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Intrauterine Contraception (IUC): Mainstreaming Family Planning Dr. Mark Hathaway
Learning Objectives • Name the two forms of intrauterine contraception available in the United States • Rank efficacy associated with intrauterine contraceptives compared with other contraceptive methods • List three selection criteria for appropriate candidates for intrauterine contraception • Dispel some myths regarding IUDs • Understand why effective contraception is important and needed
Learning Objectives (continued) • Identify two possible side effects of each type of intrauterine contraceptive • Develop skills required for proper insertion techniques for the two methods of intrauterine contraception • Discuss strategies for follow-up of intrauterine contraceptive users
Expert Medical Advisory Committee • Kirtly Parker Jones, MD • Chris Knutson, MN, ANP • Patricia Murphy, CNM, DrPH • Carolyn Westhoff, MD • Susan Wysocki, RN-C, NP • David A. Grimes, MD • Special thanks to Iris Stendig-Raskin, CRNP,MSN, & Association of Reproductive Health Professionals (ARHP (www.arhp.org)
Unintended Pregnancies in the United States Data from 2002 National Survey of Family Growth Unintended births Intended 22% 51% Elective abortions 20% 7% Fetal losses Unintended 49% 6.4 Million Pregnancies Finer LB, et al. Persp Sex Reprod Health. 2006.
Why an Update on Intrauterine Contraception? • Abortions: more than 1/3 of all U.S. women will have had an induced abortion by age 45 • Sterilization is permanent: 20% of women selecting sterilization at age 30 years or younger later express regret • Effective: couples need an effective contraceptive method that is “forgettable” or “hands-off”. • Unintended pregnancies are preventable Henshaw SK. Fam Plann Perspect 1998. Hillis SD, et al. Obstet Gynecol.1999.Stanwood NL, et al. Obstet Gynecol. 2002.
Why an Update on Intrauterine Contraception? (continued) • Myths: many exist about intrauterine contraception, and selection of candidates is unduly restrictive • Misinformation: lack of knowledge & understanding about intrauterine contraception is very common even among providers… Stanwood NL, et al. Obstet Gynecol. 2002. Weiss E, et al. Contraception. 2003.
Outdated Safety Concerns Have Held Back IUD Use • The Dalkon Shield was linked to septic miscarriage and pelvic inflammatory disease (PID), possibly due to its multifilament tails. • Available in the U.S. from 1971-1974 • Several biases in early research overstated risks of PID and infertility. • Example: the study compared IUD users with users of contraceptive methods that protect against PID, such as oral contraceptive pills. • Most research since the 1980s has shows that complications are v. rare with modern IUDs.
IUDs Are An Important Choice • IUDs will help reduce the number of unintended pregnancies due to contraceptive failures. • IUDs are very effective--more than many other methods, because no “user-failure” issues.
Contraceptive Use and Nonuse in the United States, 2003 % of Women Aged 15-50 Pill Condom Abstinence Injectable Patch IUC Other(diaphragm, ring,gel/foam, rods, EC) NaturalFamilyPlanning Sterilization (male & female) None Ortho Pharmaceutical. 2003 Annual Birth Control Study.
Advantages/Disadvantages of IUDs • Advantages: discreet, long term (up to 10 yrs), freedom from having to remember to use a contraceptive (at time of intercourse, daily, weekly, monthly, every 3 mos, etc), low risk of side effects, and cost effective • Disadvantages: requires a trained clinician, some women have increased menstrual bleeding, and lack of protection against STIs
Worldwide Use of IUC ~ Use for Married Women of Reproductive Age %UsingIUC Asia Europe Africa Oceania NorthAmerica Latin America & Caribbean Population Reference Bureau, 2002.
IUDs - Two Types in U.S. • There is a great need to promote and educate about the IUD and its multiple advantages, such as: availability to adolescents, long term effectiveness, low cost, minimal side effects, low-no maintenance, etc.
Appropriate Candidates for IUC? • Any Women (including adolescents and nulliparous women) of any reproductive age seeking a long-term, discreet, highly effective, convenient, safe, and reversible contraceptive. • Risk of PID and subsequent infertility is dependent on non-IUC factors
Why IUDs are Underused in the United States • Dearth of trained and willing professionals to insert devices • Negative publicity • Misconceptions • Fear of litigation • Upfront cost • Lack of awareness of method among women Weir E. CMAJ. 2003. Stanwood NL, et al. Obstet Gynecol. 2002. Steinauer JE, et al. Fam Plann Perspect. 1997.
