IUD Counseling for New Nurse Practitioners
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Show notes:
When it comes to GYN, it seems like a clear yes or no for most providers. They love it, or feel totally mystified.
I'm obsessed, but I know that's not the case for everyone.
IUD Counseling for New Nurse Practitioners
In this week's video I'm covering IUD counseling--
What you need to know as a PCP to discuss choosing an IUD for contraception, the differences between each kind, & side effects.
There are a few things I left out, like the actual risks of the procedure that the inserting provider usually discusses-- but it includes the general gist of what patients want to know.
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Liz Rohr (they/she) | Real World NP (00:00.418)
Well, hey there, it's Liz Rohr from Real World NP and you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster so you can take the best care of your patients. So if you caught my next one on counseling video, this is a similar type of video, only I'm going to be talking about IUDs. So I insert and remove IUDs.
And one of my dreams is that all providers, whether or not they actually do this procedure, feel comfortable enough knowing about all of the methods to be able to participate in contraceptive counseling. And I think that there's a lot of shyness around this topic, whether it's from overwhelm or feeling just not really sure how to approach it, or maybe just lack of interest. But I definitely find that there's a little bit of like, I don't really know about that. So in this video, I just want to make it really simple so that you feel comfortable having these conversations with your patients.
So when it comes to IUDs, they're very, effective, 99 % effective. And then there's two different categories. There's a hormonal method and a non-hormonal method. And they both work in the same way, which is that it's a device that's placed inside the uterus and it creates a sterile inflammatory state that's toxic to sperm and ova such that they don't meet.
and there are different ways that they work. So I'm going to start with the non-hormonal options. There's only one, which is the Paragard IUD. It's the copper IUD, and it's placed in the uterus, and it just kind of amplifies that harsh environment such that the sperm and the ova cannot meet. It also is effective for 10 years. One of the main, and one of the things that I always qualify with patients is that I think the immediate assumption is that you have to commit to 10 full years of using the device.
but I always say to them, it's effective for up to 10 years and you can remove it anytime. There is an immediate return to fertility after you take it out. The main changes, the main risks, side effects, not talking about the actual procedure, but I'm just talking about the device in general. The main side effects potentially are,
Liz Rohr (they/she) | Real World NP (01:57.347)
heavier, longer, and more crampy periods. Because there's no hormones in the device, your body cycles will remain the same as they were before. So if you have regular periods, they will continue to be regular. If they're irregular, if they're spotting, they're going to continue in the same pattern. However, with that potential risk of being heavier, longer, and more crampy. However, the evidence does support that this tends to get better over time over the course of the first six months.
And there isn't really clarity about whether or not there's a true return to baseline, but it tends to just improve over time. So the other main potential thing to think about when it comes to copper IUDs, there is a slightly increased risk of if there is a failure of the device in that 1%, it is likely to be an ectopic pregnancy. And so that's something to think about. If somebody's had multiple ectopic pregnancies,
that's definitely a concern to think about and may or may not be a great option for them. So hormonal IUDs, there's only one hormone, which is levonorgestrel. There's a number of devices though, there's a number of device options.
So this works in the same way, again, sterile inflammatory state, but the progestin tends to also create more of a mucus barrier to prevent the sperm from eating the ova. It doesn't actually suppress ovulation. The risk of, or the chances of somebody having their ovulation suppressed by the progestin is very variable. And so that's not necessarily the main mechanism of action of how it works. And it tends to be more effective for ovulation suppression.
the earlier on in the device use because there's a higher dose of the progestin as it tends to decline over time as it's coming up on needing to be removed. So yeah, so in terms of the options, there's a couple. So there is levonorgestrel 52 milligrams over the course of five years. There's two options for that. There's Mirena and Lydletta. So that's referring to the total amount of progesterone levonorgestrel in the actual device.
Liz Rohr (they/she) | Real World NP (04:00.302)
And it's released at about 20 micrograms per day, which again, declines over time over the course of use to about 10 micrograms per day at the five-year mark. And the Mirena is approved for five years. Lydletta is approved for six years by the FDA. There's two other options. The next one in terms of the lesser dose of the levonorgestrel is one called Kyelena. And that's only 19.5 milligrams compared to that 52 milligrams.
