ADVERTISEMENT

Departments

Adolescent Gynecology
Adolescents and the IUD: An Underutilized Contraception for a High-Risk Population
Forcier M, Harel Z
The Female Patient. 2011;36(6):22-24

The intrauterine device is a highly effective and easy-to-use contraceptive that is underused in sexually active young women.

While sexual activity is a normal part of adolescent development, teens and young adults have high rates of unintended pregnancy, putting millions of US teens at risk for early unplanned pregnancy.1 Misconceptions among both patients and health care providers may result in many youth missing opportunities to utilize one type of easy-to-use and effective long-acting reversible contraception (LARC)—the intrauterine device (IUD).

In 2007, ACOG and other family planning experts recommended IUDs as a fi rst-line option for contraception among adolescents. 2 Despite these recommendations, IUDs are used by less than 3% of adult American women and by an even lower percentage of teens.3,4 Well over 20 years of data confi rm the safety of IUDs and eliminate most concerns regarding their use in adolescents.5 IUDs are generally well tolerated by the majority of women and have higher continuation rates than most other contraceptive methods, including in nulliparous and adolescent populations.6,7 Th is article briefly reviews current evidence on IUDs, in order to dispel myths and allow clinicians greater confidence in recommending this effective contraception for adolescents and young adults.

back to top


 

IUDs AVAILABLE IN THE USA

While there are many versions of the IUD in international markets, in the United States, there are 2 FDA-approved devices: levonorgestrel- releasing intrauterine system (LNGIUS, Mirena®, Bayer HealthCare Pharmaceuticals) and copper IUD (Cu-IUD, ParaGard®, Duramed Pharmaceuticals). LNG-IUS is approved for 5 years of use; Cu-IUD is approved for 10 years but with effi cacy demonstrated up to 12 to 20 years.8

Additional FDA-approved indications for IUD insertion include Cu-IUD for emergency contraception and LNG-IUS for treatment of heavy menstrual bleeding in women who choose to use an IUD as their method of birth control. Benefits of IUDs include high contraceptive effectiveness, ease of adherence, and high continuation rates. IUDs can be used in patients with thrombophilia and when estrogen is contraindicated. LNG-IUS has shown some promise in the treatment of endometriosis, abnormal uterine bleeding, endometrial hyperplasia, and uterine fibroids.9

back to top


 

MECHANISM AND EFFICACY OF IUDs

Both FDA-approved IUDs' main mechanism of action is to prevent fertilization with continued ovulation. While approximately half of women continue to ovulate with LNG-IUS during the fi rst year of its use, the devices' main effect is to render both sperm and oocytes inactive. Substances released from the IUD (20 mcg levonorgestrel or copper ions) along with an infl ammatory reaction are toxic to spermatozoa and oocytes, preventing gametes from meeting as well as forming viable embryos.10 First-year failure rates for typical use are less than 1% and comparable to a reversible sterilization.11 Currently, IUDs are considered the most cost-effective reversible contraceptive strategy in the United States.12

back to top


 

REFUTING MYTHS AND TYPICAL CONCERNS

The overall risk for pelvic inflammatory disease (PID) with an IUD is the same as the risk without an IUD.13 While there is an increased risk for PID during the first 21 days of IUD use, this is most likely related to preexisting infection at time of insertion.14 PID rates are 9.7 per 1,000 women-years during days 1 to 20 following insertion, and they return to baseline general population rates of 1.4 per 1,000 women-years from day 21 on.15 It should be noted that the LNG-IUS may actually confer a protective effect against PID by thickening cervical mucous.16

As the incidence of PID in IUD users is low with or without antibiotics, there are no recommendations for prophylactic antibiotic treatment in the general population.17,18 However, prophylactic antibiotics have been shown to provide benefit in high-risk populations, reducing PID rate and return visits by one-third.19 Therefore, preinsertion sexually transmitted infection (STI) testing and antibiotic prophylaxis should be undertaken in adolescents, given the high rates of Chlamydia and gonorrhea in this age-group. Any evidence of infection, including bacterial vaginosis or Trichomonas, should be treated prior to insertion. Patients with cervicitis or PID diagnosed after insertion may leave the IUD in place, as long as there is clinical response in 48 hours.16 Clearly, patient education and counseling regarding condom use and STI prevention, as well as preinsertion STI testing and prophylaxis, are essential to alleviating patient and provider concerns regarding risks for PID.

