LARC Complex referrals

Problems with IUC and SDI - Overview

Jan 2024 Updates: Please see the LARC Remedy page for details of changes to licensing of '52mg LNG-IUD'

Please note: current LARC waiting times are up to 16 weeks for both routine and complex referrals.

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Following IUC fit, mild pain and bleeding is common. Patients will receive a leaflet about what to expect after a coil fit . Women should be taught to self-examine for coil threads and/or have a thread check 4-6 weeks after fit

• ‘Lost threads’ may indicate that the threads have moved inside the cervix but coil is in the correct place (most common), that the coil has been expelled (1 in 20), or that the coil has perforated (~1 in 1000)
• For other questions or mild symptoms, patients can use the Unity website for information about managing LARC problems.
• The FSRH have a Problematic bleeding guide for clinicians.

Following SDI fit, routine follow up is not necessary. However, in the following circumstances patients should be reviewed

• They cannot feel their implant
• It appears to have changed shape or been damaged
• They notice any skin changes, sensation changes, or pain around the site of the implant
• They have a positive pregnancy test
• They develop any condition which may contraindicate continuation of the method
• They start or are due to start an enzyme-inducing drug.

Who to refer

IUC: refer after appropriate assessment in cases of lost threads

SDI: refer after appropriate assessment for impalpable implant

What to do before referral

Lost IUC threads The following steps are initial advice for managing lost threads in primary care

• History
  1. Pregnancy risk?
  2. Need for emergency contraception today?
  3. Concerns about perforation? (recent fit, difficult procedure, pain)
• Examination
  1. Speculum – are threads visible?
• Assessment
1. Perform pregnancy test
2. If no threads seen:
   1. Emergency contraception
   2. Quick-start alternative contraception
   3. Refer for a transvaginal ultrasound scan (TVUSS) to locate IUC
3. If threads seen at speculum:
   1. reassure patient
   2. teach patient how to check threads
   3. If concerned about low-lying coil (e.g. very long threads or stem visible) follow steps above for “if no threads seen”
4. If TVUSS shows IUC in uterus, refer as below
5. If TVUSS shows no IUC in the uterus, the patient will need abdominal imaging to exclude a perforation and should not be referred to Unity.   

Implant problems   

• If the patient has any neurological symptoms the GP should directly refer the patient to Plastics without further delay.
• If on palpation a device appears broken/ damaged it is recommended that the problem is reported to the manufacturer and the MHRA yellow card scheme.
• If the implant is impalpable, do not assume that this is due to a ‘deep insertion’. Occasionally it may be due to a removal that has not been documented, or a non-insertion.
1. Check pregnancy test
2. Offer emergency and alternative contraception

Refer

ALL patients must be referred to Unity Sexual Health for complex procedures, even if they would be eligible for self-referral via other criteria

Urgent problems

If considered urgent please contact the professional advice line 0117 342 6913 during working hours in addition to submitting the referral form.

Non-urgent problems 

For Bristol and South Glos practices, please use the Unity Sexual Health LARC referral form (available as a template in EMIS). From 02/07/24 all referrals should be sent via eRS. The service is found under Genito-urinary medicine.

LARC advice is also available via eRS (also under Genito-urinary medicine)

For North Somerset Practices, refer to the WISH clinic at Weston General Hospital using this referral form (available as a template in EMIS). Email completed forms to: WishCentre@UHBW.nhs.uk Do not post referrals. Main phone number: 01934 881234.

For IUC lost threads

If a TVUSS shows the IUC in the uterus, refer and state complex (‘lost threads’) removal only if the IUC is due to be changed, or the patient requests early removal due to symptoms, or to try for pregnancy. The patient needs to have had a TVUSS within the last 6 months for removal to take place.

If the IUC is still in date it does not to be replaced early

For SDI

Always state whether the implant is palpable. If you have attempted removal, we will need 3 weeks for the wound to heal before we can see them.

If the patient has any neurological symptoms the GP should directly refer the patient to Plastics without further delay.

Resources

Other Implant troubleshooting: refer to SDI guideline

Other IUC troubleshooting Intrauterine contraception guideline

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.