Long-Acting Reversible Contraception: Difficult Insertions and Removals

 

The use of long-acting reversible contraception is on the rise across the United States and has contributed to a decrease in teen pregnancies. With the increased use of long-acting reversible contraception, physicians may encounter difficult insertions and removals of intrauterine devices (IUDs) and the contraceptive implant. Uterine structure (e.g., extreme anteversion or retroversion, uterine tone during the postpartum period and breastfeeding) can pose challenges during IUD insertion. Special consideration is also needed for IUD insertions in patients who are transgender or gender nonconforming, such as psychosocial support and management of vaginal atrophy. Missing IUD strings may complicate removal, possibly requiring ultrasonography and use of instruments such as thread retrievers, IUD hooks, and alligator forceps. Regarding implant removal, those that are barely palpable (e.g., because of an overly deep insertion or excessive patient weight gain), removal may require ultrasonography, use of vas clamps and skin hooks, and extra dissection.

Long-acting reversible contraception (LARC) includes intrauterine devices (IUDs) and the contraceptive implant (Nexplanon). The use of LARC is on the rise in the United States, accounting for more than 11.6% of all contraceptives, and has contributed to a 28% decrease in teen pregnancy from 2007 to 2012.1,2  LARC has fewer medical contraindications than contraceptives containing estrogen because it contains only progestin or copper and no estrogen. Contraindications for LARC are included in Table 1.3 In addition, hormonal IUDs are now first-line methods to control excessive menstrual bleeding from a range of benign causes,4 sparing women from surgical treatments.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Using misoprostol (Cytotec) to soften the cervix before IUD insertion is not helpful.

B

6, 7

Use of IUDs may be an option for transgender men who wish to prevent pregnancy or reduce menstrual bleeding. There are special considerations for IUD insertion in this population.

B

11, 12

A stepwise approach is useful for IUD removal when the IUD strings are not visible in the cervical os.

C

18, 2022

Some difficult implant removals, such as extremely deep insertions, require a multidisciplinary approach with a radiologist and surgeon.

C

24


IUD = intrauterine device.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Using misoprostol (Cytotec) to soften the cervix before IUD insertion is not helpful.

B

6, 7

Use of IUDs may be an option for transgender men who wish to prevent pregnancy or reduce menstrual bleeding. There are special considerations for IUD insertion in this population.

B

11, 12

A stepwise approach is useful for IUD removal when the IUD strings are not visible in the cervical os.

C

18, 2022

Some difficult implant removals, such as extremely deep insertions, require a multidisciplinary approach with a radiologist and surgeon.

C

24


IUD = intrauterine device.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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TABLE 1

Contraindications for LARC from the Centers for Disease Control and Prevention Medical Eligibility Criteria

ConditionCopper IUDProgestin IUDImplant

Distorted uterine cavity

4

4

Uterine fibroids

2

2

1

Current breast cancer

1

4

4

Past breast cancer and no evidence of current disease for five years

1

3

3

Awaiting treatment for cervical cancer

4 (initiation)

4 (initiation)

2

2 (continuation)

2 (continuation)

Severe decompensated cirrhosis

1

3

3

Endometrial cancer

4 (initiation)

4 (initiation)

1

2 (continuation)

2 (continuation)

Gestational trophoblastic disease with persistently elevated beta human chorionic gonadotropin levels or malignant disease, with evidence or suspicion of intrauterine disease

4* (initiation)

4* (initiation)

1*

2* (continuation)

2* (continuation)

Current history of ischemic heart disease

1

2 (initiation)

2 (initiation)

3 (continuation)

3 (continuation)

Hepatocellular adenoma

1

3

3

Malignant hepatoma

1

3

3

Current pelvic inflammatory disease

4 (initiation)

4 (initiation)

1

2* (continuation)

2* (continuation)

Postpartum sepsis

4

4

Pregnancy

4

4

—*

Current purulent cervicitis, or chlamydial or gonococcal infection

4 (initiation)

4 (initiation)

1

2* (continuation)

2* (continuation)

C

The Authors

show all author info

LINDA PRINE, MD, FAAFP, is a family physician at the Institute for Family Health and a professor of family and community medicine at the Icahn School of Medicine at Mount Sinai, New York, NY. She is also a faculty member at the Mount Sinai Downtown and the Harlem Family Medicine Residencies....

MEERA SHAH, MD, MS, is a family physician at Callen-Lorde Community Health Center, New York, NY.