What Do Women Find Unacceptable About IUDs? • Lack of objective information • Reported side effects • Anxiety about IUD insertion • Infection risk • Lack of personal control of IUD after insertion Asker C, et al. J Fam Plann Reprod Health Care. 2006.
Women’s Knowledge of Modern IUDs Stanwood NL, et al. Obstet Gynecol. 2006.
Use of IUDs by Female Ob/Gyns vs. All Women in the United States % Using IUDs General Population Female Ob/Gyn Physicians Population Reference Bureau. 2002. The Gallup Organization. 2004.
Characteristics of Intrauterine Contraception • Highest patient satisfaction among methods • Rapid return of fertility • Safe • Immediately effective • Long-term protection • Highly effective Belhadj H, et al. Contraception. 1986.; Skjeldestad F, et al. Advances in Contraception. 1988.; Arumugam K, et al. Med Sci Res. 1991.; Tadesse E. Easr Afr Med J. 1996.
Dispelling Common Myths About IUDs • In fact, IUDs: • Are not abortifacients • Do not cause ectopic pregnancies • Do not cause pelvic infection • Do not decrease the likelihood of future pregnancies • Are small in size
Dispelling Common Myths About IUDs (continued) • In fact, IUDs: • Can be used by nulliparous women • Can be used by women who have had an ectopic pregnancy • Do not need to be removed for PID treatment • Do not have to be removed if actinomyces-like organisms (ALO) are noted on a Pap test
IUDs Available in the United States LNG IUD • 20 mcg levonorgestrel/day • Approved for 5 years’ use Copper T 380A IUD • Copper ions • Approved for 10 years’ use
Mechanism of Action: Copper T IUD • Primary mechanism is prevention of fertilization • Reduce motility and viability of sperm • Inhibit development of ova • Inhibition of implantation is a secondary mechanism Alvarez F, et al. Fertil Steril. 1988; Segal SJ, et al. Fertil Steril. 1985; ACOG. Statement on Contraceptive Methods. 1998.
Mechanism of Action: LNG IUD • Primary mechanism is fertilization inhibition • Cause cervical mucus to thicken • Inhibit sperm motility and function • Inhibition of implantation is a secondary mechanism Jonsson B, et al. Contraception. 1991.Silverberg SG, et al. Int J Gynecol Pathol. 1986.
Hormone-Releasing IUD - Decreases Bleeding • LNG-IUD users initially experience more bleeding and spotting after insertion, but bleeding gradually decreases after three months. • 25% to 35% of LNG-IUD users have no bleeding at all by the end of the first year of use. • Counseling about bleeding changes is key to successful use. • LNG-IUD has several therapeutic applications because it reduces bleeding: • Increases blood iron levels • Treatment for menorrhagia • Progestin component of hormone replacement therapy
Copper-Bearing IUDs - Can Increase Bleeding • Copper-bearing IUDs can increase blood flow volumes by 20% to 50%. • Most common complaint among IUD users • But many women still keep their IUDs. • Rates of removal because of bleeding or pain range from 1 to 17 per 100 women. • Increased bleeding could decrease blood iron levels.
IUD Efficacy Comparable to Sterilization • 5-year gross cumulative failure rate WHO. 1987; Peterson HB, et al. Am J Obstet Gynecol. 1996.
Efficacy: 1st Year Failure Rates of Select Contraceptives (Typical Use) Adapted from Trussell J. In Hatcher RA, et al. Contraceptive Technology: 18th revised ed, 2004.
IUDs are one of the Most Effective Methods of Contraception • Women who become pregnant during first year of use: • TCu-380A: 3 to 8 per 1,000 (0.3% to 0.8%) • LNG-IUD: 1 to 3 per 1,000 (0.1% to 0.3%) • Comparable to effectiveness of female sterilization • LNG-IUD is slightly more effective than TCu-380A … • After 6 years of use, 20 women per 1,000 (2%) became pregnant while using the TCu-380A; • 5 women per 1,000 (0.5%) became pregnant while using the LNG-IUD. • … But LNG-IUD has lower continuation rates, largely because of removals due to lack of bleeding.
Safety: IUDs Do Not Cause PID • PID incidence for IUD users is similar to that of the general population • Risk is increased only during the first month after insertion • Preexisting STI at time of insertion, not the IUD itself, increases risk , ie, bacteria, not plastic cause infections • Fifteen years of research and comprehensive review have disproved myths & risks of infections caused by the device. • Bottom line: The IUD is a safe, effective, long term contraceptive, but is vastly underutilized (1-2%) in the U.S. Svensson L, et al. JAMA. 1984; Sivin I, et al. Contraception. 1991; Farley T, et al. Lancet. 1992.
