Are U in search of LARC(Long Acting Reversible Contraceptives-Forgettable contraceptives which can offer protection for long 12 yrs?. Then opt for Copper bearing Intrauterine contraceptive Device-It is free .Safe too.

Contd from previous post dated 13-10-16, Part 2 of Copper Devices contraceptives which is to be fitted inside the womb.Does intra uterine contraceptives cause too much side effects-e.g.pain in lower part of tummy, Irregular bleeding, Pelvic infection. No. Such undesirable side effects are minimal.
Is contraceptive -induced bleeding is a problem? It is myth!!!

26. Management of possible side effects of the IUD:

The list of possible side effects associated with IUD use is:

i)        Uterine Cramps

ii)      Menstrual irregularities

iii)    Pelvic infection

iv)    Spontaneous expulsion

v)      Accidental Pregnancy

            Many do not have any adverse effect at all and keeps fine. That is also why the IUD called worry-free contraceptive a forgettable contraceptive. Only few have symptoms and a few are bothered or distressed with side effects. The common discomfort quoted by the acceptors is ‘bleeding irregularities’ and ‘pelvic pain’. Why some women have side effects and other women escape? Firstly, health care providers need to know that not all women are suitable for IUD. Therefore if the acceptors are not properly selected then IUD related side effects will be more. For instance if there is pelvic infection, or uterine abnormality then side effects are bound to occur. If IUD is fitted inadvertently in such women. Side effects thus can be minimized by proper selection of clients and strictly adhering to contraindications of IUD use as framed by W.H.O. and other international agencies. Secondly, these side effects can be further minimized if the IUDs are fitted by an experienced and skilled nurse or doctor who has adequate training on IUD insertion.   The cause of cramps in lower part of tummy either during menstruation (dysmenorrhoea) or in between periods are often caused by slight malpositioned or malrotation of IUD inside the uterine cavity (womb). The pain is usually relieved by usual analgesics and NSAIDS. Persistence pelvic pain however may not only be due to abnormal position of the IUD associated PID, but also occasionally uterine perforation, beginning of expulsion of the IUD, or rarely ectopic pregnancy may also be the cause pelvic pain. One has to remember that womb is a hollow muscular organ and constantly undergoes contractions and relaxation. During a height of continue muscles of uterus pres the device particularly if it the device is not properly fitted. This may recurrently cause cramp in lower part of belly and irregular bleeding. Scientists have now devise newer frames with flexible joints in the transverse bar of ‘T’ device which allows the IUC to repeatedly yield and accommodate the changing shape of womb with each contraction and relaxation sadly, these devices are still not available in the market.

1.      IUD induced menstrual disturbances (Bleeding related problems):

Variety of menstrual disorders which however occasionally quoted by the acceptor are as follows. 1) Spotting between periods i.e. inter menstrual bleeding 2) heavy periods or longer menstrual flow (menorrhagia). These menstrual aberrations usually last for first three months after insertion of IUD and fortunately most of these subside by three to six months time. Only in few cases HCPs (Health Care Providers) are forced to remove the IUD if the magnitude of suffering is considerable persistent or none relieved by drugs.

a)      Incidence and severity of bleeding:       In a normal menstrual cycle i.e. without any IUD, the mean amount of menstrual blood loss (MBL) was previously thought to be approximately 35 ml. With improved techniques of extraction of blood from sanitary napkins, this amount is now estimated to be approximately 60ml. Excessive or prolonged menstrual bleeding (menorrhagia) affects between 5% to 30% of women of reproductive age i.e. general population not using contraceptives. It is more common among women under the age of twenty and over the age forty years than.

