Highlights from



London, UK, 5 July 2019

Complex contraception cases: discussion and Q&A with Dr Elena Valarche

Take-home messages
  • Taking the delegates through a series of case studies, Dr Elena Valarche, FSRH General Regional Training Advisor, and Associate Specialist, Central and North West London (CNWL), Contraception and Sexual Health (CASH) service, encouraged active participation from the audience in suggestions for both diagnosing and treating a diverse range of sexual and reproductive health cases. Here are summaries of three of these cases.


Jenny is 17 years of age. She had a period two weeks ago and she had been with her first boyfriend for two months. She had an emergency intrauterine device (IUD) inserted six days previously. She turned up at the clinic with constant pain. Her sexual health screen, conducted a week ago, returned negative, her pregnancy test was negative, and the patient was examined and the uterus was found to be the normal size, mobile, without tenderness and no cervical excitation. Jenny was going to a music festival in two days. She was very anxious about the pain. “There is no evidence of pelvic inflammatory disease (PID), nor evidence of expulsion of the IUD, so do we send her home?" Dr Valarche asked those clinicians gathered. Overwhelmingly the answer was not to send the patient home without some kind of intervention.

“She was a young patient and there is an infection risk for 20 days after insertion of the IUD. She was off to a music festival so even though there was no tenderness now, there might have been in a few days’ time, and would appropriate medical help have been available?” remarked Dr Valarche. “I told her that if she was in London and could access treatment readily I would tell her to go home, but given she was off to the festival, I suggested we start some treatment for PID, and I tested for mycoplasma genitalium, and told her to return if it worsened.”


Jessie is 20 years old. She had an implant that was fitted 12 days previously. She requested removal of the implant. Insertion had been straight forward with the use of anaesthetic spray. Within 24 hours she developed swelling and inflammation at the insertion site and the skin was dry and scaly. Within one week, she developed hives on the chest and abdomen, breathing difficulties and flu-like symptoms. Her GP did not want to remove the implant immediately so gave anti-histamine and hydrocortisone cream. She stated that her reaction was similar to that seen when she ate shellfish. Dr Valarche asked those listening if they would remove the implant. The majority said yes.

“We removed the implant. The skin rash disappeared after a few days. We didn’t want to take the risk due to her reaction, particularly the breathing difficulty. Her reaction was unusual, and it’s the first time I had seen it,” concluded Dr Valarche.


Sylvia is a 52-year old woman who is menopausal. She was suffering from night sweats and she had not had periods from January to March, and when she did have periods they were heavy and long-lasting. She had had an IUD in place for 10 years and requested to have the IUD removed and the Mirena IUS inserted. She last had sex three months ago. “When I saw her, she had experienced constant vaginal bleeding for three weeks. She had seen the nurse who had suggested changing the IUD to the IUS. So, do we change the IUD to an IUS?” asked Dr Valarche. Around 30% of the audience said they would change it.

“Because we have imaging equipment at the sexual health clinic, we scanned Sylvia and I found her endometrial thickness was nearly 10mm. So in summary, the three weeks of bleeding, the change in bleeding pattern, her age of 52 years, and despite her saying she had seen a gynaecologist privately who said all was well, I explained to her that there might be a problem with hyperplasia of the endometrium and the possibility of endometrial cancer. I would prefer to be cautious and refer the patient to a gynaecologist.”

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