Address correspondence to Linda Prine, MD, Mount Sinai Downtown Family Medicine Residency, 230 West 17th St., New York, NY 10011 (e-mail: lindaprine@mac.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Kavanaugh ML, Jerman J, Finer LB. Changes in use of long-acting reversible contraceptive methods among U.S. women, 2009–2012. Obstet Gynecol. 2015;126(5):917–927....

2. Lindberg L, Santelli J, Desai S. Understanding the decline in adolescent fertility in the United States, 2007–2012. J Adolesc Health. 2016;59(5):577–583.

3. Centers for Disease Control and Prevention. US Medical Eligibility Criteria (US MEC) for contraceptive use, 2016. https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html. Accessed March 7, 2018.

4. Bitzer J, Heikinheimo O, Nelson AL, et al. Medical management of heavy menstrual bleeding. Obstet Gynecol Surv. 2015;70(2):115–130.

5. Hardeman J, Weiss BD. Intrauterine devices: an update. Am Fam Physician. 2014;89(6):445–450.

6. Zapata LB, Jatlaoui TC, Marchbanks PA, Curtis KM. Medications to ease intrauterine device insertion: a systematic review. Contraception. 2016;94(6):739–759.

7. Matthews LR, O'Dwyer L, O'Neill E. Intrauterine device insertion failure after misoprostol administration. Obstet Gynecol. 2016;128(5):1084–1091.

8. Heinemann K, Reed S, Moehner S, Minh TD. Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the European Active Surveillance Study on Intrauterine Devices. Contraception. 2015;91(4):274–279.

9. Heinemann K, Barnett C, Reed S, et al. IUD use among parous women and risk of uterine perforation. Contraception. 2017;95(6):605–607.

10. Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120–1127.

11. Cipres D, Seidman D, Cloniger C III, Nova C, O'Shea A, Obedin-Maliver J. Contraceptive use and pregnancy intentions among transgender men presenting to a clinic for sex workers and their families in San Francisco. Contraception. 2017;95(2):186–189.

12. Chrisler JC, Gorman JA, Manion J, et al. Queer periods: attitudes toward and experiences with menstruation in the masculine of centre and transgender community. Cult Health Sex. 2016;18(11):1238–1250.

13. van Trotsenburg MA. Gynecological aspects of transgender healthcare. Int J Transgenderism. 2009;11(4):238–246.

14. Perrone AM, Cerpolini S, Maria Salfi NC, et al. Effect of long-term testosterone administration on the endometrium of female-to-male (FtM) transsexuals. J Sex Med. 2009;6(11):3193–3200.

15. Stika CS. Atrophic vaginitis. Dermatol Ther. 2010;23(5):514–522.

16. Bates CK, Carroll N, Potter J. The challenging pelvic examination. J Gen Intern Med. 2011;26(6):651–657.

17. Reproductive Health Access Project. Algorithm for IUD removal when no strings are visible. https://www.reproductiveaccess.org/resource/algorithm-iud-removal-no-strings-visible/. Accessed January 30, 2018.

18. Prabhakaran S, Chuang A. In-office retrieval of intrauterine contraceptive devices with missing strings. Contraception. 2011;83(2):102–106.

19. Brahmi D, Steenland MW, Renner RM, Gaffield ME, Curtis KM. Pregnancy outcomes with an IUD in situ. Contraception. 2012;85(2):131–139.

20. Verma U, Astudillo-Dávalos FE, Gerkowicz SA. Safe and cost-effective ultrasound guided removal of retained intrauterine device: our experience. Contraception. 2015;92(1):77–80.

21. Marchi NM, Castro S, Hidalgo MM, et al. Management of missing strings in users of intrauterine contraceptives. Contraception. 2012;86(4):354–358.

22. Swenson C, Royer PA, Turok DK, et al. Removal of the LNG IUD when strings are not visible: a case series. Contraception. 2014;90(3):288–290.

23. Chen MJ, Creinin MD. Removal of a nonpalpable etonogestrel implant with preprocedure ultrasonography and modified vasectomy clamp. Obstet Gynecol. 2015;126(5):935–938.

24. Odom EB, Eisenberg DL, Fox IK. Difficult removal of subdermal contraceptive implants: a multidisciplinary approach involving a peripheral nerve expert. Contraception. 2017;96(2):89–95.

25. Johnson BA. Insertion and removal of intrauterine devices. Am Fam Physician. 2005;71(1):95–102.

 

 

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