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Algorithms for predicting PID among women with risk factors for STDs have poor predictive value. Although women with STDs at the time of IUD insertion have a higher risk for PID, the overall rate of PID among all IUD users is low (51,54).

Hemoglobin: Women with iron-deficiency anemia can use the LNG-IUD (U. Women with iron-deficiency anemia generally can use Cu-IUDs (U. Measurement of hemoglobin before initiation Dexamethasone Tablets (Hemady)- Multum Cu-IUDs is not necessary because of the minimal change in hemoglobin among women with and without anemia using Cu-IUDs.

A systematic review identified four studies Praluent (Alirocumab for Solution for Subcutaneous Injection)- Multum provided direct evidence for changes in hemoglobin among women with anemia who received Cu-IUDs (58). Lipids: Screening for dyslipidemias is not necessary for the safe initiation of Cu-IUD or LNG-IUD because of the low prevalence of undiagnosed disease in women of reproductive age and the low likelihood of clinically significant changes with use of hormonal contraceptives.

A systematic review did not identify any evidence regarding outcomes among women who were screened versus not screened with lipid measurement before initiation of hormonal contraceptives (57). Liver enzymes: Women with liver disease can use the Cu-IUD (U. Although women with certain liver diseases generally should not use the LNG-IUD (U.

MEC 3) (5), screening for liver disease before initiation of the LNG-IUD is not necessary because of the low prevalence of these conditions and the high likelihood that women with liver disease already would have had the condition diagnosed. A systematic review did not identify any evidence regarding outcomes among women who were screened versus not screened with liver enzyme tests before initiation of hormonal contraceptive use (57).

In 2012, among U. Because estrogen and progestins are metabolized in the liver, the use of hormonal contraceptives among women with liver disease might, theoretically, be a concern. The use of hormonal contraceptives, specifically COCs and POPs, does not affect disease progression or severity in women with hepatitis, cirrhosis, or benign focal nodular hyperplasia (93,94), although evidence is limited, and no evidence exists for the LNG-IUD.

Clinical breast examination: Women with breast disease can use the Cu-IUD (U. Although women with current breast cancer should not use the LNG-IUD (U.

MEC 4) (5), screening asymptomatic women with a clinical breast examination before inserting an IUD is not necessary because of the low prevalence of breast cancer among women of reproductive age.

A systematic review did not identify any evidence regarding Praluent (Alirocumab for Solution for Subcutaneous Injection)- Multum among women who were screened versus not screened with a breast examination before initiation of hormonal contraceptives (95).

The incidence of breast cancer among women of reproductive age in the United States is low. Cervical cytology: Although women with cervical cancer should not undergo IUD insertion (U.

Alogliptin and Pioglitazone Tablets (Oseni)- FDA 4) (5), screening asymptomatic women with cervical cytology before IUD insertion is not necessary because of the high rates of Praluent (Alirocumab for Solution for Subcutaneous Injection)- Multum screening, low incidence of cervical cancer in the United States, and high likelihood that a woman with cervical cancer already would have had the condition diagnosed.

A systematic review did not identify any evidence regarding outcomes among women who were screened versus not screened with cervical cytology before initiation of Praluent (Alirocumab for Solution for Subcutaneous Injection)- Multum (57). Cervical cancer is rare in the United States, with an incidence rate of 9.

The incidence and Praluent (Alirocumab for Solution for Subcutaneous Injection)- Multum rates from cervical cancer have declined dramatically in the United States, largely because of cervical cytology screening (97). Flagyl 125 ml screening: Women with HIV infection can use (U.

MEC 1) or generally can use (U. MEC 2) IUDs (5). Therefore, HIV screening is not necessary before IUD insertion. A systematic review did not identify any evidence regarding outcomes among women who were screened versus not screened for HIV infection before IUD insertion (57). Other screening: Women with hypertension, diabetes, or thrombogenic mutations can use (U. Therefore, screening for these conditions is not necessary for the safe initiation of IUDs.

Top of PageComments and Evidence Summary. Potential barriers to IUD use include anticipated pain with insertion and provider concerns about difficult insertion. Identifying effective approaches to ease IUD insertion might increase IUD initiation. Evidence for misoprostol from two systematic reviews, including a total of 10 randomized controlled trials, suggests that misoprostol does not improve provider ease of insertion, reduce the need for adjunctive insertion measures, or improve insertion success (Level of evidence: I, good to fair, direct) and might increase patient pain and side effects (Level of evidence: I, high quality) (115,116).

However, one randomized controlled trial examined women with a recent failed IUD insertion and found significantly higher insertion success with second insertion attempt among women pretreated with misoprostol versus placebo (Level of evidence: I, good, direct) (117). Limited evidence for paracervical block with lidocaine from one systematic review suggests that it might reduce patient pain (115). Neither trial found differences in side effects among women receiving paracervical block compared with controls (Level of prednisolone tablet I, moderate to low quality) (118,119).

Theoretically, IUD insertion could induce bacterial spread and lead to complications such as PID or infective endocarditis. A metaanalysis was conducted of randomized controlled trials examining antibiotic prophylaxis versus placebo or no treatment for IUD insertion (120).

Use of prophylaxis reduced the frequency of unscheduled return visits but did not significantly reduce Praluent (Alirocumab for Solution for Subcutaneous Injection)- Multum incidence of PID or premature IUD discontinuation. Although the risk for PID was higher within the first 20 days after insertion, the incidence of PID was low among all women who had IUDs inserted (51).

In addition, the American Heart Association recommends that the use of prophylactic antibiotics solely to prevent infective endocarditis is not needed for genitourinary procedures (121). Studies have not demonstrated a conclusive link between genitourinary procedures and infective endocarditis or a preventive benefit of prophylactic antibiotics during such procedures (121).

Top of PageThese recommendations address when routine follow-up is needed for safe and effective continued use of contraception for healthy women. The recommendations refer to general situations and might vary for different users and different situations. Specific populations that polyphenol benefit from more frequent follow-up visits include adolescents, persons with certain medical conditions or characteristics, and persons with multiple medical conditions.

Evidence from a systematic review about the effect of a specific follow-up visit schedule on IUD continuation is very limited and of poor quality. The evidence did not suggest that greater frequency of visits or earlier timing of the first follow-up visit after insertion improves continuation of use (122) (Level of evidence: II-2, poor, direct).

Evidence from four studies from a systematic review on the incidence of PID among IUD initiators, or IUD removal as a result of PID, suggested that the incidence of PID did not differ between women using Cu-IUDs and those using DMPA, COCs, or LNG-IUDs (123) (Level of evidence: I to II-2, good, indirect).

Evidence on the timing of PID after IUD insertion is mixed. Although the rate of PID was generally low, the largest study suggested that the rate of PID was significantly higher in the pepto bismol 20 days furoate insertion (51) (Level of evidence: I to II-3, good to poor, indirect).

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