Safety - Rate of PID by Duration of IUD Use n=20,000 women Adapted from Farley T, et al. Lancet. 1992.
Safety: IUD Does Not Cause Infertility • IUD is not related to infertility • Chlamydia is related to infertility Tubal infertility by previous copper T IUD use and presence of chlamydia antibodies, nulligravid women Hubacher D, et al. NEJM. 2001.
100 80 IUC OC Diaphragm Other methods 60 Pregnancies (%) 40 20 0 12 18 24 30 36 42 0 Months After Discontinuation Fertility Rates in Parous Women After Discontinuation of Contraceptive Based on data from Vessey MP, et al. Br Med J. 1983.
Safety: IUDs May Be Used by HIV- Positive Women • No increased risk of complications compared with HIV-negative women • No increased cervical viral shedding • WHO Category 2 rating WHO. Medical Eligibility Criteria for Contraceptive Use. 2004; Morrison CS, et al. Brit J Obstet Gynaecol. 2001; Richardson B, et al. AIDS. 1999.
Safety: IUDs May Be Used in Nulligravid Women • No evidence of increased infertility in nulliparous users of IUDs • Risk of PID and subsequent infertility is dependent on non-IUD factors WHO. Medical Eligibility Criteria for Contraceptive Use. 2004; Hubacher D, et al. NEJM. 2001; Delbarge W, et al. Eur J Contracept Reprod Health Care. 2002.
Termination Rates and Reasons: LNG IUD vs. OCs in Nulligravid Women: *Statistically significant difference Suhonen S, et al. Contraception. 2004.
Cost for Patient • Patient costs are a factor in choosing contraceptive methods including up-front costs • Costs of side effects associated with IUC are minimal compared to other many other methods, especially unintended pregnancy costs • Title X clinic systems and/or pharmaceutical patient assistance programs exist for low-income or uninsured patients Chiun-Fang C. Contraception. 2003.
IUC is Very Cost Effective Five year costs of contraceptives. Trussel J, Levesque JA, Koenig JD: Am J Public Health 85(49):494,1995.
Components of Costs Associated with Contraceptive Method Use vs. No Method Use Over 2 Years
1 2 3 4 5 Screening & Counseling Goals for Providers • Review contraceptive options with patients • Allow patients to hold contraceptive devices • Promote successful use of chosen method • Allow time for questions • Provide written materials in the appropriate language and literacy level
Effectiveness Side effects Convenience Duration of action andchildbearing plans Patient choice Reversibility Non-contraceptive benefits Cost Privacy Considerations in Choice of Contraceptive Methods
Contraindicationsor Poor Candidates for Intrauterine Contraception • Known or suspected pregnancy • Puerperal or post abortion sepsis (TAB/SAB) • Unexplained vaginal bleeding • Malignancy of genital tract (cervical or uterine) • Uterine fibroids that distort uterine cavity • Acute PID, diagnosed cervicitis (current gonorrhea, chlamydia, or cervicitis within last 3 mos.) • Copper allergy or Wilson’s Disease WHO. Medical Eligibility Criteria for Contraceptive Use. 2004.
Timing of Insertion of Intrauterine Contraception Alvarez PJ. Ginecol Obstet Mex. 1994. O’Hanley K, et al. Contraception. 1992.
IUD Insertion After Spontaneous or Induced Abortion • IUDs may be safely inserted immediately after spontaneous or induced abortions • IUD insertion is not recommended after septic abortion Grimes D, et al. Cochrane Library. 2000. Manufacturers’ prescribing information.
IUD Use During Lactation • Effectiveness not decreased • Uterine perforation risk unchanged • Expulsion rates unchanged • Decreased insertional pain • Reduced rate of removal for bleeding and pain • LNG comparable to copper T in breastfeeding parameters Chi I-C, et al. Contraception. 1989; Shaamash AH, et al. Contraception. 2005.
Copper T IUD Insertion as Emergency Contraception • Can be inserted up to 5 days after unprotected intercourse to prevent pregnancy • More effective than use of emergency contraceptive pills (Plan B) Stewart F, et al. In: Hatcher RA, et al. Contraceptive Technology, 18th revised ed. 2004.
Potential Side Effects During insertion First few days First few months Type • Copper T: Heavier or prolonged menses • LNG: Gradual decrease in menstrual flow • Variable pain and/or cramping • Vaso-vagal reactions • Light bleeding and mild cramping • Intermenstrual bleeding, cramping Sivin I, et al. Contraception. 1991. Silverberg SG, et al. Int J Gynecol Pathol. 1986.
Side Effects Complications Infection Perforation Pregnancy Expulsion Missing threads Menstrualeffects IUD Side Effects & Complications