Why is the IUD Number One?
By Robert Hatcher, MD, MPH
Professor, Gynecology and Obstetrics
Emory University School of Medicine
Chairman, Editorial Advisory Board
Contraceptive Technology Update
Atlanta
What is the most commonly used reversible contraceptive in the world? It is the intrauterine device (IUD).
There are several reasons the IUD tops the list. IUDs are effective, safe, convenient, cost effective, and fully reversible.1 A single decision can lead to five to 10 (or more) years of extremely effective and very safe contraception AND at any time, it may be removed for a woman to become pregnant. Continuation rates for IUDs, 78%-81% at one year, are 10%-25% higher than for pills, patches, rings, depot medroxyprogesterone acetate (DMPA, Depo-Provera, Pfizer, New York City), or condoms.2
In the United States, there now are two IUDs: the Copper T-380 (ParaGard, Duramed Pharmaceuticals, Woodcliff Lake, NJ) and the levonorgestrel IUD (Mirena, Berlex, Montville, NJ). Good news: From 1995 to 2002, the use of an IUD tripled, according to data in the 1995 and 2002 National Surveys of Family Growth.3 Bad news: Only 2% of women now use IUDs in our country.3
Most women wanting an intrauterine device can use either the Copper-T or the Mirena IUDs. Women who can use either IUD include women who want:
- Long-term contraception from a single decision.
Women who wish to use a contraceptive that is extremely effective, very safe, and very convenient can consider an IUD, where there is nothing to do at the time of intercourse or even at daily, weekly, monthly, or three-month intervals. - Reversible contraception.
Women who want to be able to have a baby in the future can look to the IUD as a potential method. - Contraception with the highest level of patient satisfaction. Women who use IUDs represent the highest percent of patients who are "very" or "somewhat" satisfied with their method.
Patients with the following medical conditions also can consider either form of intrauterine contraception:
- anemia;
- diabetes;
- cervical intraepithelial neoplasia;
- HIV (this category includes women who are HIV-infected, at high risk for HIV, or who have AIDS, but are clinically well on antiretroviral therapy);
- previous pelvic infection that was three months or more in the past4;
- use of antibiotics (anti-tuberculosis drugs or griseofulvin) that decrease the Pill’s effectiveness;
- use of anti-seizure medication that decreases the Pill’s effectiveness.
Women who wish to use a contraceptive that dramatically reduces the risk of an ectopic pregnancy should definitely look to the IUD; the absolute risk of ectopic pregnancy is approximately one per 1,000 person years and is less than half the risk for women using no contraception.5,6
Which IUD is best?
Consider the following parameters when helping women select the proper form of intrauterine contraception. Women who might be best served by choosing the levonorgestrel IUD are those who have:
- painful or heavy periods;
- dysfunctional uterine bleeding;
- anemia;
- uterine fibroids;
- endometriosis;
- cyclic premenstrual symptoms (if related to prostaglandin release);
- Wilson’s disease (a very rare disease of copper metabolism);
- need for the lowest hormone level of all hormonal methods;
- minimal concern when provided information about the possibility of amenorrhea7;
- need for a postmenopausal progestin to protect against endometrial cancer.
Which women might be best served by choosing the ParaGard IUD? Consider the Copper-T for those women who have:
- reason to avoid using any hormone at all;
- desire to avoid irregular bleeding and spotting;
- desire to avoid missing periods (amenorrhea);
- desire for the most years of contraceptive protection (10-12 years);
- current or past occurrence of breast cancer;
- severe (decompensated) cirrhosis;
- active viral hepatitis;
- desire for IUD insertion just after delivery of placenta;
- need for the most effective emergency contraceptive available.
Although U.S. women who use the IUD love it, not many use it. This is most unfortunate. The percentage of women using an IUD tripled from 1995 to 2002.3 Perhaps IUD use in the United States will catch up to IUD use in the rest of the world in the not-too-distant future.
References
- Chiou CF, Trussell J, Reyes E, et al. Economic analysis of contraceptives for women. Contraception 2003; 68:3-10.
- Trussell J. "The Essentials of Contraception: Efficacy, Safety, and Personal Considerations." In: Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology: 18th revised edition. New York City: Ardent Media; 2004.
- Mosher WD, Martinez GM, Chandra A, et al. Use of contraception and use of family planning services in the United States: 1982-2002. Adv Data 2004; 350:1-36.
- World Health Organization. WHO Medical Eligibility Criteria for Starting Contraceptive Methods. Accessed at: www.who.int/reproductive-health/publications/MEC_3.
- Peterson HB, Curtis KM. Long acting methods of contraception. New Engl J Med 2005; 353:2,169-2,175.
- Franks AL, Beral V, Cates W Jr, et al. Contraception and ectopic pregnancy risk. Am J Obstet Gynecol 1990;163:1,120-1,123.
- Backman T, Huhtala S, Luoto R, et al. Advance information improves user satisfaction with the levonorgestrel intrauterine system. Obstet Gynecol 2002; 99:608-613.
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