Clinical Review

UPDATE: CONTRACEPTION

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

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.

In addition, a recent study found that subjects could be screened for gonorrhea and chlamydial infection when an IUD was being placed and treated after insertion if either of those tests was positive—without increasing their risk of PID.¹⁴

Mirena may, in fact, have a protective effect against infection. When the device was compared to a copper IUD (Nova-T; not available in the United States) in a randomized, comparative, multicenter trial, subjects in whom Mirena was inserted had a cumulative gross rate of PID of 0.5 at 36 months; Nova-T users had a rate of 2.0.¹⁵

As we well know, women who require protection from sexually transmitted infection (STI) need to have their partner use a condom. But condoms are not, comparatively, a very good method of contraception; for a woman who is at risk of STI and pregnancy, we need to consider what method she will use in addition to a condom to protect against pregnancy. Is she better off using a condom and an OC, or a condom and an IUD? The answer may well be that, because an IUD does not increase the risk of STI or PID and is more effective at preventing pregnancy than an OC, she would be better off using a condom plus IUD when it comes to protecting herself against STI and pregnancy.

Infertility. The risk of infertility has been linked to the risk of PID, which, simply, has been shown to be unfounded with an IUD.

In 2001, a cohort study focused on three groups of patients: women seeking treatment for primary infertility with diagnosed tubal occlusion; women seeking treatment for primary infertility without tubal occlusion; and primigravida pregnant women.¹⁶ In all three groups, the same percentage reported prior copper IUD use—suggesting no increased risk of either tubal or nontubal infertility among IUD users. This finding is in concordance with other studies that examined the risk of infertility among parous IUD users.¹⁷

Clinical guidelines from the Society of family planning

Based on the evidence reviewed by the Society of Family Planning (SFP) on the use of intrauterine contraception in nulliparous women, SFP offers recommendations.¹⁰

Level-A evidence is that:

Mirena and Paragard are effective and safe for nulliparous women
compared with other methods, IUDs have a comparable or higher continuation-of-use rate in nulliparous women
IUDs do not increase the risk of pelvic infection or infertility. Mirena probably reduces users’ risk of infection.

Level-B evidence is that:

because of the expulsion rate and bleeding profile, Mirena might be better tolerated than Paragard in nulliparas
insertion of an IUD may be more challenging in nulliparous women; given the benefits, however, clinicians should not be discouraged from considering them as a first-line contraceptive choice in this population.

Level-C evidence is that:

adolescent women should be considered a candidate for an IUD.

What ACOG recommends

Are adolescents more likely to discontinue use of an IUD than they are known to discontinue OCs and injectable contraceptives?

According to ACOG’s most recent Committee Opinion on IUDs in adolescents,¹⁸ the rate of IUD discontinuation might be slightly higher because of side effects, but this problem might be alleviated by counseling patients about the rate of amenorrhea with Mirena and providing adequate education about the side effects seen with both IUDs.

The authors of ACOG’s Committee Opinion also recommend that clinicians be familiar with their state’s consent laws regarding adolescents and contraception.

The conclusion of the Committee?

The IUD is a highly effective method of contraception that is underused in the United States. Because adolescents contribute disproportionately to the epidemic of unintended pregnancy in this country, top-tier methods of contraception, including IUDs and implants, should be considered as first-line choices for both nulliparous and parous adolescents.

How do I put the IUD into practice for these populations?

Here are tips about placing an IUD in nulliparous or adolescent women, gleaned from practice. Consider discussing placement techniques with clinicians and using their experiences as a way of expanding your repertoire when dealing with a difficult insertion.

A small body of literature on misoprostol and ibuprofen, including two recent randomized controlled trials,^19,20 has failed to show that pain associated with insertion is relieved using either treatment. Below, we offer several recommendations on this point.

Counsel the patient extensively about what to expect with an IUD. Namely:

how the IUD is inserted, with attention to female anatomy
the most common side effects, especially bleeding
cramping and pain with insertion
spotting after insertion
the need to use back-up contraception
the need to use a condom to prevent STI.

Have various items available, as needed, during insertion. This includes, but isn’t limited to: