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Dr Alyson EllimanFFSRH, MIPM
Consultant Croydon Health Services NHS TrustWith (huge) thanks to Dr Zara Haider
1LARC for London March 2012
Order of presentationLARC – what’s newStarting and switching methodsLost threadsMigrating implantsManaging unscheduled bleeding
2LARC for London March 2012
•Different application device•Less theoretical risk of deep or non-insertion•Different insertion technique
•One-handed•Radio-opaque (x-ray, CT as well as USS, MRI)
Nexplanon vs Implanon
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6
Implanon failures
Bensouda-Grimaldi et al Gynecol Obstet Fertil 2005; Harrison-Woolrych et al Contraception 2005; data on file, Organon UK
%Unintended
pregnancies
LARC for London March 2012
New Mirena inserterSlightly narrower outer diameter of inserter
tubeThreads inside the handleScale on both sides of inserter tubeModified sliderNo change in actual IUSLocal Bayer events and training cascade
9LARC for London March 2012
New IUS inserterYour experience? Current vs. ‘old’ inserter.Need for improvement of current inserter?
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Quick Start – why?Reduce time at risk
of pregnancyRetain information
from consultationMaintain enthusiasm
for methodRemoves costs,
barriers and need for repeat consultation
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Quick Starting
Quick starting
Pregnancy risk excluded:Offer immediate start any method (additional precautions)
Quick Starting Contraception Sept 2010www.fsrh.org.ukLARC for London March 2012
Quick StartingPregnancy not excluded:
Assess for ECCan quick start CHC (not co-cyprindiol), POP, implant
DMPA only if other methods not acceptable
Advise re theoretical risks, additional precautions*, PT in 3-4 weeks
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*Quickstart and extra precautionsPost EHC
Levonorgestrel –additional precautions for 2 days (POP) or 7 days (CHC, implant, injectable)
UPA –additional precautions –add a further 7 days (due to PRM effect)
14LARC for London March 2012
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IUT Problems - Lost Threads
CausesExpulsion / perforation / uterine enlargementExclude pregnancy
Consider ECRecommend additional contraceptionLocate the device
refer for scan / x-ray
LARC for London March 2012
Expelling IUD/IUSNo knowing for how long may not have been
protective if found at CxNon-fundal placement –no evidence of
reduced effect?Remove and replace with IUD if sure a
negative PT excludes very early pregnancy?Remove and give EHC
20LARC for London March 2012
Migrating subdermal implants2 papers:
2005 – 2 casesJ Fam Plann Reprod Health Care 2005:31;71-73
(Evans et al.)
2006 – study of 100 patients looking at migration 3 and 12 months post insertion
J Fam Plann Reprod Health Care 2006:32;157-159 (Ismail et al.)
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2 case studiesCase 1
33yr old, attending 3+ yrs after insertionNorplant removed prior to insertionDistal end 11cm from insertion site, proximal
end approaching axilla
Case 235 yr old, attending 3 yrs after insertionNorplant removed prior to insertionDistal end 7.3cm from insertion site
22LARC for London March 2012
Newcastle study100 women, implanon inserted:
Location verified after insertion, 3 months and 12 months
Same doctor inserting all SDIAfter insertion, distal end of all was 1cm from
insertion site
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J Fam Plann Reprod Health Care 2006:32;157-159
LARC for London March 2012
ConclusionSignificant migration unlikely to occur if SDI
is correctly inserted
If there is migration, more likely to be caudal and by less than 2cm
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Implants continuedIf impalpable or no “pop – up” do not
attempt to remove Refer to deep implant removal centreDeep implants – incorrect insertion (less
theoretically likely with Nexplanon) or weight increase
Failed insertion – not with Nexplanon (look at the other arm!!)Etonogestrel levels –contact company
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Implants continuedMultirod implants – Norplant (6) and Jadelle
(2), removal by specialist with ultrasound
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Implants continuedSome other SDI (inserted abroad) with 2-6
rods – scan to confirm how many are in situ prior to removal
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Troublesome bleeding – a case study28yr old, Nexplanon in situ since 4
months. 2 month history of irregular bleeding. Bleeding unpredictable, variable amount. Several occasions, postcoital.
Amenorrhoeic for 2 months after SDI insertion
Management………..
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HistoryOther symptoms
Pelvic pain, dyspareunia,Menstrual pattern prior to SDIPregnancy riskDrug interactions with SDI (inc. OTC
preparations like St. Johns Wort)Cervical screening historySexual history
Partner healthPartner changePrevious STI check
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ExaminationPTSTI testsCervical smear if indicatedSpeculum and bimanual examinationsTVSEndometrial biopsy????
Exclude other causes before implicating SDI
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Irregular bleeding with Implanon923 women in 11 clinical trials
Amenorrhoea 22.2% Infrequent bleeding 33.6% Frequent 6.7% and/or prolonged bleeding 17.7%
35
Eur J Contracept Reprod Health Care 2008;13(Suppl 1):13-28
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Implanon: Bleeding patterns
0
10
20
30
40
50
60
1 2 3 4 5 6 7 8
Three-monthly assessments
Perc
enta
ge
Amenorrhoea Infrequent bleedingFrequent bleeding Prolonged bleeding
FSRH 2003LARC for London March 2012
Mechanism of irregular bleeding with SDI
Incompletely understoodIncomplete oestrogen suppression
Increased follicular diameter Increased endometrial thickness
Unstable endometriumFragile surface vesselsEpithelium detaches easily from underlying
stromaDefective epithelium repair mechanisms
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Treatment3/12 COC (if no contraindications) 30 –
35μg containing norethisterone or levonorgestrel, continuously or cyclically (unlicensed) CEU
Mefanamic acid bd or tds 500mg 5/7 CEU
No published evidence:High dose cyclical progestogen for up to 3/12
(MPA or NET)Desogestrel POP for 3 months
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Discontinuation rates with Progestogen only LARC methods
LARC Discontinuation rates
Most common reason
Injectables 50% within one year Unacceptable bleeding
Implant 43% within 3 years Unacceptable bleeding
IUS 60% within 5 years Unacceptable bleeding and pain
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Research neededExploration of methods to stabilise/repair
endometriumMifepristoneDoxycycline – potent inhibitor of matrix
metalloproteinase enzymes of endometrium
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