So it comes out to be about 17.5 micrograms per day. So only a little bit, slightly less than the Liletta and the Mirena, which declines over time as well. And then the lowest amount of levonorgestrel and the shortest amount of time is the Skyla. So Skyla is only approved for three years. There's only 13.5 milligrams in total in the device. So it's about 14 micrograms per day, again, which declines over the course of the three years.
And so why would you pick one over the other? Well, let me talk about the side effects first. So all of them, the main side effect for them is bleeding, bleeding changes. And so that can either be amenorrhea, so lack of a period at all. Someone's period can be the same as it was. There can be light spotting that's kind of a regular here and there, or just a regular bleeding that's unpredictable. And so that is just one of the choices that the person in front of you has to make in terms of whether or not they're willing to risk that side effect.
It is a locally acting drug. However, there is some evidence that it is systemically located. So there's been some studies about looking at the blood content of somebody with an IUD and looking at the progestin levels. And there's actually about like one fifth the amount of like a combined oral contraceptive. So it is detected peripherally. So because of that, for patients who are especially sensitive to hormones,
may have things like acne, weight changes, hirsutism, headaches, nausea, and mood changes. So those are things to think about whenever you have progestin in general, but especially for somebody who's really struggling with acne, really struggling with mood changes, really bad headaches all the time. Like those might...
Liz Rohr (they/she) | Real World NP (06:10.946)
factor into the decision making. Again, not a contraindication, but something you want to talk about with the patient and if they're willing to risk that. Because for them, for that person in front of you, the risk of pregnancy is more important to them than managing their acne, if that makes sense. So those are the kind of general thoughts. Couple of notes is that the weight changes. I wasn't able to find any hard...
data about the actual amount of weight that people gain. And so I don't think that there's a ton of evidence for those extra side effects aside from the bleeding changes. And one other note I wanted to make is that the amenorrhea side effect of not having a period at all is highest in the Mirena and the Liletta. The higher the dose of the progesterone has more, about like 20 % chance, I think, of the lack of periods at all, which is a benefit for some people and is a negative for other people.
And then again, kind of coming back to the timing, why would you choose one over the other? It's really up to the patient. And again, I always say to them, you don't have to commit to five or six years. You can use it for a year. I mean, probably I recommend, generally speaking, that you have the desire to have it for at least a year. But I don't necessarily have data about the cost effectiveness of one versus the other. But it's really up to them. It's their choice. It's their body, all of that stuff.
In terms of the other reasons to choose one, if they know that they're going to want it for at least five years, they know they want to optimize the lack of period, they might opt for the Mirena or the Laila, versus if they know it's only going to be three years, they could just do the Skyla, or they could do the Mirena, just take it out early. It doesn't matter. One other potential thing to think about is the size of the device. And so the Skyla, and I believe the Kailena, I don't actually insert the Kailena myself. I only insert the Laila and the Skyla and the Mirena. But there is a slight
size differential in terms of the diameter of the actual device for insertion. And so I think it's kind of like marketed more towards null paris or younger patients who haven't had a vaginal birth before, or even older patients that haven't had vaginal birth before, things like that. So that's, and I find actually the Paraguard IUD has a really narrow diameter as well for insertion, but there's no reason why somebody who hasn't had a vaginal birth before can't have an IUD of any kind.
Liz Rohr (they/she) | Real World NP (08:30.54)
So hopefully this video is helpful. Please let me know if you have any questions. And if you haven't already, head over to realworldnp.com slash guide to grab your ultimate resource guide for the new NP. You'll also get these videos and straight to your inbox every week.
notes from me, patient stories, and other bonus content that I really just don't share anywhere else. If you like this video, hit like and subscribe and share with your NP friends so together we can reach as many nurse practitioners as possible to help make their first years of practice or even later years of practice a little bit easier. Thank you so very much for watching. Hang in there and I'll see you soon.
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