The amount of blood lost in each menstrual cycle is slightly greater in women using copper-bearing IUDs than in nonusers. With the most commonly used IUD there is only an average increase of 20-55% in MBL which most women accept. By contrast, with the levonorgestrel releasing IUD (Mirena IUS) which is now used in India for last 5 years the amount of blood loss is significantly reduced, declining to approximately 25ml/cycle.

b)      How to gaze severity of bleeding?           A personal interview and total number of napkins needed per 24 hours will often help the HCP to assess the severity of bleeding. If a woman who is on IUD complaint of weakness in addition to excessive bleeding then HCP can think of chronic anemia due to persistent heavy bleeding. In absence of any other evidence of blood loss e.g. piles, worm’s infestation and haematemesis the possibility of IUD induced anemia should always be considered. It implies that menstrual bleeding is too much to cause anemia. In these cases the HCP should insist on hemoglobin estimation. If the level is below 9 gm% then he (HCP) can request for estimation of serum Ferritin level in blood provided such laboratory facilities exists in the locality in which the client resides. Serum Ferritin is a very sensitive indicator of tissue iron stores. Persistent menorrhagia without concomitant iron supplementation is likely to cause significant decrease in serum Ferritin levels. Low blood Ferritin is an indicator of depletion of iron store in the bone narrow as well. Therefore a conscientious HCP may occasionally request for ferrtin  estimation amongst women with menstrual bleeding disorder and levels less than 4mg/lit should always require oral iron supplementation to prevent further anemia.

c)      Why bleeding and pain? As said earlier most bleeding irregularities including painful cramps occur due to improper fitting of IUD. If there is slight tilt or rotation of IUD inside the womb or angulation between the long axis of womb and long axis of IUD then device will lead to repeated mild trauma in the inner wall of womb and induce pain and menstrual bleeding. We know that muscle of womb contracts and relax at definite intervals even in nonpregnant state. If the device inside the womb is ill fitting then it will hinge the inner wall of womb and induce pain and bleeding during height of contractions. A comparison can be drawn with small foreign body (fishbone) stuck at throat which causes pain during each act of swallowing unless the fishbone passes down (antoadjustment) or removed.

In addition to ill-fitting the other causes of pain and excessive bleeding are due to – i) P.I.D. ii) at the beginning of expulsion of IUD iii) associated PID or ectopic pregnancy (tubal pregnancy) All these may cause pelvic pain and bleeding. Hence persistent pain or bleeding should be always investigated properly by the experts.

d)      How to prevent bleeding ?:        Besides selecting the acceptor the proper selection of appropriate sized IUD and proper placement of IUD by a skilled person are key factors to minimize bleeding related side effects. Researchers have now been able to devise new devices which cause minimal menorrhagia (excessive menstrual loss). These new IUDs have also succeeded in reducing the likelihood of expulsion and lowering of pregnancy rate further. It is hoped that future designs of IUD will focus on reducing these side effects even further.

e)      How to treat pain and bleeding:    For short-term relief three types of drugs are used with varying success. These are tranexamic acid, NSAIDS or mefanamic acids with varying success. One can try with tranexamic acid, 500 mg 3 times daily for three days and then 500 mg twice daily for 2 day particulars during heavy or prolonged bleeding phases. This drug is available as Pause 500, TX 500 etc. Alternatively, NSAID group of drugs e.g. ibuprofen (400 mg), indomethacin (25 mg) two times daily may be tried. Mefanamic acid tablets are increasingly used nowadays. These should be taken twice daily after meals for 5 days and this may ameliorate heavy or prolonged bleeding. These are available as ponstan 500 or meftal 500 etc.

Some doctors prescribe nonsteroidal anti-flammatory drugs (NSAIDS) e.g. ibuprofen, mefanamic acid etc. prophylactic ally i.e. from the onset of first menses after IUD insertion and maintain such schedule for three to five consecutive days. This by decreasing pain and bleeding certainly increase clients her confidence on IUD. NSAIDS therefore prescribed in anticipation will yield a dividend most cases.

Occasionally these drugs will not work and heavy or prolonged bleeding persists. If there is no reason to suspect on underlying local cause i.e. gynecological diseases, there are two options.

Firstly she can continue using IUD method and in that event she should take iron tablets and/or eat foods containing iron, to help prevent anemia. This policy, however, is only acceptable when pain and bleeding is partly reduced by above mentioned drugs and the woman is not that distressed with pain and bleeding.  Secondly,  if she shows signs of severe anemia and severity of bleeding is unacceptable then one should remove the device and advise her to choose another method.

