Findings of a survey of clinicians. In a 2008 poll of 816 health care providers (including 399 physicians and 402 advanced practice clinicians), 40% did not offer intrauterine contraception to any patients who sought contraception.7 Most (55%) providers considered less than one quarter of their patients to be a candidate for intrauterine contraception.
Furthermore, fewer than one half of providers considered nulliparous, immediate postpartum or post-abortion, or teenage patients to be a candidate for intrauterine contraception. They also thought that women who had a history of ectopic pregnancy or pelvic inflammatory disease, or who were HIV-positive, were not candidates for intrauterine contraception—despite recommendations by the Centers for Disease Control and Prevention and the World Health Organization to use intrauterine contraception in those populations (TABLE).8,9
TABLE
Medical eligibility criteria for using an IUD (in selected conditions)*
| Condition | Paragard | Mirena |
|---|---|---|
| Age | ||
| • Menarche to age 20 | 2 | 2 |
| • ≥Age 20 | 1 | 1 |
| Parity | ||
| • Nulliparous | 2 | 2 |
| • Parous | 1 | 1 |
| Postpartum (breastfeeding or not breastfeeding, including post-cesarean section) | ||
| • <10 min after placental delivery | 1 | 2 |
| • 10 min after placental delivery to 4 weeks | 2 | 2 |
| • ≥4 weeks | 1 | 1 |
| Postabortion | ||
| • First trimester | 1 | 1 |
| • Second trimester | 2 | 2 |
| Past ectopic pregnancy | 1 | 1 |
| Past pelvic inflammatory disease (PID) (assuming no current risk factors for sexually transmitted infection) | ||
| • With subsequent pregnancy | 1 | 1 |
| • Without subsequent pregnancy | 2 | 2 |
| Continuation with current PID, infection with Chlamydia trachomatis or Neisseria gonorrhoeae | 2 | 2 |
| HIV-infected | 2 | 2 |
| Obesity | 1 | 1 |
| Venous thromboembolic disease | ||
| • History of deep-venous thromboembolism (DVT) or pulmonary embolism (PE) | 1 | 2 |
| • High risk for DVT or Pe | 1 | 2 |
| • Acute DVT or Pe | 2 | 2 |
| Key 1 There is no restriction on the use of the contraceptive method for this condition 2 The advantages of using the contraceptive method generally outweigh its theoretical or proven risks in this condition 3 The theoretical or proven risks of the contraceptive method generally outweigh its benefits in this condition * Adapted from: centers for Disease control and Prevention. US Medical eligibility criteria for contraceptive Use, 2010. MMWR early release 2010;59:52-7. for other recommendations, see: centers for Disease control and Prevention.8 | ||
IUDs are safe
Do you relate to what respondents said in the survey just discussed? Do you have concerns about intrauterine contraception in adolescents or nulliparas, especially about:
- perforation at the time an IUD is placed
- risk of expulsion
- side effects
- risk of PID
- risk of infertility?
Let’s examine each of these concerns against the backdrop of clinical guidelines issued recently by the Society of Family Planning and the group’s analysis of the medical literature on which those guidelines are based.10
Perforation at placement. No studies have examined the rate of perforation during IUD placement in nulliparas or adolescents alone; we do know that the overall (i.e., for all women) risk of perforation when an IUD is inserted has been reported as zero to 1.3%. General studies of perforation include a very small number of nulliparas; results are difficult to generalize to a larger population. At least two ongoing large, multicenter trials include a large number of nulliparas; one of them includes adolescents.
Expulsion. The rate of IUD expulsion in parous women has varied across studies and types of IUDs. In a recent retrospective cohort study, nulliparous and parous women were compared for complications with both copper and levonorgestrel-releasing IUDs. Rates of expulsion for copper IUDs were 0 to 1.2% a year. Rates of expulsion for the levonorgestrel-releasing IUDs were 0 to 0.2% a year. Nulliparous women did not have more complications than parous women.11
A review of studies examining the expulsion rate with the copper IUD found a slightly higher rate in nulliparas, but the copper IUD that had been used in 19 of 20 of those studies was not Paragard, the only copper IUD available in the United States. In the one study included in the review that looked at Paragard, there was one expulsion in the nulliparous group and none in the parous group.12
Side effects. In a review of copper-based IUDs, removals for pain and bleeding were slightly higher in nulliparas. Again, the majority of these studies reviewed did not use Paragard. In the one study that did examine Paragard, there were no removals for bleeding or pain in nulliparas or multiparas.10
No studies have compared nulliparous and parous women in regard to side effects associated with Mirena.
Pelvic inflammatory disease. Misgivings that providers have about the IUD often hearken back to the Dalkon Shield, which had a multifilament string that allowed bacteria to climb from the vagina into the uterus, with damaging consequences. Current IUDs have a monofilament string; they do not increase the user’s risk of pelvic infection.
Through recent research on antibiotic prophylaxis for IUD insertion, we have learned that the risk of PID in this setting is not as great as once thought. Antibiotic prophylaxis is unnecessary for IUD insertion because cases of PID after IUD insertion occur infrequently, with or without an antibiotic. A randomized clinical trial of 1,833 patients treated with azithromycin or placebo before IUD insertion demonstrated this low risk of PID: Only one patient in each group was given a diagnosis of salpingitis during the 90-day period after insertion.13