Amelia would be a good candidate for the LNG-IUS because she is in a stable relationship and wants to postpone pregnancy for several years. Although she has some symptoms suggestive of endometriosis (dyspareunia), they could be relieved by this method.14 Because thinning of the endometrial lining is an inherent mechanism of action of the LNG-IUS, this method could reduce her heavy bleeding.
She should be advised of the risks and benefits of the LNG-IUS, which can be inserted when she begins her next menstrual cycle.
CASE 2: Mother of two with no immediate desire for pregnancy
Tamika is a 19-year-old black woman (G2P2) who has arrived at your clinic for her 6-week postpartum visit. She is not breastfeeding. Her BMI is 25.7 kg/m2. She reports that her baby and 2-year-old are doing “OK” and says she does not want to get pregnant again anytime soon. She is in a relationship with the father of her baby and says he is “working a good job and taking care of me.” Her menstrual cycles have always been normal, with no cramping or heavy bleeding.
Examination reveals that her cervix is clear, her uterus is anteverted and nontender, and her ovaries appear to be normal.
Would this patient be a good candidate for a LARC?
Tamika is an excellent candidate for the copper IUD or LNG-IUS and should be educated about both methods. If she chooses an IUD, it can be inserted at the start of her next menstrual period.
These first two cases illustrate the importance of making no assumptions on the basis of general patient characteristics. Although Tamika may appear to be at greater risk for STI than Amelia, such “typecasting” may lead to inappropriate counseling.
Related Article Malpositioned IUDs: When you should intervene (and when you should not)
At the time of IUD insertion, both patients should be instructed to check for the IUD string periodically, and this recommendation should be documented in their charts.
CASE 3: Anovulatory patient with heavy periods
Mary, 25, is a nulliparous Hispanic woman who has been referred by her primary care provider. She has a BMI of 35.4 kg/m2 and has had menstrual problems since menarche at the age of 14. She reports that her periods are irregular and very heavy, with intermittent pelvic pain that she manages, with some success, with ibuprofen. She has never had a sexual relationship, but she has a boyfriend now and asks about her contraceptive options.
On examination, you discover that Mary has pubic hair distribution over her inner thigh, with primary escutcheon and acanthosis nigricans on the inner thigh. Her vulva is marked by multiple sebaceous cysts, and a speculum exam shows a large amount of estrogenic mucus and a clear cervix. Her uterus is anteverted and nontender. Her ovaries are palpable but may be enlarged, and transvaginal ultrasound reveals that they are cystic. Her diagnosis: hirsutism with probable polycystic ovary syndrome.
Would an IUD be appropriate?
Mary is not a good candidate for an IUD. Neither the copper IUD nor the LNG-IUS would suppress ovarian function sufficiently to reduce the growth of multiple follicles that occurs with polycystic ovary syndrome. She would benefit from a hormonal method (specifically, a combination oral contraceptive) to suppress follicular activity.
Time for a renaissance?
The IUD may be making a comeback. With the unintended pregnancy rate remaining consistently at about 50%, it is important that we offer our patients contraceptive methods that maximize efficacy, safety, and convenience. Today’s IUDs meet all these criteria.
Data-driven tactics for reducing pain on IUD insertion
Many patients worry about the potential for pain with IUD insertion—and this concern can dissuade them from choosing the IUD as a contraceptive. This is regrettable because the IUD has the highest satisfaction rating among reversible contraceptives, as well as the greatest efficacy.
How much pain can your patient expect? In one recent prospective study involving 40 women who received either 1.2% lidocaine or saline infused 3 minutes before IUD insertion, 33% of women reported a pain score of 5 or higher (on a scale of 0–10) at tenaculum placement. This finding means that two-thirds of women had a pain score of 4 or lower. In fact, 46% of women had a pain score of 2 or below.15 (The mean pain scores for insertion were similar with lidocaine and placebo [3.0 vs 3.7, respectively; P=.4]).
Pain reducing options
The evidence validates (or fails to disprove) the value of the following interventions to make insertion more comfortable for patients:
• Naproxen (550 mg) administration 40 minutes prior to insertion. One small study found it to be better than placebo.9
• Nonopioid pain medication. One small, randomized, double-blinded clinical trial found that tramadol was even more effective than naproxen at relieving insertion-related pain.16
• Injection of lidocaine into the cervix. Although this intervention is common, data supporting it are scarce. One small, high-quality study found no benefit, compared with placebo. However, if you have had success with this approach in the past, I would not discourage you from continuing to offer it, as a single small study is insufficient to disprove it.15 More data are needed.
• Keeping the patient calm. Anxiety increases the perception of pain. Studies have demonstrated that women who expect pain at insertion are more likely to experience it. Encourage the patient to breathe diaphragmatically, and remind her that she is likely to be very happy with her choice of the IUD.
Many other interventions don’t seem to be effective, although they may be offered frequently. Unproven methods include administration of NSAIDs other than naproxen, use of misoprostol (which can increase cramping), application of topical lidocaine to the cervix, and insertion during menses (although the LNG-IUS is inserted during the menstrual period to render it effective during the first month of use).
The studies described here come from the general population of reproductive-age women. If a patient has cervical scarring or a history of difficult or painful insertion, she may be more likely to experience pain, and these data may not apply to her.
—Jennifer Gunter, MD
Dr. Gunter is an ObGyn in San Francisco. She is the author of The Preemie Primer: A Complete Guide for Parents of Premature Babies—from Birth through the Toddler Years and Beyond (Da Capo Press, 2010). Dr. Gunter blogs at www.drjengunter.com, and you can find her on Twitter at @DrJenGunter. She is an OBG Management Contributing Editor.
Dr. Gunter reports no financial relationships relevant to this article.