Removal due to pain and bleeding is less common among older women, multipara and in long-term users. The removal rate depends a lot on the pre-insertion counseling and support that a woman receives and on her altitude, both familial personal, towards her trouble with IUDs.

How does bleeding affects general health of a woman? The effect of bleeding is almost nil in healthy women but may lead to increased anemia already anaemic woman. Indian National Family Health Survey-3 (study period 2005-’06) has unearthed the fact that 39% of Indian women are mildly anaemic hemoglobin level <10 to 10.9 gm/d and 16% are moderately anemic. There is         of       women by 4% the period 1098-99 to 2004-05. <70-9.9 gm (d) and 2% are severely, anemic (H level       7 g/d).

Anaemic usually passes off within a month or two. The client should be reassured about it. In fact, no aggressive treatment is warranted.

f)       Removal Rate:      The single most common side effect leading to IUD discontinuation is disturbance in menstrual bleeding. The experience of excess bleeding is often accompanied by pain also. These two side effects either alone or in combination are not too uncommon. In spite of adequate counseling and medical treatment in 2-10% of cases IUD have to be removed for persistent menstrual bleeding and pelvic pain. Providers should always offer clients the choice of switching method if they are not satisfied or if their needs or preferences have changed.

g)      How women and society view about normal menstruation?:            Women’s attitudes about menstruation are shaped not only by experience but also by beliefs about the social and cultural meaning of menstruation and what is acceptable monthly bleeding, taboos, and behavioral restrictions. Although not all beliefs are reflected in practice, in many places cultural and religious beliefs prevent menstruating women from participating in worship, sex, domestic works and many social activities. In some societies menstruating women should not visit places of worship. In some conservative societies menstruating women are not allowed to perform event heir domestic chores such as cooking and washing clothes. Sexual intercourse should be avoided during monthly bleeding. In contrast, only about half of women in the United Kingdom, the only developed country in the study, believed sex should be avoided during monthly bleeding. Even among women who thought that it was acceptable, however, many did not have sex then as a matter of personal choice.

h)      How women react to menorrhagia? If is retreated that these bleeding changes are rarely harmful, and they do not signify underlying or impending illness. But a woman reacts to bleeding changes and to what extent one tolerates depend on many factors, such as on the type and severity of bleeding changes and how severe it is, or whether it interferes with her daily activities or personal relationship, and also traditional beliefs or restrictions surrounding bleeding days. These changes however are not signs that something is wrong with her health. It is not the bleeding change itself, but rather how the woman feels about it and interprets it that will determine how she reacts. It should be stressed that these bleeding changes are normal and not signs of serious illness.

i)        Do other contraceptives cause such bleeding?            Bleeding and spotting at unexpected times are also common among women using oral contraceptives (20% of cases particularly during the first three months). The good news is that this drop to about 10% of cycles during the next three months, and to approximately 5% of cycles during the last six months of a 12-month period.

In summary, the following information may help the clients.

a)      Spotting or light bleeding                                  b)   Heavier or longer menstrual

Between menstrual periods.                         Bleeding than normal

(Not amounting to anaemia)                        menstrual periods. (The amount

                                                                         Blood loss is such that there is a

                                                                         Threat for becoming anemic)

a)      HCP should counsel that spotting or light bleeding is common during the first 3-6 months of copper-bearing IUD use. It is not harmful and usually decreases over time.	a)      The following treatment should be offered during the days of menstrual bleeding. Non-steroidal anti-flammatory drugs (NSAIDS) or Tranexamic acid haemostatic agent). Aspirin should not be used.
b)      If she desires treatment, a short course of non-steroidal anti-flammatory drugs (NSAIDS) may be prescribed during the days of bleeding.	b)      If bleeding continues to be very heavy or in spite of blood coagulating agents and there are clinical signs of anaemia, or if she finds the bleeding unacceptable, early removal of the IUD is the best option.
c)      If women are bothered with persistent spotting and bleeding then one should exclude other gynecologic problem. If a gynecologic problem is identified, it should be treated by a specialist. There is no need to removal IUD.
d)      If no gynecologic disease can be held responsible for bleeding, and she finds the bleeding unacceptable removal of the IUD should be done and one should help her to choose another method.

(Courtesy: World Health Organization)