Intrauterine contraception safe and effective in teens and adults
For long-term use, teens may benefit from additional counseling
Executive Summary
Results from a recent retrospective analysis indicate that similar to adults, intrauterine device (IUD) use in adolescents and nulliparous women is effective and associated with low rates of serious complications. Analysis of findings indicates, however, that teens might benefit from additional counseling regarding symptoms associated with IUD use due to higher discontinuation rates following the first year of use.
• Counseling women of all ages about the expected bleeding changes tied to IUD use before device insertion might enhance tolerance. Teens and young women who participated in the Contraceptive Choice project had high rates of method continuation.
• The American College of Obstetricians and Gynecologists supports expanding use of long-acting reversible contraceptives to women across the reproductive age spectrum, including teens and nulliparous women.
Results from a recent retrospective analysis indicate that similar to adults, intrauterine device (IUD) use in adolescents and nulliparous women is effective and associated with low rates of serious complications. Analysis of findings indicate, however, that teens might benefit from additional counseling regarding symptoms associated with IUD use due to higher rates of discontinuation following the first year of use.1
The results come from a multicenter retrospective chart review of adolescents and women in the Baltimore, Washington, DC, and southeastern Virginia area, ages 13-35, who had an IUD inserted for contraception between June 2008 and June 2011. The chart for each study participant was reviewed from the time of IUD insertion through March 31, 2013. Researchers reviewed 2,523 patients’ charts; 2,138 patients were included in the analysis. Thirteen percent of the study population was nulliparous.
After a mean follow-up of 37 months, scientists found the overall rates of IUD expulsion and pregnancy were 6% and 1%, respectively, and were not significantly different by age or parity. Intrauterine device discontinuation rates for all ages were 19% at 12 months and 41% after a mean follow-up of 37 months. At 12 months, discontinuation rates for teens ages 13-19 was 23%, which was not statistically different than IUD discontinuation rates for women ages 20-24 or women ages 25-35, both which were 18%.
Despite similar rates of IUD discontinuation between age groups at 12 months of use, females age 13-19 were more likely to request IUD removal by the end of the total follow-up period. After adjusting for age and parity, the analysis indicates that copper IUD users were more likely to experience expulsion and contraceptive failure compared with levonorgestrel IUD users (hazard ratios 1.62, 95% confidence interval [CI] 1.06-2.50 versus hazard ratios 4.89, 95%, CI 2.02-11.80, respectively).1
There continues to be a significant amount of fear regarding IUD use in the public and the medical community, and this concern is even greater regarding the use of IUD in adolescents, says Veronica Gomez-Lobo, MD, director of pediatric and adolescent obstetrics and gynecology at MedStar Washington Hospital Center and Children’s National Medical Center, both in Washington, DC. A professor of clinical obstetrics and gynecology at Georgetown University School of Medicine in Washington, DC, and an adjunct associate professor of clinical obstetrics and gynecology at the Uniformed Services University of the Health Sciences in Bethesda, Gomez-Lobo served as a senior author of the paper.
Clinicians also have operated under the mistaken, and now proven false, impression that IUDs are less effective and more likely to be expelled in adolescents when compared to adult women,2 said Gomez-Lobo. "This study reviewed in great detail a large number of charts at three very different sites of women who utilize IUDs for contraceptive purposes and found IUD [use] to be equally safe and effective in both adult and adolescent users," states Gomez-Lobo.
Counsel for success
According to Contraceptive Technology, counseling women of all ages about the expected bleeding changes associated with IUD use before device insertion might enhance tolerance of the method.3
Counseling information from the successful Contraceptive Choice project in St. Louis might be helpful in talking with women of all ages when it comes to continuation of IUD use. Teens and young women who participated in the CHOICE project had high rates of LARC method continuation. In the overall St. Louis cohort, 87.5% continued with the levonorgestrel IUD, and 84.1% continued with the copper-T IUD at 12 months. When stratified by age, at one year 80.6% of teens ages 14-19 continued with the levonorgestrel IUD, with 75.6% continuing with the copper-T IUD.4,5 (To review the research on LARC, see the Contraceptive Technology Update articles "Options might begin to emerge with new data out on LARC," March 2014, p. 25, and "Get practice up to speed on LARC methods," April 2014, p. 40.)
For the levonorgestrel IUD, CHOICE project counselors used the following information to inform women about possible bleeding: "Some women have irregular bleeding and cramping after the hormonal IUD is inserted. The irregular bleeding is greatest in the first three to six months, but usually improves. After this period of time, your period is typically much lighter and shorter. Twenty percent of women stop having their periods altogether after the first year."
For the copper T-380A IUD, the project’s counseling script includes the following wording: "Some women have spotting for the first few months after the copper IUD Is inserted. In some women, periods may be heavier or crampier, especially within the first three to six months after insertion, although this may get better over time." (Download the patient counseling script in English and Spanish at the project’s LARC First web site, www.larcfirst.com. Click on "Counseling," then "The Counseling Session.")
ACOG backs teen IUD use
As Gomez-Lobo notes, many clinicians might cling to old myths when it comes to IUD use in younger, nulliparous women. Supporters of long-acting reversible contraception (LARC) are working to dispel such myths.
The American College of Obstetricians and Gynecologists (ACOG) is enthusiastic in its support for expansion of LARC use to women across the reproductive age spectrum and particularly adolescents and nulliparous women, says Eve Espey, MD, MPH, who chairs ACOG’s Long Acting Reversible Contraception Work Group. Espey has just been named chair of the obstetrics and gynecology department the University of New Mexico in Albuquerque.
ACOG is taking steps to help clinicians improve their knowledge regarding appropriate candidates for IUD use, especially adolescents. Espey outlined the following steps:
• publication of a practice bulletin outlining the evidence that LARC methods are safe and effective for women of all ages and more effective for teenagers than short-term methods;6
• publication of a committee opinion supporting adolescent use of LARC methods;2
• publication of a committee opinion highlighting the potential for LARC methods to reduce unintended pregnancy and abortion in the United States;7
• webinar series addressing the spectrum of appropriate candidates;
• talks at numerous ACOG conferences regionally and nationally discussing appropriate candidates;
• development of resources supporting LARC training and practice, including evidence-based slide sets for use in residency training, for grand rounds, etc., and LARC coding and billing materials to support appropriate reimbursement. (Go to the ACOG LARC web page,www.acog.org/goto/larc, to find all appropriate materials);
• routine distribution and promotion to the full ACOG membership of all of the above listed publications, resources, and events through the LARC Program webpage, the LARC Program e-newsletter, and ACOG social media channels.
REFERENCES
- Aoun J, Dines VA, Stovall DW, et al. Effects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol 2014; 123(3):585-592.
- Committee on Adolescent Health Care Long-Acting Reversible Contraception Working Group, The American College of Obstetricians and Gynecologists. Committee opinion no. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2012; 120(4):983-988.
- Dean G, Schwarz EB. Intrauterine contraceptives. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.
- Rosenstock JR, Peipert JF, Madden T, et al. Continuation of reversible contraception in teenagers and young women. Obstet Gynecol 2012; 120(6):1,298-1,305.
- Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol 2011; 117:1,105-1,113.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 121: Long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2011; 118(1):184-196.
- American College of Obstetricians and Gynecologists Committee on Gynecologic Practice; Long-Acting Reversible Contraception Working Group. ACOG Committee Opinion no. 450: Increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol 2009; 114(6):1,434-1,438.
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