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Recommendations for Contraceptive Use |
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Levonorgestrel-Releasing IUDs |
Classification of Selected
Procedures for Levonorgestrel IUDs (LNg IUDs)
| Procedure |
Class |
Rationale |
| Pelvic examination (speculum and
bimanual) |
A |
Bimanual and
speculum exams are essential and mandatory before IUD use, to rule out contraindications
(pregnancy, Pelvic inflammatory disease (PID) and endocervical infection, cervical
lesions) and to determine uterine position in order to avoid perforation. If the woman is
pregnant, presence of the IUD will lead to spontaneous abortion (miscarriage) in about
half of all pregnancies, and there is significant risk of septic abortion1. If a purulent endocervical discharge is present at the time the IUD
is inserted through the cervical canal, bacteria in the canal may be introduced into the
sterile uterine cavity and lead to PID2. |
| Blood pressure |
C |
The use of this method does not
affect blood pressure. |
| Breast examination |
C |
There is no evidence linking the
LNg IUD to breast cancer. The LNg IUD provides a very low dose of progestin. |
| Sexually transmitted disease
(STD) screening by risk assessment |
A |
Assessment of STD risk by
personal history and socio-demographic risk factors is an essential procedure for
identifying women at risk of PID. |
| STD screening by lab tests (for
asymptomatic persons) |
B |
Assessment of STD risk by
personal history and socio-demographic risk factors may be the most practical method of
identifying women at risk for PID. The speculum and bimanual exam may also detect some
STDs. When feasible, negative test results provide reassurance to corroborate the woman's
history. For those clients with a personal history
or with socio-demographic risk factors which suggest high risk, the clients who still make
an informed choice of an IUD must understand they may have an STD without any signs or
symptoms. While negative STD lab tests would be somewhat reassuring in this circumstance,
they will not alter the clients' future STD risk. |
| Cervical cancer screening |
C |
IUD insertions and continued IUD
use have no known relation to the risk of acquiring cervical carcinoma3. Although WHO considers cervical cancer for IUD insertion to be
Class 4 (a condition which represents an unacceptable health risk), clinically apparent
cervical lesions are detectable from observation during a pelvic exam1. |
| Routine, mandatory lab tests
(e.g., cholesterol, glucose, liver function tests) |
C |
These tests are not necessary to
perform before insertion. |
| Proper infection prevention
procedures. |
A |
Proper infection prevention
procedures are essential and mandatory to minimize the risk of infection to clients and
providers. |
Specific counseling points for
LNg IUDs:
- efficacy
- common side effects, including change in menses (irregular
or absent menstrual bleeding)
- correct use of method
- signs and symptoms for which to see a health provider
- STD protection (when/as appropriate), and counseling about
condom use for women who are at high risk for STDs.
Note: Women currently at high risk for STDs, in
general, should not receive IUDs.
- benefits (anemia and dysmenorrhea improved)
|
A |
Accurate client education is
essential for maximum quality of family planning (FP) services. Appropriate counseling about common contraceptive side effects at
the time of method selection can lead to improved client satisfaction and contraceptive
continuation.
Women at risk should be counseled on high risk behavior
for contracting STDs and potential complications from IUD use.
The woman should be encouraged to return if she has any
problems or at any time she has questions or concerns. |
KEY:
Class A = essential and mandatory or otherwise
important in all circumstances, for safe and effective use of the contraceptive method
Class B = medically/epidemiologically rational in
some circumstances to optimize the safe and effective use of the contraceptive method, but
may not be appropriate for all clients in all settings
Class C = may be appropriate for good preventive
health care, but not materially related to safe and effective use of the contraceptive
method
Class D = not materially related to either good
routine preventive health care or safe and effective use of the contraceptive method
Citations for Procedures Table:
- World Health Organization. Improving
access to quality care in family planning: medical eligibility criteria for contraceptive
use. Geneva: WHO, 1996.
- Mishell DR, Jr. Contraception,
sterilization and pregnancy termination. In: Herbst AL, Mishell DR Jr., Stenchever MA,
Droegemueller W, editors. Comprehensive Gynecology, second edition. St. Louis: Mosby Year
Book, 1992: 295-362.
- Lassise DL, Savitz DA, Hamman RF,
Baron AE, Brinton LA, Levines RS. Invasive cervical cancer and intrauterine device use.
InternationalJournal of Epidemiology 1991;20(4):865-70.
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