There is good evidence that IUDs have no impact on future fertility and that they may be safely used in nulliparous patients.5,20,21 Of note, while infection with Chlamydia is associated with tubal infertility, prior Cu-IUD use is not.22 IUDs do not cause increased risk for ectopic pregnancy, though a pregnancy occurring during IUD use has a risk of being ectopic. 23 If pregnancy does occur with an IUD in place, location must be determined immediately. In addition, IUDs have not been linked to breast, endometrial, or other cancers.24,25

back to top


 

NONCONTRACEPTIVE BENEFITS OF IUDs

There is good evidence for LNG benefi ts for heavy menstrual bleeding, dysmenorrhea, and endometrial cancer protection.26,27 Over time, LNG-IUS significantly reduces menstrual blood loss or results in amenorrhea, while Cu-IUD typically leads to somewhat heavier, crampier periods, making the LNG-IUS a more attractive option for adolescents with heavy menstrual bleeding.28,29 Furthermore, LNG-IUS may alleviate symptoms of dysmenorrhea, a common problem for many adolescents.30 HIV-positive IUD users may experience additional benefits with some improvement in anemia and with no demonstrated increases in viral shedding, overall complications, infection rates, or morbidity.31 Finally, effects such as weight gain, acne, and mood changes are infrequent with the LNG-IUS.

back to top


 

IUD USE IN NULLIPAROUS WOMEN/ADOLESCENTS

While there are a number of reviews about IUD use in younger and nulliparous populations, there is a need for additional studies focusing on IUD use in adolescents and young adults.32-34 Available literature reports suboptimal awareness of the device, misconceptions about safety and efficacy, and low positive regard/knowledge about IUDs among adolescents. Whitaker et al showed that less than 2% of women ages 15 to 24 ever used an IUD and that IUD use was associated with increasing parity and cohabitation/ marriage, but not with previous adolescent pregnancy.35

Only about 50% of already pregnant youth have heard of IUDs, while 71% were unsure of its safety and 58% unsure of its efficacy.36 Reassuringly, it has been demonstrated that even a short 3-minute education session offered by a clinician can enhance positive regard for IUD.37 Studies of IUD use in teens and nulliparous women report ability to tolerate insertion and continuation rates comparable to those of older women. In a study of nulliparous women ages 18 to 25, about 80% reported no pain to only mild/moderate pain with insertion of LNG-IUS.38

Throughout use, nulliparous and adolescent patients seem to have expulsion rates for LNG-IUS comparable to those of parous women (less than 5%), though one review demonstrated both higher expulsion and removal for side effects of bleeding and pain with the Cu-IUD.6,39 A recent study in adolescents found continuation rates of 75% with LNG-IUS and 45% with Cu-IUD at 6 months after IUD insertion.40 Finally, it is important to note that IUD has been shown to reduce the risk of repeat adolescent pregnancies.41

back to top


 

PREPARATION FOR INSERTION AND MINIMIZING SIDE EFFECTS

Most sexually active teens are eligible for IUD insertion. The only contraindications are possible pregnancy, cervical or uterine cancer, current or recent serious intrauterine or pelvic infections, and uterine anomalies/fibroids.42 Satisfaction and continuation may be enhanced with careful preinsertion counseling regarding management of expected and/or common side effects such as irregular bleeding, amenorrhea, and cramping, as these are the most common reasons for discontinuation. 39 NSAIDs are first-line management of bleeding and pain associated with IUD insertion and continued use.43,44 While misoprostol is often used prior to procedure, evidence regarding its benefit for ease of IUD insertion and alleviation of pain during insertion is mixed.45,46

back to top


 

CONCLUSION

Despite the strong evidence demonstrating multiple benefi ts of IUDs, misinformation, cost, unfounded fears of adverse side effects, and clinician reluctance contribute to suboptimal utilization of this first-line highly effective and easy-to-use contraceptive.47,48

Dr Forcier reports no actual or potential conflict of interest in relation to this article. Dr Harel receives research support from Teva/ Duramed Pharmaceuticals.

back to top



Michelle Forcier, MD, MPH, is Assistant Professor, and Zeev Harel, MD, is Professor, both at Brown University Warren Alpert School of Medicine and at Division of Adolescent Medicine, Department of Pediatrics, Hasbro Children's Hospital, Providence, RI.

