Update your practice when it comes to IUDs
Update your practice when it comes to IUDs
Consider the following patients: a 15-year-old young mother, a 30-year-old married woman with no previous pregnancies, a 30-year-old single woman with no children, and a 30-year-old HIV-positive woman with three children. When discussing contraceptive options, do you include intrauterine contraception in talking with these women?
If not, it may be time to rethink your approach. Updated medical eligibility criteria from the World Health Organization (WHO) and revised product labeling now make the intrauterine device (IUD) available to a wider patient population, says Bryna Harwood, MD, assistant professor of obstetrics and gynecology and director of family planning at the University of Illinois at Chicago. Harwood reviewed patient guidelines at the recent Contraceptive Technology conference in Washington, DC.
The expanded eligibility criteria have not yet translated into increased use, notes Harwood. Take a look at the statistics: Just 2.1% of U.S. women use IUDs.1 In a recent survey of young pregnant women ages 14-25, while half of the women said they had heard of the IUD, 71% did not know about its safety, and 58% did not know about its efficacy.1
Two intrauterine contraceptives are available in the United States: the Mirena levonorgestrel intrauterine system (Mirena LNG IUS, Berlex; Wayne, NJ) and the Copper T 380A intrauterine device (ParaGard IUD, Duramed, a subsidiary of Barr Pharmaceuticals; Pomona, NY). The ParaGard IUD is approved for 10 years of contraception; the Mirena is approved for five years of birth control.2
The ParaGard IUD is approved for use for nulliparous women in stable relationships from age 16 through menopause. Women with a history of sexually transmitted diseases or pelvic inflammatory disease (PID) are no longer contraindicated for use of ParaGard, unless a patient currently has acute PID or engages in sexual behavior suggesting a high risk for the disease, the labeling states.
The WHO eligibility criteria classes use of IUDs in young women age 20 and younger, as well as for nulliparous women, as a "2" — situations in which the advantages of using the method generally outweigh the theoretical or proven risks.3 Clinicians may hesitate to place an IUD in these women due to unfounded concerns about potential increased risk of PID leading to increased risk for tubal infertility. Findings from a case-control study should alleviate such concerns, notes Harwood. Research indicates that the previous use of a copper IUD is not associated with an increased risk of tubal occlusion among nulligravid women.4
For HIV-positive women, the WHO gives a classification of "3"— a situation in which the theoretical or proven risks usually outweigh the advantages of using the method.3 Results from a prospective cohort study of HIV-infected and noninfected women in Nairobi, Kenya, suggest, however, that the IUD may be an appropriate contraceptive method for HIV-infected women with ongoing access to medical services.5
For women with a Copper T 380A IUD, should there be concerns about use of magnetic resonance imaging (MRI)? Many people have questioned whether it was safe to undergo an MRI exam with a ParaGard in place, now that MRI units have increased Tesla strengths, observes Miriam Zieman, MD, adjunct associate professor of obstetrics and gynecology at Emory University in Atlanta. In performing an in-vitro examination of a ParaGard in a 3.0 Tesla MRI unit, the outcomes measured revealed no safety concerns for the use of the device, she notes.6
Despite recent changes in the labeling of intrauterine devices, clinicians commonly restrict use of the method.7 This may be particularly true in the case of nulliparous women, observes Harwood. In researching an IUD checklist screening tool based on the WHO contraceptive eligibility criteria, scientists found that some providers were concerned about placing an IUD in nulliparous women. Why? If conception proved difficult in the future, the IUD and the provider would be blamed for these difficulties.8
"I think we have very good evidence to back up the use of the IUD in nulliparous women and not having it increase the risk of tubal infertility," says Harwood.
Why do family planners look to intrauterine contraception? Consider the following four reasons, says Harwood:
- It has the highest efficacy possible.
- It is safer than tubal sterilization.
- It is the second most long-acting method.
- It requires attention only at insertion and removal.9
What is the trouble with IUDs? "More women don't have one," says Harwood.
References
- Stanwood NL, Bradley KA. Young pregnant women's knowledge of modern intrauterine devices. Obstet Gynecol 2006; 108:1,417-1,422.
- Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology: 18th revised edition. New York City: Ardent Media; 2004.
- World Health Organization. Medical eligibility criteria for contraceptive use. Geneva (Switzerland): World Health Organization; 2004.
- 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.
- Morrison CS, Sekadde-Kigondu C, Sinei SK, et al. Is the intrauterine device appropriate contraception for HIV-1-infected women? BJOG 2001; 108:784-790.
- Zieman M, Kanal E. Copper T 380A IUD and magnetic resonance imaging. Contraception 2007; 75:93-95.
- Grossman D, Ellertson C, Abuabara K, et al. Barriers to contraceptive use in product labeling and practice guidelines. Am J Public Health 2006; 96:791-799.
- Wesson J, Gmach R, Gazi R, et al. Provider views on the acceptability of an IUD checklist screening tool. Contraception 2006; 74:382-388.
- Harwood B. Intrauterine contraception: What's new? Presented at the Contraceptive Technology conference. Washington, DC; March 2007.
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