Sunday February 10, 2013
Coil to prevent pregnancy
THE DOC SAYS . . .
By Dr MILTON LUM
The intra-uterine contraceptive device is made of plastic and/or copper, and is inserted into the uterus to help prevent pregnancy.
AN intra-uterine contraceptive device (IUCD) is a small contraceptive device that is inserted into the uterus. It is made of plastic and/or copper, and is called a “coil” or “loop” by many. It has threads, at one end, which protrude from the opening at the neck of the uterus (cervix) into the upper part of the vagina.
The IUCD prevents pregnancy by releasing copper, which induces a body response that changes the composition of the fluids in the uterus and fallopian tubes, thereby preventing the egg from meeting a sperm. The accepted legal and medical view is that an IUCD is a contraceptive method, and not a method of abortion, as it is extremely unlikely that it interferes with implantation.
The IUCD is an effective and reversible contraceptive method. There are 0.6 pregnancies in 100 women in one year of use.
Most women can use an IUCD, including women who have never been pregnant. It is effective immediately after insertion by a doctor. One does not have to worry about contraception as long as it is in place. It does not interfere with sex, and is effective for three to 10 years or until it is removed. It can be used with breastfeeding.
Fertility is restored when it is removed, and there is no interaction with other medicines.
There is no evidence that IUCDs increase the risk of cancers of the cervix, endometrium and ovaries. A very small number of users may complain of changes in mood and libido.
Complications after having an IUCD fitted are rare, and if they do occur, this will happen within the first year after insertion.
The periods may be heavier and last longer, especially in women who have always had heavy periods. This usually occurs in the first few cycles after insertion, which may then improve.
Sometimes, there is spotting or bleeding in between periods. The periods may also be painful. A small percentage (5-15%) of users will have the IUCD removed because of pain and bleeding.
If the problems persist, an intrauterine system may be considered. This will be discussed later.
An IUCD does not protect against sexually transmitted infections (STIs). As such, those at risk of STIs, ie those who have more than one partner or if the partner has more than one partner(s), have to use condoms as well.
There is a small increase in the chances of getting a pelvic infection in the 21 days following insertion, especially in women who have risk factors for STIs. The risk of pelvic infection at any time is increased in those at increased risk of STIs.
If an IUCD user gets an STI when it is inserted, it may lead to a pelvic infection if untreated.
The risk of pelvic infection from an IUCD itself is rare. Less than one in 100 women whose risk of STI is low will get such an infection.
Most doctors recommend screening for possible existing STI before inserting an IUCD. This includes an internal examination.
The IUCD may be expelled or displaced. The expulsion rates vary in the first year of use. The majority of expulsions occur within three months of insertion and the user may be unaware of its occurrence. That is the reason why the user is taught how to check the IUCD threads regularly.
The IUCD may, very rarely (about one in 1,000 insertions), go through (perforate) the uterus. Perforation is more likely to occur if the insertion is done after childbirth. This leads to lower abdominal pain that may require surgery to remove the IUCD.
If the pain is severe, immediate medical attention should be sought.
If an IUCD user gets pregnant, there is a risk that the pregnancy will develop outside the uterus, usually in the fallopian tube (ectopic pregnancy). Such an event is potentially life threatening. As less than 1% of IUCD users have an unintended pregnancy, the absolute risk of an ectopic pregnancy is lower in women using an IUCD when compared to sexually active women using no contraception.
If a pregnancy occurs despite the IUCD, it is removed as soon as possible in a continuing pregnancy.
Who can use an IUCD?
Most women can use an IUCD. However, women with any of the following conditions should not use an IUCD: those who may be pregnant; have an untreated STI or is at increased risk of getting an STI; now have or previously had an ectopic pregnancy; have heavy and painful menstrual periods; have any problems with the uterus or cervix; have bleeding in between periods or after sex; or have an artificial heart valve.
Because of one or more of the above reasons, the IUCD is not usually recommended for teenagers, unless they have given birth. The doctor will advise whether an IUCD is suitable for an individual, depending on her medical history.
The IUCD is usually inserted towards the end of a menstrual period or a few days after, before the estimated time of ovulation. It can also be inserted four to six weeks after childbirth, or immediately after a miscarriage below 24 weeks gestation. If the miscarriage occurs above 24 weeks gestation, the IUCD can be inserted a few weeks after the miscarriage.
It can also be inserted within five days of unprotected sexual intercourse as emergency contraception. It is safe to use sanitary towels or tampons with an IUCD in place.
Before an IUCD is inserted, the doctor will check that there is no pregnancy or existing pelvic infection, which, if present, would be treated. An internal examination is done to determine the size and position of the uterus.
A speculum is inserted into the vagina to keep it open, just like when a cervical smear is taken. The IUCD is inserted through the cervix into the uterine cavity. The process may be uncomfortable and occasionally painful, with lower abdominal cramps after the insertion.
Some women may require painkillers before an IUCD insertion, although many do not. The insertion process usually takes about 10 to 15 minutes.
After an IUCD insertion
It is advisable to consult the doctor after an IUCD has been inserted if one feels unwell, or has lower abdominal pain, a smelly vaginal discharge or fever, which are features of pelvic infection.
Users will be taught how to feel the IUCD threads to make sure that it is in place. This should be done a few times in the first month after insertion, and then after menstruation at regular intervals after that.
It is very unlikely that the IUCD will come out. However, if the threads cannot be felt, or the IUCD itself is felt, the doctor should be consulted and another contraceptive method used (until the IUCD has been located).
On rare occasions, the partner may feel the threads during sexual intercourse. A consultation with the doctor will lead to the threads being moved out of the way or shortened.
The IUCD will need to be checked by your doctor about three to six weeks after insertion, and then at least once a year after that. If there are any problems at any time, especially if the user or partner is at increased risk of STI, the doctor should be consulted as STIs can lead to pelvic infections.
An IUCD can be removed at any time. If one does not want another IUCD inserted and does not want to become pregnant, alternative contraceptive methods have to be used.
Pregnancy with an IUCD in place
It is very rare for a woman to become pregnant with an IUCD. The doctor should be consulted immediately if the periods are delayed or light, or if there is sudden or unusual lower abdominal pain, as these may be warning signs of an ectopic pregnancy.
If one is pregnant, and it is not an ectopic pregnancy, the doctor will remove the IUCD, as this reduces the chances of a miscarriage.
On the very rare occasions that the IUCD cannot be removed and the pregnancy proceeds, the risk of premature delivery is increased four times.
There is no evidence of increased risk of the IUCD causing congenital malformation if the pregnancy goes to term.
Levonorgestrel-releasing intra-uterine system
This is an IUCD containing 52 milligrams of levonorgestrel. It releases 20 micrograms of levonorgestrel every 24 hours. It is used as a contraceptive and in the treatment of heavy periods (menorrhagia) and endometrial protection for women on oestrogen replacement therapy.
It is effective for five years, and less than one in 100 women will get pregnant in a year of use. It is, however, ineffective as emergency contraception.
It is different from other IUCDs in that it reduces menstrual blood loss and painful periods. There is also a possible reduction of pelvic infection, as compared to the copper IUCDs, because it thickens the cervical mucous.
Menstrual irregularities are not uncommon in the first few months after insertion. After three months, the menstrual blood loss is reduced by 75%.
After twelve months, most women bleed lightly for one day and many have no periods. This is not medically harmful.
However, the commonest reason for its removal is unacceptable bleeding.
IUCDs are an effective contraceptive method. However, it is not usually recommended for teenagers or women who are at risk of sexually transmitted infections.
■ Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. For further information, e-mail email@example.com. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.