Pulse February 2019 issue - Page 27

27 FSRH has supported extended use of an IUS for contraception until menopause or the age of 55 if inserted at age 45 or over, even if the woman is not amenorrhoeic. Note that this applies to use as contraception and not when used as the progestogen component of HRT for endometrial protection (when the device should be changed every five years). 4 During the perimenopause, isolated serum oestradiol, FSH and LH levels are not reliable and should not be used to decide whether to stop contraception as ovulation may still occur with a risk of pregnancy. Contraception does not affect the timing of menopause or duration of the perimenopause but it may mask perimenopausal symptoms. In women using the IUS, bleeding patterns cannot be used to determine menopausal status. If a woman over 50 years with amenorrhoea wishes to stop using the IUS (or a progestogen-only method) before age 55, FSH level can be checked: • If FSH level is >30IU/l the IUS can be discontinued after one more year. • If FSH level is in premenopausal range then the IUS should be continued and FSH level checked again one year later. Women can cease contraception at age 55 as spontaneous conception after this age is exceptionally rare, even in women who are still experiencing menstrual bleeding. Menstrual cycles during the perimenopause are irregular because women experience intermittent ovulation and anovulation. Women may experience changes in their bleeding patterns during this time. The return of menses before 55 with a device fitted after age 45 should not cause concern about contraceptive efficacy as this would not be an indication that the device is no longer providing contraception. In women with unscheduled bleeding, however, other causes are possible, such as gynaecological pathology, and an endometrial biopsy should be considered. ONLINE Choosing between different IUS options. Go online for advice on this, plus drug interactions to be aware of pulse-learning. co.uk Q Why do you think many women are hesitant to consider LARC as their contraceptive method? How do you think we might be able to increase uptake rates? An endometrial biopsy should be considered in women with unscheduled bleeding Many factors determine the method of contraception a woman chooses to use. There are several reasons why LARC methods may not appeal to women. They may have concerns regarding the effect of LARC on fertility. It’s important to reassure them that return of fertility after implant use is generally similar to fertility rates after discontinuation of oral contraceptives and barrier methods. The injectables are an exception here. Women should be informed that there can be a delay of up to one year in the return of fertility after discontinuation of DMPA – but they should also be reassured that there is no long-term effect on fertility. Women may have fear of pain during insertion of intrauterine methods. Factors that predict pain include nulliparity or no history of vaginal delivery, anxiety and length of time since last pregnancy or last menses. There is evidence that cervical local anaesthetic block effectively reduces the pain associated with gynaecology procedures and it is generally advised for any procedure that requires dilatation of the cervix. There is limited evidence regarding the routine use of cervical block for IUC insertion. 1 It’s important to advise patients that the majority of insertions are uneventful and with manageable discomfort. The potential long duration of use can feel daunting to some women so it can be valuable to remind them that they are the ones ‘in control’ of how long the long-acting method stays in place. A Q Erratic bleeding, at least initially, seems to be the main problematic side-effect for LARC and often causes women to want to switch methods. How should GPs approach this problem? Before starting hormonal A contraception, women should be advised about the bleeding patterns expected both initially and in the longer term. 5 Knowing what to expect facilitates prolonged use. While contraception can cause an irregular bleeding pattern, women with unscheduled bleeding should be assessed for their individual risk of STI. Other causes of bleeding should be considered, such as gynaecological pathology or pregnancy. Bleeding is common in the initial months of using any progestogen-only method and often settles without treatment. If treatment encourages women to continue with the method, it may be considered. There is no strong evidence as to the most appropriate treatment option for women with unscheduled bleeding on LARC methods. For women who are medically eligible, COC may be tried for three months (this can be used in the usual cyclic manner or continuously without a pill-free interval). Longer-term use of COC has not been studied in relation to the progestogen- only injectable, implant or IUS methods. If bleeding recurs following three months use of COC, longer-term use is a matter of clinical judgment but where the woman has no contraindication to oestrogen this is widely encouraged by specialists in contraception. For women using a progestogen-only injectable contraceptive who have problematic bleeding and who cannot use oestrogen, mefenamic acid 500mg twice daily (or up to three times daily) for five days can reduce the length of a bleeding episode but has little effect on bleeding in the longer term. Although unsupported by evidence, it seems reasonable to try this for users of other LARC methods who cannot use oestrogen if the user wishes to continue with the method. Dr Priyanka Patel is a specialty trainee in community sexual and reproductive health at Homerton University Hospital. Dr Tracey Masters is a consultant in sexual and reproductive health at Homerton University Hospital. For your appraisal folder Key points • There are circumstances when the copper IUD might be chosen over the IUS, such as women being uncomfortable with the idea of no menses, or having a history of breast cancer • The IUS may be used beyond its licensed five years in certain situations – but not if it is being used as the progestogen component of HRT • Women can be reassured that the LARCs, other than injectables, should have no effect on the return of fertility after cessation • Most IUD/IUS insertions are uneventful and cause little discomfort Audit ideas • How many patients have had their IUS for more than five years? In how many is this appropriate? 1.5 CPD HOURs Go to pulse-learning.co.uk to test your learning and download your certificate Pulse February 2019