References

  1. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006;38(2):90-96.
  2. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 392, December 2007. Intrauterine device and adolescents. Obstet Gynecol. 2007;110(6):1493-1495.
  3. Tolaymat LL, Kaunitz AM. Long-acting contraceptives in adolescents. Curr Opin Obstet Gynecol. 2007;19(5): 453-460.
  4. Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat 23. 2005;(25):1-160.
  5. Lyus R, Lohr P, Prager S; Board of the Society of Family Planning. Use of Mirena LNG-IUS and Paragard CuT380A intrauterine devices in nulliparous women. Contraception. 2010;81(5):367-371.
  6. Brockmeyer A, Kishen M, Webb A. Experience of IUD/ IUS insertions and clinical performance in nulliparous women—a pilot study. Eur J Contracept Reprod Health Care. 2008;13(3):248-254.
  7. Paterson H, Ashton J, Harrison-Woolrych M. A nationwide cohort study of the use of the levonorgestrel intrauterine device in New Zealand adolescents. Contraception. 2009;79(6):433-438.
  8. Sivin I. Utility and drawbacks of continuous use of a copper T IUD for 20 years. Contraception. 2007;75(6 Suppl):S70-S75.
  9. Fraser IS. Non-contraceptive health benefi ts of intrauterine hormonal systems. Contraception. 2010;82(5): 396-403.
  10. Ortiz ME, Croxatto HB. Copper-T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action. Contraception. 2007;75(6 Suppl):S16-S30.
  11. Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during fi ve years of use: a randomized comparative trial. Contraception. 1994;49(1):56-72.
  12. Trussell J, Lalla AM, Doan QV, Reyes E, Pinto L, Gricar J. Cost effectiveness of contraceptives in the United States. Contraception. 2009;79(1):5-14.
  13. Grimes DA. Intrauterine device and upper-genitaltract infection. Lancet. 2000;356(9234):1013-1019.
  14. Farley TM, Rosenbery MJ, Rowe PJ, Chen JH, Meirik O. Intrauterine devices and pelvic infl ammatory disease: an international perspective. Lancet. 1992;339(8796): 785-788.
  15. Mohllajee AP, Curtis KM, Peterson HB. Does insertion and use of an intrauterine device increase the risk of pelvic infl ammatory disease among women with sexually transmitted infection? A systematic review. Contraception. 2006;73(2):145-153.
  16. Toivonen J, Luukkainen T, Allonen H. Protective eff ect 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.
  17. Martínez F, López-Arregui E. Infection risk and intrauterine devices. Acta Obstet Gynecol Scand. 2009;88 (3):246-250.
  18. Grimes DA, Schulz KF. Antibiotic prophylaxis for intrauterine contraceptive device insertion. Cochrane Database Syst Rev. 2001;(2):CD001327.
  19. Grimes DA, Schulz KF. Prophylactic antibiotics for intrauterine device insertion: a meta-analysis of the randomized controlled trials. Contraception. 1999;60 (2):57-63.
  20. 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.
  21. Skjeldestad FE. Th e impact of intrauterine devices on subsequent fertility. Curr Opin Obstet Gynecol. 2008; 20(3):275-280.
  22. Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra-Infante F, Guzmán-Rodríguez R. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med. 2001;345(8):561-567.
  23. Iavazzo C, Salakos N, Vitoratos N, et al. Intrauterine devices and extrauterine pregnancy. A literature review. Clin Exp Obstet Gynecol. 2008;35(2):103-106.
  24. Curtis KM, Marchbanks PA, Peterson HB. Neoplasia with use of intrauterine devices. Contraception. 2007;75(6 Suppl):S60-S69.
  25. Backman T, Rauramo I, Jaakkola K, et al. Use of the levonorgestrel-releasing intrauterine system and breast cancer. Obstet Gynecol. 2005;106(4):813-817.
