HORMONAL
IUCD
Presenter- Dr Gargey
Moderator- Prof Sangeeta Rai
Background
■ India’s population, which crossed one billion in 2000, is projected to
reach 1.53 billion by 2050, making it the most populous country in the
world.
■ Women of reproductive age group (15-49 years) make up
approximately 248 million. The Reproductive and Child Health (RCH)
Program in India promotes responsible and planned parenthood
through the Government’s Family Welfare Program with voluntary use
and free choice of contraceptive methods.
■ The Total Fertility rate - 2.03 births per woman (2021) in India
Source-NFHS-3
■ The National Population Policy 2000 has recognized as its
immediate objective of bringing the Total Fertility Rate
(TFR) to replacement level by 2010 ( i.e to reduce the Net
Reproductive Rate to 1) so as to achieve the long-term
goal of population stabilization by 2045.
■ As per NFHS –3, the contraceptive prevalence rate in India
is 56.3 %, which varies widely among different states and
the unmet need for family planning is high at 13% (6% for
spacing).
■ .
Source-AIIMS Consortium for emergency contracep
Hormonal IUCD
These are 3RD generation hormonal
IUCD–
■ Progestasert : T shaped device
filled with 38mg of Progesterone,
releasing 65mcg daily.
LNG 20
■ LNG 20 (Mirena): T shaped IUCD
releasing 20mcg of Levonorgestrel
–More potent
■ The Mirena is approved for 5 years
of use, although studies through 7
years of use show no loss of
efficacy
LNG-IUCD
■ 52-mg LNG-IUDs have remarkably low pregnancy rates, less than 0.2
per 100 woman-years. Total pregnancies over a 7-year period were
only 1.1 per 100 for the LNG-IUD.
■ LNG-IUDs protect against ectopic pregnancy. The LNG-IUD, by
releasing levonorgestrel, reduces menstrual bleeding and cramping.
■ Multiple randomized controlled trials of the 52-mg LNG-IUS have reported a
Pearl Index (PI, pregnancy rate per 100 women-years) of 0.1 to 0.2 for the first
year of use and a 5-year cumulative failure rate of 0.16% to 1.1%
Source- Berek Novak and AJOG
IUCDs that are available :
■ Two 52 mg levonorgestrel-releasing IUDs (Mirena and Liletta),
■ 19.5-mg levonorgestrel releasing IUD (Kyleena),
■ 13.5-mg levonorgestrel-releasing IUD (Skyla-releases 6 mcg
daily).
LNG-IUS (Emily)
■ Progesterone containing IUCD
looking like Multiload Cu375
with inverted U shaped flexible
plastic serrated fins and a
vertical limb containing LNG 52
mg with daily release of 20
mcg.
■ Simple to insert.
■ Available in India.
Other Hormonal IUD
■ The FibroPlant 14 LNG-IUS (Contrel Research,
Ghent, Belgium) is a frameless
levonorgestrel-releasing IUD which contains
a nonreabsorbable thread with a knot that is
implanted into the myometrium of the
uterine fundus. The attached implant
delivers either 14 or 20 mcg of
levonorgestrel each day and is approved for
5 years of use. The reported pregnancy rate
at 5 years is 0.4%, with similarly low
expulsion and perforation rates
Source-Berek Novak
Source- nicolejardim.
Mechanism of action
IUDs cause the formation of “biologic
foam” within the uterine cavity that
contains strands of fibrin, phagocytic
cells, and proteolytic enzymes.
All IUDs stimulate the formation of
prostaglandins within the uterus,
consistent with both smooth muscle
contraction and inflammation;
Source- Berek novak and FOGSI
Timing of Insertion
■ Within 7 days of the beginning of last menstrual period or anytime
during the menstrual cycle ensuring that woman is not pregnant.
■ Immediately or within 48 hours after delivery (by a provider who is
trained in inserting IUCDs during this time) or more than 6 weeks post
partum.
■ Concurrently with 1st trimester medical termination of pregnancy.
■ After 1st menstrual period following spontaneous/medical/second
trimester abortion In a woman with Lactational Amenorrhea provided
pregnancy can be ruled out.
■ Within 5 days of unprotected sex as an emergency contraception.
Indications for IUCD removal
■ Personal reasons (offers no reason at all) The woman has a right to
discontinue the method at any time, regardless of the reason.
■ IUCD to be replaced (i.e., at the end of its effective life of 10 years or
before if she desires) ensure that she has undergone appropriate
assessment to determine whether she is eligible for IUCD reinsertion
at this time.
■ Medical reasons (e.g., pregnancy, heavy menstrual bleeding) ensure
that she has undergone the appropriate assessment to determine
whether routine IUCD removal is safe for her at this time.
Warning signs
(PAINS) The following signs/symptoms (which spell the word
PAINS) are warning signs for IUCD users and may indicate a
serious problem:
• P: Period problems/ pregnancy symptoms
• A: Abdominal pain or pain during intercourse
• I: Infections or unusual vaginal discharge
• N: Not feeling well, fever, chills
• S: String problems
Source; FOGSI 2020, PPIUCD
Benefits
• Long-term, highly effective(LARC) reversible protection
against
• Good efficacy, low failure rate.. Failure rate is 0.2/HWY.
