Clinical Review

UPDATE: CONTRACEPTION

OBG Manag. 2010 August;22(8):16-23

Demand for long-acting reversible contraception is growing, including in adolescents and nulliparas. We need to challenge our historical reservations about the IUD and heed the call.

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IN THIS ARTICLE

Barriers to IUD use
Medical eligibility criteria for using an IUD
What ACOG recommends

References

1. Guttmacher Institute. Facts on induced abortion in the United States. In Brief. http://www.guttmacher.org/pubs/
fb_induced_abortion.pdf. Published May 2010.

2. Stanwood NL, Bradley KA. Young pregnant women’s knowledge of modern intrauterine devices. Obstet Gynecol. 2006;108(6):1417-1422.

3. Deans EI, Grimes DA. Intrauterine devices for adolescents: a systematic review. Contraception. 2009;79(6):418-423.

4. Whitaker AK, Johnson LM, Harwood B, Chiappetta L, Creinin MD, Gold MA. Adolescent and young adult women’s knowledge of and attitudes toward the intrauterine device. Contraception. 2008;78(3):211-217.

5. United Nations Department of Economic and Social Affairs, Population Division. World contraceptive use 2005. http://www.un.org/esa/population/publications/contraceptive2005/2005_World_
Contraceptive_files/WallChart_WCU2005.pdf. Accessed May 25, 2010.

6. Sonfield A. For the Guttmacher Institute. Popularity disparity: attitudes about the IUD in Europe and the United States. Guttmacher Policy Review. 2007;10(4):http://www.guttmacher.org/pubs/gpr/10/4/gpr100419.pdf. Accessed May 21, 2010.

7. Harper CC, Blum M, de Bocanegra HT, et al. Challenges in translating evidence into practice: the provision of intrauterine contraception. Obstet Gynecol. 2008;111(6):1359-1369.

8. Centers for Disease Control and Prevention. U.S. medical eligibility criteria for contraceptive use, 2010. MMWR. 2010;59(Early Release; RR04):1-6.

9. World Health Organization, Department of Reproductive Health and Research Medical eligibility criteria for contraceptive use. Geneva: WHO; 2009.

10. Lyus R, Lohr P, Prager S. for Board of the Society of Family Planning. Use of the Mirena LNG-IUS and Paragard CuT380 devices in nulliparous women. Contraception. 2010;81(5):367-371.

11. Veldhuis HM, Vos AG, Lagro-Janssen AL. Complications of the intrauterine device in nulliparous and parous women. Eur J Gen Pract. 2004;10(3):82-87.

12. Hubacher D. Copper intrauterine device use by nulliparous women: review of side effects. Contraception. 2007;75(suppl 6):S8-S11.

13. Walsh T, Grimes DA, Frezieres R, et al. for IUD Study Group. Randomised controlled trial of prophylactic antibiotics before insertion of intrauterine devices. Lancet. 1998;351(9108):1005-1008.

14. Goodman S, Hendlish SK, Benedict C, Reeves MF, Pera-Floyd M, Foster-Rosales A. Increasing intrauterine contraception use by reducing barriers to post-abortal and interval insertion. Contraception. 2008;78(2):136-142.

15. Toivonen J, Luukkainen T, Allonen H. Protective effect of intrauterine release of levonorgestrel on pelvic infection: three years’ comparative experience of levonorgestrel- and copper-releasing intrauterine devices. Obstet Gynecol. 1991;77(2):261-264.

16. Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra-Infante F, Guzmán-Rodrigues R. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med. 2001;345(8):561-567.

17. Hov GG, Skjeldestad FE, Hilstad T. Use of IUD and subsequent fertility—follow-up after participation in a randomized clinical trial. Contraception. 2007;75(2):88-92.

18. ACOG Committee Opinion No. 392, December 2007. Intrauterine device and adolescents. Obstet Gynecol. 2007;110(6):1493-1495.

19. Sääv I, Aronsson A, Marions L, et al. Cervical priming with sublingual misoprostol prior to insertion of an intrauterine device in nulliparous women: a randomized controlled trial. Hum Reprod. 2007;22(10):2647-2652.

