How to overcome myths and barriers when it comes to intrauterine devices
Despite high efficacy, less than 2% of U.S. women choose IUD
Ask the next patient who comes in your office, "What is the most effective reversible contraceptive?" How many of them will name the intrauterine device (IUD)?
Not many, if U.S. usage rates of the method are any indication. According to the most recent cycle of the National Survey of Family Growth, just 1.3% of contracepting women in the United States chose the IUD as their preferred method of birth control.1
Clinicians and women still may operate under misconceptions and myths when it comes to intrauterine contraception, says Eleanor Bimla Schwarz, MD, MS, assistant professor in the departments of medicine and obstetrics, gynecology, and reproductive medicine at the University of Pittsburgh School of Medicine. Schwarz presented updated information on intrauterine contraception at the 2008 Contraceptive Technology conference in Boston.2
Intrauterine contraception and tubal sterilization are leading methods of fertility regulation with comparable high effectiveness, and both offer convenient "forgettable contraception" that lasts for years, notes David Grimes, MD, vice president of biomedical affairs at Family Health International in Research Triangle Park, NC, and clinical professor in the Department of Obstetrics and Gynecology at the University of North Carolina at Chapel Hill School of Medicine. Grimes just co-authored a review of intrauterine contraception as an alternative to interval tubal sterilization.3
There are two intrauterine contraceptives available in the United States: The ParaGard Copper T-380A copper intrauterine contraceptive (Duramed Pharmaceuticals, a subsidiary of Barr Pharmaceuticals; Pomona, NY), and the levonorgestrel-releasing intrauterine system (Mirena IUS, Bayer HealthCare Pharmaceuticals; Wayne, NJ). ParaGard has an approved 10-year indication from the Food and Drug Administration (FDA). The Mirena has an approved five-year indication.
"The IUD provides the same high contraceptive effectiveness as does interval tubal sterilization, and it also features immediate reversibility, which tubal sterilization does not," states Grimes. "Hence, young women who choose an IUD can enjoy top-tier contraception, but keep their options open should their social situation change."
Counter myth with fact
One of most persistent myths regarding IUDs is that a woman with an IUD in place is at higher risk of developing pelvic inflammatory disease (PID) than she would have been without the IUD in place, says Schwarz.
"We know from large studies, conducted by the World Health Organization involving close to 23,000 women, this is not the case,"4 she says. "Only if a woman has a cervical infection at the time of insertion does she face an increased risk of PID."
The stigma associated with the Dalkon Shield, an intrauterine device that has not been used in the United States for a quarter century, is fortunately continuing to fade away, observes Andrew Kaunitz, MD, professor and associate chair in the obstetrics and gynecology department at the University of Florida College of Medicine –Jacksonville. The FDA asked the Dalkon Shield manufacturer, A.H. Robins, to withdraw the device from market in 1974 after numerous safety issues were raised.
"Although there is no question that myths regarding safety persist, safety concerns seem less prevalent than five years ago," says Kaunitz.
Confusion still circles around potential candidates for IUD use. The World Health Organization (WHO) eligibility criteria classes use of IUDs in young women ages 20 and younger, as well as for nulliparous women, as a "2," which means the advantages of using the method generally outweigh the theoretical or proven risks.5 The ParaGard IUD is approved for use for nulliparous women in stable relationships from age 16 through menopause. Current labeling for the Mirena recommends use of the method in women who have had at least one child. Research indicates the method is safe and effective for use in nulliparous women.6
Women with a history of sexually transmitted diseases or pelvic inflammatory disease (PID) no longer are contraindicated for use of ParaGard, unless a patient currently has acute PID or engages in sexual behavior suggesting a high risk for the disease, the labeling states.
For HIV-positive women, the WHO gives a classification of "3,"which means the theoretical or proven risks usually outweigh the advantages of using the method.5 Results from a prospective cohort study of HIV-infected and noninfected women in Nairobi, Kenya, suggest, however, that the IUD may be an appropriate contraceptive method for HIV-infected women with ongoing access to medical services.7
Get the word out
While providers may be operating under outdated information when it comes to IUDs, there appear to be few persistent myths regarding IUDs among women. The majority have never even heard of the method, says Schwarz.
Results of a 2007 survey of women bear out this fact. In young women ages 14-24, more than half of those surveyed had never heard of an intrauterine device, and 97% had never used one.8
The IUD Subcommittee of the U.S. Agency for International Development's Maximizing Access & Quality Initiative launched the online IUD Toolkit in 2006 to help providers around the world get the most up-to-date facts on intrauterine contraception. By going to www.iudtoolkit.org, providers can review comprehensive, evidence-based information about intrauterine devices to help improve access to and quality of services. Many of the full-text resources on the web site are available in French and Spanish.
If women are considering surgical sterilization, review the reversible option of intrauterine contraception with them. Research indicates the characteristic most often associated with post-sterilization regret is the youthfulness of the patient. Women under 30 are twice as likely to regret their decision as those who are older than 30 at the time of sterilization.9 All women, particularly young women, who are at high risk for sterilization regret, should be encouraged to consider an IUD in lieu of a surgical procedure.3
The tide may be turning for IUD use, according to results of an informal survey performed at the April 2008 Contraceptive Technology conference in San Francisco. Robert Hatcher, MD, MPH professor of obstetrics and gynecology at Emory University in Atlanta, quizzed 10 nurse practitioners, nurse midwives, and physicians who were inserting IUDs five years ago about how many IUDs they had inserted in the past year. The 10 clinicians had inserted approximately 250 IUDs five years ago; however, that number grew to 1,173 IUD insertions in the past year. In the last year, clinicians reported 904 of the procedures used the Mirena IUS; 268 of the 1,173 insertions were for nulliparous women.
"This more than fourfold increase in IUDs inserted suggests an increased interest in this long-term, highly effective reversible form of contraception," says Hatcher.
References
- Chandra A, Martinez GM, Mosher WD, et al. Fertility, family planning, and reproductive health of U.S. women: Data from the 2002 National Survey of Family Growth. Vital Health Stat 2005; 25:95.
- Schwarz EB. Still afraid of the IUD? Overcoming myths and barriers. Presented at the Contraceptive Technology conference. Boston; March 2008.
- Grimes DA, Mishell DR Jr. Intrauterine contraception as an alternative to interval tubal sterilization. Contraception 2008; 77:6-9.
- Jacobstein R. Long-acting and permanent contraception: An international development, service delivery perspective. J Midwifery Womens Health 2007; 52:361-367.
- World Health Organization. Medical eligibility criteria for contraceptive use. Geneva: World Health Organization; 2004.
- Prager S, Darney PD. The levonorgestrel intrauterine system in nulliparous women. Contraception 2007; 75(6 Suppl):S12-15.
- Morrison CS, Sekadde-Kigondu C, Sinei SK, et al. Is the intrauterine device appropriate contraception for HIV-1-infected women? BJOG 2001; 108:784-790.
- Johnson L, Whitaker A, Harwood B, et al. Adolescent and young women's knowledge and attitudes toward using intrauterine contraceptive devices (IUDs). J Pediatr Adolesc Gynecol 2007; 20:S115-S116.
- Wilcox LS, Chu SY, Eaker ED, et al. Risk factors for regret after tubal sterilization: 5 years of follow-up in a prospective study. Fertil Steril 1991; 55:927-933.
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