IUDs in Nulliparous Women
Abstract & Commentary
By Rebecca H. Allen, MD, MPH, Assistant Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI, is Associate Editor for OB/GYN Clinical Alert.
Dr. Allen reports no financial relationships relevant to this field of study.
Synopsis: This national survey of providers of family planning services revealed that 30% believed the IUD was not safe for nulliparous women despite current recommendations to the contrary.
Source: Tyler CP, et al. Health care provider attitudes and practices related to intrauterine devices for nulliparous women. Obstet Gynecol 2012;119:762-771.
To investigate the attitudes and practices of health care providers toward intrauterine device (IUD) use in nulliparous women, the authors performed a national survey of both office-based physicians and Title X health care providers from December 2009 to March 2010. Title X clinics provide family planning and other preventive health services to low-income families through the Department of Health and Human Services. Two thousand office-based physicians were randomly sampled from the American Medical Association Masterfile and included obstetrics and gynecology, family medicine, and adolescent medicine providers. Two thousand Title X clinics also were randomly sampled. Only those office-based physicians and Title X clinics that provided family planning services at least twice per week were eligible to participate.
After excluding ineligible providers, the authors obtained a sample of 635 office-based physicians and 1323 Title X health care providers. The Title X health care providers consisted of nurses, mid-level providers, and physicians (specialty was not reported). The response rate after accounting for ineligibility was as follows: OB/GYNs, 51.8%; family medicine physicians, 68%; adolescent medicine physicians, 68%; and Title X providers, 77.5%.The majority (89.2%) of the Title X providers surveyed were nurses or mid-level providers. The two outcomes of interest were health care provider attitudes toward the safety of IUD use in nulliparous women and the frequency of provision of the IUD to nulliparous women. Both the copper IUD and the levonorgestrel intrauterine system (LNG-IUS) were studied.
The authors found that 30% of respondents perceived the IUD to be unsafe, very unsafe, or unsure (about the safety) for nulliparous women, whether copper IUD or LNG-IUS. The prevalence of this misconception regarding the safety of the copper IUD was higher among family medicine physicians compared to OB/GYNs (44.2% vs 14.7%; adjusted odds ratio [OR], 3.20; 95% confidence interval [CI], 1.73 to 5.89). Similar results were found for the LNG-IUS when comparing family medicine to OB/GYN providers (adjusted OR, 2.03; 95% CI, 1.10 to 3.76). Attitudes of Title X physicians were not significantly different from attitudes of OB/GYNs (adjusted OR for copper IUD, 1.34; 95% CI, 0.70 to 2.56; adjusted OR for LNG-IUS, 1.16; 95% CI, 0.60 to 2.24). Providers trained in IUD insertion and those who had IUDs available on-site were less likely to report misconceptions about safety.
Not surprisingly, the provision of IUDs to nulliparous women was higher among providers with on-site availability. Similarly, health care providers with misconceptions about safety of the copper IUD in nulliparous women had increased odds of infrequent provision (adjusted OR, 6.04; 95% CI, 2.00 to 18.31). These estimates were similar for the LNG-IUS. Overall, the majority of providers reported rarely or never providing IUDs to nulliparous women, ranging from 56% for office-based OB/GYNS with the LNG-IUS to 86% for office-based family medicine physicians for the copper IUD. Among all providers, the most common reasons cited for infrequent provision of the IUD were patient preference for another method and lack of method availability. Five percent to 15% of providers also cited safety as a reason.
Commentary
According to the United States Medical Eligibility Criteria for Contraceptive Use released in June 2010, IUD use in nulliparous women is classified as Category 2, a condition for which the advantages of using the method generally outweigh the theoretical or proven risks.1 The American College of Obstetricians and Gynecologists has also endorsed the use of IUDs in nulliparous women.2 Concerns that IUDs cause infertility in nulliparous women have not been supported by more recent studies.3 While this survey was conducted before the release of the U.S. Medical Eligibility Criteria for Contraceptive Use, the labeling on the copper IUD had been changed in 2005 to allow for use in nulliparous women. There is no contraindication to the use of the LNG-IUS in the labeling. Therefore, it is disappointing that 30% of providers still believed that the IUD is unsafe for nulliparous women and that the majority do not provide this long-acting and highly effective form of contraception to this population of women.
Long-acting reversible contraception, due to its high efficacy and continuation rates, is considered in the top tier of contraceptive efficacy. In the United States, however, only 5.5% of women practicing contraception used IUDs as of 2008.4 Even fewer of these, approximately 0.5%, were nulliparous women.5 The two IUDs currently available in the United States, the LNG-IUS and the copper IUD, are important tools in reducing the high unintended pregnancy rate. The advantages of the IUD include few contraindications, cost-effectiveness, and high user satisfaction. Continuation rates in nulliparous women are comparable to multiparous women for the LNG-IUS.6 Clearly, more training of health care providers on IUD insertion and evidence-based recommendations for IUD use is needed.
Many clinicians may be hesitant to perform IUD insertion in nulliparous women due to concerns about insertion difficulty or pain. While each patient is different, most nulliparous women tolerate the procedure well. The routine use of misoprostol for pre-procedure cervical ripening has not been shown to significantly improve ease of insertion or relieve pain during the procedure.7 In fact, women receiving misoprostol have more pain due to uterine cramping. I personally only use misoprostol for IUD insertion if a previous insertion attempt has failed. Rarely, cervical dilation may be needed for IUD insertion if the IUD inserter is unable to pass through the internal os of the cervix. Unfortunately, we lack proven interventions for pain with IUD insertion. NSAIDs, such as ibuprofen 600 to 800 mg, taken prior to the IUD insertion may improve pain due to uterine cramping after the insertion but will not affect insertion pain itself.8 A paracervical block may also be an option for nulliparous women if cervical dilation is required, although the administration of the block itself causes pain. Also, remember that IUDs may be placed immediately after surgical treatment of miscarriage or induced abortion. In this scenario, the cervix is already dilated and insertion will be easier and perforation risk is not increased.
References
- Centers for Disease Control and Prevention. U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR 2010;59.
- ACOG Committee Opinion no. 450: Increasing use of contraceptive implants and intrauterine devices to reduce unintended pregnancy. Obstet Gynecol2009;114:1434-1438.
- Hubacher D, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345:561-567.
- Mosher WD, Jones J. Use of contraception in the United States: 1982-2008. Vital Health Stat 2010;23:1-44.
- Kavanaugh ML, et al. Characteristics of women in the United States who use long-acting reversible contraceptive methods. Obstet Gynecol 2011;117:1349-1357.
- Peipert JF, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol 2011;117:1105-1113.
- Vickery Z, Madden T. Difficult intrauterine contraception insertion in a nulligravid patient. Obstet Gynecol 2011;117:391-395.
- Hubacher D, et al. Pain from copper intrauterine device insertion: Randomized trial of prophylactic ibuprofen. Am J Obstet Gynecol 2006;195:1272-1277.
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