20. Hubacher D, Reyes V, Lillo S, Zepeda A, Chen PL, Croxatto H. Pain from copper intrauterine device insertion: randomized trial of prophylactic ibuprofen. Am J Obstet Gynecol. 2006;195(5):1272-1277.

Fast Track

Women in the United States use the most effective forms of birth control at lower rates than the rest of the developed world

Antibiotic prophylaxis is unnecessary for IUD insertion because cases of PID after IUD insertion occur infrequently, with or without an antibiotic

ACOG recommends that IUDs and implants be considered as first-line contraceptive choices for both nulliparas and adolescents

Counsel the patient about the need to use a condom in addition to the IUD to prevent STI

Adolescents, nulliparous women, and the IUD

The professional journals scattered on your desk every month always seem to have a review article, or a study, on “long-acting reversible contraception” (LARC)—and you’re not certain why. More and more, your younger patients are asking about intrauterine devices and contraceptive implants, but you’re unsure about the most up-to-date information on the safety of these methods in adolescents. Nulliparous women are inquiring about contraception with, for one, the levonorgestrel-releasing intrauterine system (LNG-IUS; Mirena), but the Mirena package insert tells you that they are not candidates for the method.

Does this sound familiar? How do you sort through all data and advice on IUD use in adolescents and nulliparas?

Fortunately for clinicians, a great deal of research in the last few years has focused on these topics. Recommendations and reviews have been published, and public health agencies have developed easily accessible guidelines for reference.

Our goal in this year’s installment of the Update on Contraception is to familiarize you with the evidence and ease any confusion, even misgivings, you might have about the two intrauterine devices available in the United States, the copper T380A (Paragard*) and Mirena* (FIGURE), especially in regard to their use in adolescents and nulliparous women.

*For ease of discussion only, we call these two systems by their brand names throughout.

FIGURE Two intrauterine devices for long-term contraception

There is real need for long-acting reversible contraception

The public health perspective

Consider these statistics about adult and adolescent women:

Approximately 3 million pregnancies annually in the United States are unintended
In almost half of those pregnancies, the woman undergoes an abortion
Approximately one half of all US women have an unintended pregnancy by 45 years of age
Given current statistics, nearly one third of all women will have chosen abortion by 45 years of age
80% of pregnancies in adolescents are unintended; 45% end in abortion
54% of women who have an abortion used a contraceptive method during the month they became pregnant—generally, a condom or an oral contraceptive.^1,2

Patients’ perspective

More and more, adolescent women and nulliparous women request an IUD. Indeed, recent studies show that these populations are interested in the long-term protection that an IUD offers, and are likely to be more compliant with the method. Recent data from the National Survey of Family Growth showed an increase in IUD use in the United States: 5.5% of women who use birth control use an intrauterine device, and 14% of women who choose an IUD are adolescents.

A review of IUD use in adolescents found that, across six cohort studies and seven case reports, the continuation rate with an IUD after 1 year ranged from 48% to 88%—similar to, or better than, what is seen with oral contraceptives (OCs).³ Furthermore, two recent studies^3,4 showed that:

young nulliparous and parous women exhibit a positive attitude toward IUD use once they have been counseled on the risks and benefits of the device
they desire effective long-term contraception
more than 50% of the women who were surveyed thought positively about IUDs after being educated about them.

Barriers to IUD use

Intrauterine contraceptive use in the United States is very low compared to the rates in other developed countries—as noted, the rate here is 5.5%, for both types of IUD. Contrast that rate with what is documented in other nations: France, 20%; China, 34%; and Norway, 24%, for example. Across the developed world, IUD use is at 7.6%; in developing nations, the rate is even higher: 14.5 %.^5,6

Women in the United States use the most effective forms of birth control at lower rates than the rest of the developed world; conversely, they choose permanent sterilization at a higher rate. When American women were asked, they expressed a desire for longer-acting contraception that is easy to use. Yet, they fail to take advantage of the options—often, because they lack information about them or have received erroneous education.²

Indeed, when providers of contraceptive services have been surveyed about barriers to IUD use, they point to women’s misconceptions about the devices and express their own concerns about the incidence of pelvic inflammatory disease (PID) and infertility; difficulty of insertion; and expulsion.