six weeks now even if someone had had a Caesarean section because there is no evidence to support that.
 
 
Jessica:
 
Okay. You said there was no indication to swab for BV prior to insertion. If detected on swab however, do you recommend treating? What about chlamydia?
 
 
Amy:
 
Yes, so bacterial vaginosis does definitely, it is implicated in pelvic inflammatory disease, so I think if you have had a swab you are kind of obligated to treat it, but we do not recommend doing a standard swab as part of an IUD workup. So no indication to do that. Having said that, if for whatever reason I was doing a speculum exam as part of an IUD assessment and I noticed the characteristic discharge or smell of BV, I would definitely take a swab, consent the woman after the examination and say, if this comes back as BV we need to treat. So asymptomatic people do not need a swab before IUD insertion, symptomatic people should, and if it is there you need to treat it because if they do develop PID then you know, you are potentially on a much higher dose of antibiotics than just treating simple BV.
 
 
Jessica:
 
Okay, so we have got a case study that has come through. So a 47-year-old woman with heavy menstrual bleeding associated with iron deficiency, STD negative, CST normal, TVUS, endometrial thickness 7 millimetres or MM, would you consider it safe to insert IUD or would you refer to gynae initially?
 
 
Amy:
 
I think this one would be absolutely fine to insert. So that was a transvaginal ultrasound, TVUS, so she has had a normal STI screen and cervical screen test, so if she is 47, so she is perimenopausal, so is still having periods so again she is perimenopausal. The upper limit of normal for an endometrial thickness is 12 millimetres. You know she is over 45 and it is brand new heavy menstrual bleeding, that is when an endometrial biopsy at a minimum is recommended and potentially referring to a gynaecologist because new onset heavy menstrual bleeding over the age of 45 really does require a gynae opinion and potentially a hysteroscopy and D&C. If that was not practical, so for example you are an IUD inserter in maybe a rural area and it would take a lot of work for her to get to see someone or a long time, any IUD inserter should be able to take an endometrial biopsy, it is a very small tube, it is a little pipelle, you take a sample and send it off. And that plus and endometrial thickness of less than 12 millimetres in a perimenopausal woman is extremely reassuring that it is not endometrial hyperplasia if the biopsy is normal. And certainly if she is 47, but she has been having an increase in bleeding for the last three or four years, you know, the periods have been getting slightly heavier, getting a bit closer or getting a bit irregular and there is other good history of this is not new onset bleeding, it is a couple of years of perimenopausal bleeding that is increasing, then I would absolutely insert it. If I was still a little bit worried, then I would maybe organise a follow-up ultrasound at maybe three or six months and definitely make sure I keep a close eye on her, but I think she would absolutely be safe.
 
 
Jessica:
 
Okay. One last question. Is it safe to use Primolut and Estradot patches in a patient aged over 65 years?
 
 
Amy:
 
So any of the menopause hormone treatment patches are fine. It is not the age, it is the age that you start. So if you are talking about starting someone over the age of 65, then no you cannot do that. You cannot start menopause hormone treatment over the age of 60 or if it has been more than 10 years since menopause, but if it is continuing and again, they have not had a big break, then it is as safe as prescribing it to someone who is 55. So yes, that would absolutely be fine.
 
 
Jessica:
 
Okay, I have just got one last one that has come through. Would you just treat as BV if suspicious, as my understanding a swab can often come back negative?
 
 
Amy:
 
Yes, it definitely can. And BV is one of those ones you know, you think that you definitely have seen it and smelt it. I think if you know, that type of discharge and that type of smell, I would often treat before the swab comes back. So I would say you know, I think you have got BV for these reasons and here is the thing. The other thing you can do, and you just need to buy some litmus papers, there are is some pH paper, and if the pH is over 4.7, and they have got the characteristic discharge and smell, that is what is called Amsel’s criteria, and again it is spelt AMSEL, Amsel’s criteria, if they meet the characteristics of discharge, the characteristics of smell and the increase in pH then it is actually diagnostic of BV regardless of what the swab looks like.
 
 
Jessica:
 
Okay. Well I think that pretty much wraps this up for tonight. So, thank you all very much. This is the last women’s health webinar for the year, so we have started off very small with just the two part menopause series and seven sessions later, here we are. So, a huge thank you to Dr Amy Moten for giving up her time to present over these last few months. We have definitely had overwhelmingly positive feedback and we are certainly looking at running some more sessions again next year, and hopefully some face to face ones for those that are based in SA and the Northern Territory. So again I will be sending through an evaluation form this evening just to get your feedback on tonight’s session. And again, thank you Amy for all of your time in the last few months, it has been wonderful.
 
 
Amy:
 
Thanks so much, Jess. And thank you to everyone who has participated and thank you for all your wonderful questions which as I said have been very thought provoking and made me work very hard.
 
 
Jessica:
 
Okay, thank you all very much.
 

Other RACGP online events

Originally recorded:

6 October 2020

In this two part series, we will take common contraceptive questions and attempt to answer them. Are all Pills equal? What's the best Pill for me? When do I stop contraception? What about the new IUD? The first session will focus on oral contraception and the second session will focus on LARC. The aim of these webinars is to provide practical guidance for providing contraception in general practice.

Facilitator

Jessica Fry
RACGP NT Representative

Presenter

Dr Amy Moten
General Practitioner

Dr Amy Moten is the Coordinator: Medical Education at SHINE SA where she provides clinical education to doctors, registered nurses and midwives and other health professionals in South Australia. She also works as a GP with a special interest in sexual and reproductive health care and is currently chair of the RACGP Specific Interest Group in Sexual Health Medicine.

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