Consider IUC method for teen contraception
By Anita Brakman, MS, Assistant Director of Education & Research
Physicians for Reproductive Choice and Health
New York City
Melanie Gold, DO, FAAP, FACOP
Clinical Professor of Pediatrics
University of Pittsburgh School of Medicine
Staff Physician
University of Pittsburgh Student Health Service
While increased use of contraception has contributed to declines in teen pregnancy over the past two decades,1 the methods most teens choose oral contraceptive pills or condoms require ongoing maintenance and carry a high possibility of user errors. Fifty-four percent of females ages 15-19 who use contraception rely on oral contraceptive pills. Twenty-three percent rely on condoms.2
There are two forms of intrauterine contraception (IUC) approved by the Food and Drug Administration (FDA) that can provide teens with effective, long-term protection from pregnancy with few challenges in adherence. They are the Copper T380A (ParaGard CuT380A IUD, Teva Women's Health, Woodcliff Lake, NJ) and the levonorgestrel intrauterine system (Mirena IUS, Bayer HealthCare Pharmaceuticals, Wayne, NJ). Intrauterine contraception is easily kept private, does not require periodic visits to a health care provider for refills, and has perfect and typical use failure rates lower than 1%.3 Still, less than 6% of American women, and less than 4% of women ages 15-19, choose to use IUC.2 Lack of knowledge about IUC among adolescents creates one barrier to greater utilization. In one recent study, only 20% of participants under age 18 had ever heard of IUC methods.4
Concerns about pelvic inflammatory disease (PID), infertility, expulsion, and pain during insertion prevent many clinicians from providing IUC to adolescents. However, these concerns are mostly unfounded. Use of IUC does not increase the risk of PID, and some evidence suggests the LNG-IUS is protective against pelvic infection.5-7 There also is strong evidence against linking IUC use with future infertility.8 Available evidence suggests expulsion rates, estimated at 2-10%, are comparable between nulliparous and parous women using the LNG-IUS but might be slightly increased for users of the CuT380A.9
Young women might experience higher levels of anxiety and perceived pain during IUC insertion compared to older women. Pre-insertion treatment with misoprostol for cervical softening, analgesics, anti-inflammatory medications, or paracervical blocks have the potential to decrease pain, but evidence to date has not uniformly supported their use for this purpose.10,11
The American Congress of Obstetricians and Gynecologists (ACOG) and World Health Organization (WHO) support IUC use in female adolescents. In 2007, ACOG recommended IUC as a first-line choice for contraception in nulliparous and parous female adolescents.12 The WHO classifies IUC as Category 2 for this age group, meaning the method generally can be used.13 The CuT380A is FDA approved for use in women as young as age 16 and for nulliparous women.
Young women need specific counseling to choose a contraceptive method that meets their needs. Irregular bleeding, a common side effect of the LNG-IUS, might be poorly tolerated by female adolescents if they have not been carefully counseled. It is critical to counsel that irregular bleeding generally decreases with duration of use.14 Likewise, counsel CuT380A users that they may experience heavier menses and cramping, but dysmenorrhea can be lessened with non-steroidal anti-inflammatory medications.
Considering the prevalence of sexually transmitted infections (STIs) in this population, adolescents should be screened routinely for chlamydia and gonorrhea prior to IUC insertion. When an STI is diagnosed, IUC insertion should be delayed until one week after the completion of antibiotic treatment. If an IUC is already in place when the infection is detected, antibiotic treatment should commence without removal. Condom use should be encouraged, as IUC use does not protect against STIs.12
More research is needed to understand which form of IUC is most appropriate for adolescents. However, female adolescents who have dysmenorrhea, menorrhagia, or anemia are better candidates for LNG-IUS compared to the CuT380A.15
By educating teens about IUC use and offering the method as an option, clinicians aid women in preventing pregnancy during critical years when they might finish school and begin careers.
References
- Santelli JS, Lindberg LD, Finer L, et al. Explaining recent declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. Am J Public Health. 2007;97:150-156.
- Mosher WD, Jones J. Use of contraception in the United States: 1982–2008. Vital Health Stat 23 2010;29:1-44.
- Fu H, Darroch JE, Haas T, et al. Contraceptive failure rates: new estimates from the 1995 National Survey of Family Growth. Fam Plan Perspect 1999;31:56-63.
- Whitaker AK, Johnson LM, Harwood B, et al. Adolescent and young adult women's knowledge of and attitudes towards the intrauterine device. Contraception 2008;78:211-217.
- Ebi KL, PIziali RL, Rosenberg M, et al. Evidence against tailstrings increasing the rate of pelvic inflammatory disease. Contraception 1996;53:25-32.
- Lee NC, Rubin GL, Borucki R. The intrauterine device and pelvic inflammatory disease revisited; new results from the Women's Health Study. Obstet Gynecol 1988;72:1-6.
- 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;77:261-264.
- Hubacher D, Lara-Ricalde R, Taylor DJ, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345:561-567.
- Society for Family Planning. Use of the Mirena LNG-IUS and ParaGard CuT380A intrauterine devices in nulliparous women. Contraception 2010;81:367-371.
- Hubacher D, Reyes V, Lillo S, et al. Pain from copper intrauterine device insertion: randomized trial of prophylactic ibuprofen. Am J Obstet Gynecol 2006;195:1272-1277.
- Saav 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;22:2647-2652.
- American College of Obstetricians and Gynecologists (ACOG). ACOG Committee Opinion No. 392, December 2007. Intrauterine device and adolescents. Obstet Gynecol 2007;110:1493-1495.
- World Health Organization. Intrauterine devices. In: Medical Eligibility Criteria for Contraceptive Use. Third ed. Geneva: WHO; 2004.
- Grimes, DA. Intrauterine devices. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology. New York, NY: Ardent Media; 2007.
- Gold MA, Duffy K. Patient acceptability, safety and efficacy of the levonorgestrel-releasing intrauterine system (LNG-IUS). Clin Med Rev Womens Health 2010; 2:51-59.
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