Definitions of the grades of recommendation, based on levels of evidence (A-C, Good Practice Point), are provided at the end of the "Major Recommendations" field.
What should a clinician assess before considering levonorgestrel-releasing intrauterine system (LNG-IUS) use?
- After counselling, the LNG-IUS is a suitable option for most women who need contraception and/or treatment for menorrhagia (Grade C).
After counselling about other contraceptive methods, women who are assessed as at a higher risk of sexually transmitted infection (STI) may still choose to use the LNG-IUS (Good Practice Point).
After considering other contraceptive methods, a woman may use the LNG-IUS within 3 months of treated pelvic infection, provided she has no signs or symptoms (Good Practice Point).
Women with a history of migraine with focal symptoms may use the LNG-IUS. If, however, migraine with focal symptoms develops in a LNG-IUS user, these new symptoms should be investigated and other contraceptive options discussed (Good Practice Point).
Non-hormonal contraception is most appropriate for a woman with a history of breast cancer. However, the LNG-IUS may be considered individually, and in consultation with the woman's breast surgeon (Good Practice Point).
- Levels of LNG in breast milk are low with the LNG-IUS. Therefore, women who are breastfeeding and are 4 or more weeks postpartum may choose this method (Grade B).
- Women using the LNG-IUS may be reassured that there is no evidence of reduced efficacy with liver enzyme-inducers or other drugs (Grade B).
What do women need to know before considering the LNG-IUS?
- Women should be informed that the LNG-IUS works primarily by its effect on the endometrium, thus preventing implantation. In addition, effects on cervical mucus prevent sperm penetration. Most women will continue to ovulate (Grade B).
- Women should be advised that the LNG-IUS is an effective, reversible method of contraception with a failure rate of less than 1 per 100 woman-years (Grade A).
- Women should be informed that the failure rate of the LNG-IUS is similar to that of modern intrauterine devices (IUDs) (Grade A).
- Women should be informed that the LNG-IUS is licensed for 5 years' use (Grade C).
All women using the LNG-IUS should be advised to return for review after 5 years' use to discuss the need for removal and replacement (Good Practice Point).
Women should be advised that a small increase in the risk of pelvic infection occurs following LNG-IUS insertion but thereafter the risk of infection is low (Good Practice Point).
- Women can be reassured that the risk of ectopic pregnancy with the LNG-IUS is low (Grade A).
- Women can be reassured that there is rapid return of fertility following LNG-IUS removal (Grade B).
- Women should be informed that the most likely cause of LNG-IUS failure is expulsion. The risk of this happening is around 1 in 20 (Grade A).
- Women may be informed that uterine perforation occurs in fewer than 1 in 1,000 LNG-IUS insertions (Grade B).
- Women should be informed that the LNG-IUS can reduce menstrual blood loss by over 90% (Grade A).
- Women should be informed that altered patterns of menstrual bleeding (prolonged bleeding and amenorrhoea) are common with the LNG-IUS (Grade A).
- Women may be informed that, although hormonal symptoms are reported by LNG-IUS users, these are not significantly different from IUD users (Grade A).
- Women may be reassured that, although ovarian cysts occur in LNG-IUS users, there is no significant increased risk compared to IUD users (Grade A).
- Women may be reassured that there is no evidence to suggest the LNG-IUS has a detrimental effect on bone mineral density (Grade C).
All women considering the LNG-IUS should be informed of potential bleeding patterns and hormonal symptoms that may occur with this method of contraception (Good Practice Point).
What are the potential non-contraceptive uses of the LNG-IUS?
- The LNG-IUS can be used as a first-line option to treat menorrhagia (Grade A).
- The LNG-IUS is effective in the management of menorrhagia, even in the presence of fibroids (Grade C).
- It is not generally recommended that the LNG-IUS be used if fibroids are distorting the uterine cavity (Grade C).
- Surgery (hysterectomy, endometrial resection, or ablation) is more effective than the LNG-IUS in treating menorrhagia at 1 year (Grade A).
- The LNG-IUS is as effective as conservative surgery (resection and ablation) in the management of menorrhagia after the first year (Grade A).
- Patient satisfaction and quality of life appear similar following LNG-IUS or surgical treatment of menorrhagia (Grade A).
- There is insufficient evidence to support the use of the LNG-IUS routinely for women with pain in the absence of heavy bleeding (Grade C).
- Women using oestrogen replacement may choose the LNG-IUS to provide protection against hyperplasia and malignancy, but this is outside the current license (Grade A).
- The LNG-IUS should not be used routinely as a treatment for endometrial hyperplasia or malignancy (Grade B).
- Women may be advised that there is insufficient evidence that the LNG-IUS alone is effective in the treatment of premenstrual symptoms (Grade C).
When can the LNG-IUS be inserted?
- Ideally, the LNG-IUS should be inserted in the first 7 days after the onset of menstruation (Grade C).
- The LNG-IUS is not effective as emergency contraception (Grade C).
The LNG-IUS can be inserted at any time in a woman's cycle if it is certain she is not pregnant and has not been at risk of pregnancy in that cycle. Barrier contraception is advised for the next 7 days (Good Practice Point).
Which examinations and tests should be performed prior to LNG-IUS insertion?
- All women considering the LNG-IUS should have examinations and tests as for insertion of any intrauterine method of contraception (Grade C).
- Endometrial assessment (biopsy or ultrasound scan) is not routinely required prior to LNG-IUS insertion for the management of menorrhagia (Grade C).
What procedures and documentation are required for LNG-IUS insertion?
Procedures and documentation should follow those outlined for the IUD in the Faculty of Family Planning and Reproductive Health Care (FFPRHC) guideline "The Copper Intrauterine Device as Long-Term Contraception."
What follow-up is required following LNG-IUS insertion?
- Women who present with persistent menorrhagia, despite LNG-IUS use, should be advised to return for further assessment of the uterine cavity (biopsy or ultrasound scan) to exclude pathology (Grade B).
A follow-up visit should be advised after the first menses, or 3 to 6 weeks after LNG-IUS insertion (Good Practice Point).
How are LNG-IUS problems managed?
- Suspected perforation, lost threads, pregnancy, presence of actinomyces-like organisms, and pelvic infection should be managed as for IUD use (Grade C).
- Women using the LNG-IUS who present with a change in pattern of bleeding should be advised to return for further investigation to exclude infection, pregnancy, and gynaecological pathology (Grade B).
When can the LNG-IUS be removed?
The LNG-IUS may be removed at any time if the woman wishes to conceive; otherwise unprotected sex should be avoided in the 7 days prior to removal (Good Practice Point).
Definitions
Grades of Recommendation based on levels of evidence as follows:
A: Evidence based on randomised controlled trials (RCTs)
B: Evidence based on other robust experimental or observational studies
C: Evidence is limited but the advice relies on expert opinion and has the endorsement of respected authorities
Good Practice Point where no evidence exists but where best practice is based on the clinical experience of the Expert Group
