dr alyson elliman ffsrh, mipm consultant croydon health services nhs trust with (huge) thanks to dr...

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


•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


Nexplanon


New inserter for implantYour experience?


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

7

Transverse image (deep Implanon)


8

Radio opaque implant


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


New IUS inserterYour experience? Current vs. ‘old’ inserter.Need for improvement of current inserter?


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


*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)


BridgingBridging:

CHC, POP (DMPA)


17CEU Sept 2010LARC for London March 2012

18

IUT Problems - Lost Threads

CausesExpulsion / perforation / uterine enlargementExclude pregnancy

Consider ECRecommend additional contraceptionLocate the device

refer for scan / x-ray


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


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.)


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


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

23

J Fam Plann Reprod Health Care 2006:32;157-159


At 3 months

24



At 12 months

25



ConclusionSignificant migration unlikely to occur if SDI

is correctly inserted

If there is migration, more likely to be caudal and by less than 2cm


Migration of implantYour experience??


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


Implants continuedMultirod implants – Norplant (6) and Jadelle

(2), removal by specialist with ultrasound


Implants continuedSome other SDI (inserted abroad) with 2-6

rods – scan to confirm how many are in situ prior to removal


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………..


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


ExaminationPTSTI testsCervical smear if indicatedSpeculum and bimanual examinationsTVSEndometrial biopsy????

Exclude other causes before implicating SDI


34

fsrh.org


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


36

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

Bleeding patterns with implantYour experience??


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


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


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


Research neededExploration of methods to stabilise/repair

endometriumMifepristoneDoxycycline – potent inhibitor of matrix

metalloproteinase enzymes of endometrium


ConclusionTheory and practice need to be reconciled in

real life scenariosRemember cultural acceptance/non-

acceptance of frequent or absent bleedingLARC targets affected by word of mouth,

wish for regular and non-heavy bleeds


dr alyson elliman ffsrh, mipm consultant croydon health services nhs trust with (huge) thanks to dr...

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