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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

Oxford Handbook of Midwifery (118 page)

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A withdrawal bleed may occur after oestrogen therapy.
The treatment may be repeated if an acceptable bleeding pattern does not occur subsequently.
Amenorrhoea
At least 90% of users have ceased having periods by 6 months.
Prolonged amenorrhoea may cause hypo-oestrogenism, adverse lipid effects, and osteoporosis.
When this form of contraception is administered over a long period of time, the woman should be reviewed at least once every 2 years by a doctor specializing in contraception. A bone mineral density scan may be undertaken.
Weight gain
This may be slow and insidious or rapid and marked. Most women gain 0.5–2.0kg in the first year, and 10–12kg after 4–6 years of use.
Progesterone use may increase the appetite, a similar effect to that of high progesterone levels in pregnancy. Weigh the woman regularly if weight gain is apparent or suspected.
The evidence is that this weight gain is as a result of increased fat and not secondary to anabolic effect or fluid retention.
CHAPTER 22
Contraception
548
Mood
- Some women on Depo-Provera
  ^®complain of premenstrual-type depression.
- Others have reported marked mood swings, which were not there before they started to use Depo-Provera
  ^®.
- For postnatal mothers, these progestogenic side-effects may exacerbate postnatal depression.
- Women with history of endogenous depression should not be given Depo-Provera
  ^®if there is a suitable alternative.
- Hormone replacement therapy (HRT) on reaching menopause is advisable for women with a history of prolonged use of
  Depo-Provera
  ^®.
  Bone mineral density changes
- Large, well-controlled studies are currently in progress.
- The evidence is that structure and bone mass return to normal once the drug is no longer taken.
  1
  World Health Organization (2004).
  Selected Practice Recommendations for Contraceptive Use
  , 2nd edn. Geneva: WHO.
  MIRENA
  ^®INTRAUTERINE SYSTEM‌‌
  Mirena
  ®
  intrauterine system
  Content
  The IUS is a long-acting reversible contraceptive inserted into the uterus, mounted on a Nova T
  ^®IUD frame. It contains a Silastic capsule along its shaft, which secretes levonorgestrel 20micrograms daily.
  It is licensed for 5 years’ duration. If left longer than this the contraceptive effect of the IUD will continue, but the progestogenic effects will cease.
  Indications for use
  There are two main uses:
Contraception, particularly in women who have heavy menstrual periods. After pregnancy a woman may experience notable and debilitating increase in menstrual flow and the IUS is ideal in these cases.
Menorrhagia: the use of an IUS may prevent the need for hysterectomy.
Other conditions: endometriosis, chronic pelvic pain, dysmenorrhoea and anaemia, associated with heavy menstrual bleeding, where there is no pathological cause.
It is
not
used for post-coital emergency contraception.
How does the IUS work?
In addition to the foreign body effect of the IUD there is the progestogenic effect:
Frequency of ovulation is reduced
Cervical mucus thickens to inhibit the passage of sperm through the cervix
The foreign body reaction within the uterus causes the release of leucocytes and prostaglandins from the endometrium, making the environment hostile to the blastocyst
The endometrium is thinned
Menstrual bleeding becomes much lighter—this is in direct contrast to the copper IUD, which may cause heavier menstrual bleeding
Irregular spotting or bleeding may occur in the first few months after insertion, but diminishes after the first 3 months.
The IUS and breastfeeding
The IUS and other progesterone-only contraceptives are not shown to affect milk supply or infant growth.
¹The risk of intrauterine perforation is increased in a lactating mother and fitting should ideally be delayed until at least 12 weeks post birth.
Fitting
For infection screen, when it is fitted and insertion notes, and other infor- mation, b see Intrauterine devices, p. 550. As with other IUDs it
must
be fitted by a doctor or nurse trained and competent in the technique, assessing suitability and dealing with possible immediate complications. It is not usually fitted in a nullipara.
1
Truitt S, Fraser A, Grimes D, Gallo M, Schulz K (2003). Combined hormonal versus nonhor- monal versus progestin-only contraception in lactation.
Cochrane Database Systematic Review
2
, CD003988.
549
CHAPTER 22
Contraception
550‌‌
Intrauterine devices
- These are small polyethylene and copper devices, which come in a variety of shapes and sizes (Fig. 22.5), and are inserted into the uterus.
- IUDs provide excellent contraception, have the benefit of no ‘user failures’, and are the most popular form of contraception in some parts of the world, e.g. China.
- It is a myth that a nulliparous woman cannot be fitted with an IUD. Developments in IUDs now make this possible, particularly the frameless Gynefix
  ^®, which is ideal for nulliparae.
- In some parts of the world the IUD had received a negative press, but is now increasing in popularity again, as the newer IUDs are able to offer up to 10 years’ contraceptive protection, and longer in the older woman, whose fertility is declining towards menopause.
- It is unsuitable for a woman who has a true copper allergy and for certain other women with uterine abnormalities, previous or current pelvic inflammatory disease or bacterial endocarditis, or those whose lifestyle puts them at high risk of pelvic infection.
  Other contraindications include past ectopic pregnancy, established immunosuppression, menorrhagia, unexplained vaginal or uterine bleeding, and heart valve replacement.
  •
  It is important that the midwife knows the woman’s medical, obstetric, gynaecological, and sexual history before advising her about an IUD.
  How does the IUD work?
- The mode of action is not exactly known, but it is thought that the main mechanism of the copper is in preventing fertilization, by altering the composition of tubal and uterine fluids. In this way the IUD
  does not cause abortion. Within the uterus the IUD causes a foreign body reaction within the endometrium, with increased numbers of leucocytes.
- If fertilization does occur, then the IUD will stop implantation in the uterus, but this would only usually occur only if the woman keeps the device
  in situ
  longer than the recommended number of years for the copper content of the individual device to be effective. For the different IUDs this period ranges from 5 to 10 years.
- 2 The IUD provides excellent post-coital emergency contraception, for the above reason, and may be removed after the next normal period or left
  in situ
  for long-term contraception.
- As the woman gets older, her fertility declines, so the IUD is more effective in women over 30. If an IUD is fitted in a woman over 40, it need not be changed and is removed at the time of the menopause.
  When is it inserted?
- After 1st trimester abortion
  : it can be inserted immediately.
- After 2nd trimester abortion
  : wait 2–4 weeks, to allow uterine involution, and avoid the risk of expulsion.
- After vaginal birth
  : wait at least 6 weeks, to allow full uterine involution. If breastfeeding, the mother may be at increased risk of uterine perforation, and, if fully breastfeeding day and night, she could wait
INTRAUTERINE DEVICES
The actual size of the IUD Palpating the threads after insertion
(a) (b) (c) (d)
Fig. 22.5
The IUD. (a) Gyne T280; (b) Multiload Cu375; (c) Gynefix
^®; and (d) Nova T380.
Copyright © fpa 2007 and reproduced by permission of the publisher.
551
up to 12 weeks to have her IUD inserted, because breastfeeding will prevent ovulation.