• Suitable for use by most women
• Safe for use in breastfeeding women
• Acts as an emergency contraceptive if inserted within
five days of unprotected sexual intercourse (in case of
multiple unprotected sexual contacts, within five days of
first unprotected intercourse)
Source-MHFW and bedside
■ One time cost effective procedure
■ No requirement of daily attention or special attention before sexual
intercourse
■ Immediate return of fertility upon removal of IUCD
■ No drug interaction
■ May help protect against endometrial and cervical cancer
Non Contraceptive benefits
■ The LNG-IUD, by releasing levonorgestrel, reduces menstrual bleeding
and cramping. It is used extensively to treat heavy menstrual
bleeding.
■ Also used in Europe and the United Kingdom as an alternative to
hysterectomy for menorrhagia. The LNG-IUD has a beneficial effect on
menorrhagia from uterine fibroids; the benefit may be diminished with
distorting submucosal fibroids.
■ The LNG-IUD is an effective way to deliver the necessary progestin
therapy in postmenopausal women on estrogen therapy.
■ Reduced risk of endometrial cancer and improvement in symptoms of
endometriosis and adenomyosis .
Source-IUCD
Conclusion-
This meta-analysis provides valuable insights into the effectiveness of oral progestins and LNG-IUD
treatment within a 12-month timeframe for patients with early-stage endometrial cancer who desire to
preserve fertility. These findings have the potential to assist in personalized treatment decision-making for
patients
■ LNG-IUDs protect against ectopic pregnancy
■ Risk of any pregnancy with a LNG-IUD is between 0.1 and 0.2 per 100
woman-years. The rate of an ectopic in users of this device is reported
as 0.02 per 100 woman-years
■ IUDs and tubal sterilization increase the probability of the pregnancy
being ectopic when pregnancy occurs, but the rate of any pregnancy
is so low that women using either of these methods have much lower
rates of ectopic pregnancy than women not using contraception
Source-Berek novak
Absolute contraindications of
LNG-IUCD (MEC)WHO
2015(Category
■ Pregnancy
4)
■ Undiagnosed vaginal bleeding pre evaluation
■ Presence of puerpal or immediate postabortal sepsis
■ Gestational trophoblastic disease- persistently elevated beta hcg levels or
malignant disease
■ Cervical cancer and endometrial cancer
■ Breast cancer-past and evidence of current disease for 5 years
■ Uterine fibroid with distortion of cavity
■ PID
■ Current purulent cervicitis or chlamydial infection or gonorrhea
■ Pelvic tuberculosis
Relative contraindications
(category 3) of LNG IUG
■ Postparum- more than or equal 48 hrs to less than 4 wks
■ Acute DVT/Pulmonary embolism
■ APLA positive
■ Migraine with Aura at any age
■ Breast cancer past and no evidence of current
■ Ovarian cacer
■ increased risk of STI
CONCLUSION: The risk of gynecologic and breast cancers exhibits a site-specific
effect among LNG-IUD users. It is important to note that the observed effect is small
for breast cancer and the results are limited by the observational study design.
Clinical recommendations regarding the use of LNG-IUD should carefully weigh its
potential benefits and risks. Close monitoring is advisable for the potential
development of breast cancer, particularly among women with a family history of
breast cancer.
Expulsion and Perforation
■ The 36-month cumulative expulsion rate is 10.2 per 100 IUD users
and did not vary by IUD type (LNG-IUD 10.1 vs. copper IUD 10.7, p =
0.99) (83 ).
■ The cumulative rate of expulsion is lower in nulliparous women
compared to parous women and higher in females aged 14 to 19
years compared to older women.
■ The risk of uterine perforation associated with insertion is dependent
on the inserter. The risk in experienced hands is on the order of 1 per
1,000 insertions or less . The risk of perforation is no different
between the copper and the LNG IUDs . Multiparity decreases the risk
of perforation .
Source-Berek novak
REFERENCES
■ Berek Novak’s GYNAECOLOGY, 16th edition
■ Bedside clinics in gynaecology, arup kumar majhi
■ Suzuki Y, Ferris JS, Chen L, Dioun S, Usseglio J, Matsuo K, Xu X, Hershman DL,
Wright JD. Fertility-preserving Treatment for Stage IA Endometrial Cancer: A
Systematic Review and Meta-Analysis. Am J Obstet Gynecol. 2024 Jul
18:S0002-9378(24)00761-0. doi: 10.1016/j.ajog.2024.07.018. Epub ahead of
print. PMID: 39032722.
■ aiims.edu/aiims/events/Gynaewebsite
■ AJOG articles
■ IUCD Reference Manual for Medical Officers, MHFW
■ FOGSI manual 2020 on PPIUCD and progesterone .
T
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THANKYOU
