Old myth debunked: Data show IUD is safe birth control option for teens
Teens’ rates of complications from IUDs no higher than for adults
Intrauterine devices (IUDs) are as safe for adolescents, including those who have never given birth, as they are for adults, according to just-published research.1
Researchers from the University of Texas Medical Branch at Galveston looked at private insurance claims from about 90,000 IUD users ages 15-44 to examine complications, failures, and discontinuation rates associated with device use. Results were compared by age and type of IUD used, which include the levonorgestrel IUD (LNG IUD, Mirena, Bayer HealthCare Pharmaceuticals, Wayne, NJ) and the copper T 380A IUD (ParaGard, Teva North America, North Wales, PA) Investigators examined whether adolescent IUD users were more likely to experience complications such as dysmenorrhea, amenorrhea, or IUD failure. Data analysis suggests the following:
• Serious complications resulting from IUD use, including ectopic pregnancy and pelvic inflammatory disease (PID), occurred in less than 1% of women regardless of age.
• Early discontinuation didn’t differ between adolescents and older women, indicating that the IUD was not associated with greater complications among this age group.
• Use of the LNG IUD was associated with fewer complications and lower rates of discontinuation than the copper T 380A IUD in all age groups.1
What prompted the research team to look at private insurance claims to gain understanding of intrauterine contraception among adolescents and other reproductive-age women? Using such information allowed investigators to examine the outcomes of a large number of young women, according to Abbey Berenson, MD, director of the Center for Interdisciplinary Research in Women’s Health at the university. “This large sample size allowed us to examine outcomes in a more expedient and cost-effective manner than would have been possible with a prospective study,” states Berenson, who served as lead author of the research paper. “Moreover, we felt that examining billing codes for serious consequences, such as ectopic pregnancy, would be more accurate than a study which relied solely on interview data.”
Because this was a retrospective study, the findings should be confirmed by a prospective trial on IUD use in adolescents, Berenson adds.
IUDs safe for teen use
In 2012, the American College of Obstetricians and Gynecologists (ACOG) issued a committee opinion stating that long-acting reversible contraceptives such as the IUD and the contraceptive implant are safe, effective, and appropriate options for adolescents.2 (To read more about the opinion, see the Contraceptive Technology Update article, “Long-acting methods safe for teens: include options in your counseling,” December 2012, p. 133.)
The U.S. Medical Eligibility Guidelines For Contraceptive Use (US MEC) ranks use of the Copper T-380A and the levonorgestrel IUDs as a “Category 2” (a condition for which the advantages of using the method generally outweigh the theoretical or proven risks) for women under age 20, with the same rating for nulliparous women.3 With the ACOG US MEC guidance in hand, clinicians can make evidence-based decisions in safely using the contraceptive method in adolescents.
Assess potential pain
Fear of pain has been cited as a barrier to IUD use, so talk with prospective users about this possibility.4 Intrauterine device insertion has been variably described by nulliparous women as ranging from “period pain” (62%) to “severe abdominal pain” (14%).5 In a study of nulliparous women age 25 or younger, 13.8% reported no pain at insertion, 65.9% reported mild to moderate pain, and 21.3% noted severe pain.6
Providers might underestimate patient pain levels: in a recent secondary analysis of a randomized placebo-controlled trial of 200 women that looked intracervical lidocaine gel as an analgesic during IUD insertion, data indicates a wide expanse between providers’ and patients’ perceptions. On a 100-point visual analog scale, patients’ mean perceived pain score was 63.8, registering moderate pain, while the providers’ assessment of their patients’ pain level was recorded at a mean of 35.3, registering as mild pain.7
In talking about intrauterine contraception, tell women that some patients experience dizziness and/or cramps after insertion.8 Such pain is normal. If they want to take medication to alleviate the pain, products that contain ibuprofen or naproxen are best.8
Prescribing information for the Mirena LNG-IUD continues to recommend that the device be used in women who have had at least one child. When the ParaGard copper-releasing IUD was first marketed in the United States in 1988, the prescribing information contained a “recommended patient profile,” which included a history of childbearing; in 2005, the labeling was amended so it no longer discourages use by nulliparous women.
In January 2013, the Food and Drug Administration approved Skyla, a new IUD from Bayer HealthCare Pharmaceuticals. Skyla is smaller in size and contains a smaller dosage of levonorgestrel than Bayer’s other intrauterine contraceptive, Mirena. Skyla is approved for up to three years of contraceptive use; Mirena is labeled for up to five years of use. Skyla’s product labeling specifically states that it can be used whether or not a woman has had a child, whereas the labeling for Mirena states it is recommended for women who have had at least one child. (To read more about the device see “FDA approves smaller levonorgestrel intrauterine system — a ‘mini Mirena,’” CTU, March 2013, p. 25.)
Although it is possible to insert the larger Mirena IUD in most young women, never-pregnant women, and nulliparous women, to avoid potential insertion pain, Skyla might be a good fit for young nulliparous women, observes Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta. The fact that the device is labeled for three years’ use might appeal to younger women who might not want to commit to the LNG or Copper T380A intrauterine contraceptives, both which have longer labeled efficacy rates, he notes.
Talk it up
Researchers at the University of Texas Medical Branch at Galveston reported “significant” growth in the frequency of teenagers using an IUD for contraception in their current study.1 However, many teenagers received their device after delivery of an infant, which suggests that IUDs might not be prescribed as often to nulliparous teenagers. Educational programs might be needed to communicate the safety of IUD use in adolescents who have not given birth, they note.
References
1. Berenson AB, Tan A, Hirth JM, et al. Complications and continuation of intrauterine device use among commercially insured teenagers. Obstet Gynecol 2013; 121(5):951-958.
2. 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.
3. Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use. MMWR 2010; 59(RR04):1-6.
4. Hillard PJ. Practical tips for intrauterine devices use in adolescents. J Adolesc Health 2013; 52(4 Suppl):S40-46.
5. 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; 13:248-254.
6. Suhonen S, Haukkamaa M, Jakobsson T, et al. Clinical performance of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: A comparative study. Contraception 2004; 69:407-412.
7. Maguire K. Accuracy of providers’ assessment of pain during intrauterine device insertion. Presented at the American Congress of Obstetricians and Gynecologists Annual Clinical Meeting. San Diego; May 2012.
8. Dean G, Schwarz EB. Intrauterine contraceptives (IUCs). In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology. 20th revised ed. New York: Ardent Media; 2011.
Intrauterine devices (IUDs) are as safe for adolescents, including those who have never given birth, as they are for adults, according to just-published research.1You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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