What are the considerations for a female patient of reproductive age using Lunette (intrauterine device, IUD) as a form of contraception?

Lunette (Levonorgestrel IUD) for Contraception in Reproductive-Age Women

Direct Recommendation

The levonorgestrel-releasing IUD (LNG-IUD) is an excellent first-line contraceptive option for reproductive-age women, offering superior efficacy compared to oral contraceptives with 12-month adherence rates of 86% versus 55% for pills, and should be offered to most women including nulliparous patients and adolescents. 1, 2

Pre-Insertion Screening Requirements

Mandatory Clinical Assessment

• Perform bimanual examination and cervical inspection before insertion to rule out anatomical abnormalities that would distort the uterine cavity (absolute contraindication, Category 4). 3, 1, 4
• Screen for sexually transmitted infections (chlamydia and gonorrhea) by history and physical examination; testing can occur at time of insertion without delaying the procedure. 1, 4, 2
• Confirm the patient is not pregnant using standard criteria before insertion. 3, 1

Absolute Contraindications (Category 4)

• Current pregnancy 3
• Current pelvic inflammatory disease (must complete antibiotic treatment first) 3, 1
• Purulent cervicitis, active chlamydia, or gonorrhea (treat first) 1
• Distorted uterine cavity from congenital or acquired abnormalities incompatible with insertion 3, 1
• Current cervical or endometrial cancer awaiting treatment 3, 1
• Current breast cancer (Category 4 for LNG-IUD due to hormonal sensitivity) 3
• Puerperal sepsis 3
• Persistently elevated β-hCG levels or malignant gestational trophoblastic disease 3

Relative Contraindications (Category 2-3)

• Past PID without subsequent pregnancy (Category 2) - advantages generally outweigh risks. 3
• Nulliparity (Category 2) - concern exists for expulsion risk and STI risk from sexual behavior, but IUDs remain appropriate. 3, 2
• Age <20 years (Category 2) - similar concerns as nulliparity, but adolescents can use IUDs as first-line contraception. 3, 2
• Past breast cancer with no evidence of disease for 5 years (Category 3) - theoretical concerns about hormonal effects. 3
• Uterine fibroids (Category 2) - may increase expulsion rates (11% vs 0-3%), but most women experience improved bleeding and anemia. 3

Timing of Insertion

Standard Timing Protocol

• The LNG-IUD can be inserted at any time if reasonably certain the patient is not pregnant. 3, 1
• If inserted within first 7 days of menstrual bleeding, no backup contraception needed. 3
• If inserted >7 days since menstrual bleeding started, patient must abstain or use backup contraception for 7 days. 3

Special Circumstances

• Postpartum: Can insert immediately after placenta delivery (Category 2) or ≥4 weeks postpartum (Category 1). 3
• First-trimester abortion: Can insert immediately (Category 1), including at time of surgical abortion (no backup needed). 3
• Second-trimester abortion: Can insert immediately (Category 2), but expulsion rates higher than first-trimester. 3

Expected Side Effects and Management

Bleeding Pattern Changes

• Counsel all patients that approximately 50% will experience amenorrhea or oligomenorrhea by 2 years of use. 4
• For breakthrough bleeding in first 3-6 months, prescribe NSAIDs for 5-7 days as first-line treatment. 1
• If bleeding persists beyond 6 months, consider short-term hormonal treatment with low-dose combined oral contraceptives or estrogen for 10-20 days. 1
• The LNG-IUD reduces menstrual blood loss by 71-95%, making it comparable to endometrial ablation for heavy menstrual bleeding. 1

Other Common Effects

• Irregular bleeding during first months after insertion 5, 6
• Hormonal effects including headache, acne, breast tension, and functional ovarian cysts 5
• Dysmenorrhea may improve with LNG-IUD use (unlike copper IUDs which worsen it) 3

Complications and Risk Mitigation

Infection Risk

• Risk of pelvic inflammatory disease is slightly elevated only in first 20 days after insertion (about 6 infections per 1000 woman-years). 5, 2
• Routine prophylactic antibiotics are NOT recommended prior to insertion. 2
• If PID develops with IUD in place, treat with antibiotics and do NOT remove IUD unless no clinical improvement after 72 hours or patient requests removal. 3, 2

Mechanical Complications

• Expulsion occurs in 5-10% of cases within 5 years, with 30% recurrence rate. 5
• Uterine perforation is rare (0.6-16 per 1000 insertions), with higher risk if inserted <4-6 weeks after delivery or abortion. 5
• Difficult insertion, pain, bleeding, and syncope occur in <1.5% of cases overall. 5

Pregnancy-Related Risks

• Contraceptive failure rate is 0.27 per 100 woman-years, significantly lower than oral contraceptives (4.55). 1
• If pregnancy occurs with IUD in place, about 25% end in live birth if device left in place versus 90% if removed. 5
• Ectopic pregnancies are rarer in IUD users than non-contraceptors, but about 1 in 20 IUD pregnancies is ectopic. 5

Specific Patient Populations

Ideal Candidates

• Parous women in stable relationships (Category 1 for age ≥20 years). 3, 4
• Women requiring long-term menstrual suppression when estrogen is contraindicated. 1
• Women with history of deep venous thrombosis, pulmonary embolism, or coronary events (copper IUD preferred, but LNG-IUD acceptable). 5
• Breastfeeding women, including immediately postpartum. 5
• Women with diabetes or HIV infection. 5, 2

Special Considerations

• Nulliparous women and adolescents: Only concerns are insertion pain and more frequent expulsions; otherwise appropriate first-line option. 5, 2
• Women with liver disease including decompensated cirrhosis can safely use IUDs. 4
• HIV-positive women can safely use IUDs. 2

Critical Pitfalls to Avoid

• Do NOT delay insertion waiting for next menstrual period if reasonably certain patient is not pregnant. 3
• Do NOT routinely prescribe prophylactic antibiotics before insertion. 2
• Do NOT automatically remove IUD if PID develops; treat with antibiotics first and only remove if no improvement after 72 hours. 2
• Do NOT screen for bacterial vaginosis routinely in asymptomatic women. 2
• Do NOT withhold IUDs from nulliparous women or adolescents based solely on parity or age. 2