  26. Bednarek PH, Jensen JT. Safety, effi cacy and patient acceptability of the contraceptive and non-contraceptive uses of the LNG-IUS. Int J Womens Health. 2010;1:45-58.
  27. Varma R, Sinha D, Gupta JK. Non-contraceptive uses of levonorgestrel-releasing hormone system (LNGIUS)— a systematic enquiry and overview. Eur J Obstet Gynecol Reprod Biol. 2006;125(1):9-28.
  28. Andersson JK, Rybo G. Levonorgestrel-releasing intrauterine device in the treatment of menorrhagia. Brit J Obstet Gynaecol. 1990;97(8):690-694.
  29. Rivera R, Chen-Mok M, McMullen S. Analysis of client characteristics that may aff ect early discontinuation of the TCu-380A IUD. Contraception. 1999;60(3):155-160.
  30. Aslam N, Blunt S, Latthe P. Eff ectiveness and tolerability of levonorgestrel intrauterine system in adolescents. J Obstet Gynaecol. 2010;30(5):489-491.
  31. Stringer EM, Levy J, Sinkala M, et al. HIV disease progression by hormonal contraceptive method: secondary analysis of a randomized trial. AIDS. 2009;23(11): 1377-1382.
  32. Yen S, Saah T, Hillard PJ. IUDs and adolescents—an under-utilized opportunity for pregnancy prevention. J Pediatr Adolesc Gynecol. 2010;23(3):123-128.
  33. Deans EI, Grimes DA. Intrauterine devices for adolescents: a systematic review. Contraception. 2009;79(6): 418-423.
  34. Gold MA, Johnson LM. Intrauterine devices and adolescents. Curr Opin Obstet Gynecol. 2008;20(5):464-469.
  35. Whitaker AK, Dude AM, Neustadt A, Gilliam ML. Correlates of use of long-acting reversible methods of contraception among adolescent and young adult women. Contraception. 2010;81(4):299-303.
  36. Stanwood NL, Bradley KA. Young pregnant women's knowledge of modern intrauterine devices. Obstet Gynecol. 2006;108(6):1417-1422.
  37. 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.
  38. Suhonen S, Haukkamaa M, Jakobsson T, Rauramo I. Clinical performance of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: a comparative study. Contraception. 2004;69(5):407-412.
  39. Hubacher D. Copper intrauterine device use by nulliparous women: review of side eff ects. Contraception. 2007;75(6 Suppl):S8-S11.
  40. Godfrey EM, Memmel LM, Neustadt A, et al. Intrauterine contraception for adolescents aged 14-18 years: a multicenter randomized pilot study of levonorgestrelreleasing intrauterine system compared to the Copper T 380A. Contraception. 2010;81(2):123-127.
  41. Atkin LC, Alatorre-Rico J. Pregnant again? Psychosocial predictors of short-interval repeat pregnancy among adolescent mothers in Mexico City. J Adolesc Health. 1992;13(8):700-706.
  42. World Health Organization. Medical eligibility criteria for contraceptive use. 4th ed. Geneva: WHO; 2010. Available at: http://whqlibdoc.who.int/publications/ 2010/9789241563888_eng.pdf. Accessed April 5, 2011.
  43. Allen RH, Bartz D, Grimes DA, Hubacher D, O'Brien P. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev. 2009;(3):CD007373.
  44. Grimes DA, Hubacher D, Lopez LM, Schulz K. Nonsteroidal anti-infl ammatory drugs for heavy bleeding or pain associated with intrauterine-device use. Cochrane Database Syst Rev. 2006;(4):CD006034.
  45. Fiala C, Gemzell-Danielson K, Tang OS, von Hertzen H. Cervical priming with misoprostol prior to transvaginal procedures. Int J Gynaecol Obstet. 2007;99(Supp 2): 68-71.
  46. Sääv I, Aronsson A, Marions L, Stephansson O, Gemzell- Danielsson K. 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.
  47. Trussell J, Wynn LL. Reducing unintended pregnancy in the United States. Contraception. 2008;77(1):1-5.
  48. Cleland J. Contraception in historical and global perspective. Best Pract Res Clin Obstet Gynaecol. 2009;23 (2):165-176.

back to top


ADVERTISEMENT
ADVERTISEMENT

Breaking News

More Headlines