Implantable Devices

There are currently three implantable contraceptive devices available, two containing a progestin and one nonhormonal device. After insertion, Mirena, a levonorgestrel-re-leasing IUD, can provide contraceptive protection for up to 5 years. Paragard T 380A, a copper IUD, can provide contraceptive protection for up to 10 years. Implanon, the newest of the implantable devices, is an etonogestrel-releasing system that is surgically implanted under the skin of the upper arm and is effective for up to 3 years. Surveys have shown that IUDs have the highest satisfaction rate among patients using reversible contraceptives.

Although the mechanism of action for IUDs is not completely understood, several theories have been suggested. The original theory is that the presence of a foreign body in the uterus causes an inflammatory response that interferes with implantation. It is believed that copper-containing IUDs may have a direct toxic effect on spermatozoa. Progestin-containing implantable contraceptives can have direct effects on the uterus, such as thickening of cervical mucus and alterations to the endometrial lining. Mirena and Implanon can inhibit ovulation because they contain a progestin, but Paragard T 380A does not prevent ovulation.

It is important to evaluate a patient to determine if she is an appropriate candidate for an implantable contraceptive. Implantable contraceptives are recommended for women with at least one child, in a monogamous relationship, who have no history of pelvic inflammatory disease (PID) and no history or risk of ectopic pregnancy. There are also multiple contraindications to IUD use. Evaluation of the patient is essential because IUDs cannot be used in the following situations: (a) pregnancy or suspected pregnancy, (b) anatomically abnormal or distorted uterine cavity, (c) acute PID or history of PID, unless there has been a subsequent intrauterine pregnancy, (d) postpartum endometritis or infected abortion in the past 3 months, (e) known or suspected uterine or cervical neoplasia or unresolved abnormal pap smear, (f) genital bleeding of unknown etiology, (g) untreated acute cervicitis or vaginitis, (h) acute liver disease or liver tumor, (i) woman or her partner has multiple sexual partners, (j) previously inserted IUD still in place, (k) conditions associated with increased susceptibility to infections (e.g., leukemia or acquired immune deficiency syndrome), (l) genital actinomycosis, (m) hypersensitivity to any component of the IUD, (n) known or suspected carcinoma of the breast, (o) history of ectopic pregnancy or a condition that would predispose to ectopic pregnancy, and (p) Wilson's disease.41'42

There are potential side effects of IUD use. The most common adverse effects are cramping, abnormal uterine bleeding, and expulsion of the device. Other side effects seen are ectopic pregnancy, sepsis, PID, embedment of the device, uterine or cervical perforation, and ovarian cysts.41,42

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