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Check option of IUD for emergency contraception
When it comes to emergency contraception (EC), placement of a Copper T 380A intrauterine device [(IUD), ParaGard, Duramed Pharmaceuticals, a subsidiary of Barr Pharmaceuticals; Pomona, NY] offers excellent protection against unwanted pregnancy, as well as long-term contraception. What are some of the roadblocks that may hinder its use?
Many women and clinicians don't know it is an option, says Eleanor Bimla Schwarz, MD, MS, assistant professor of medicine, and obstetrics, gynecology, and reproductive sciences at the University of Pittsburgh. Schwarz and research colleagues have just published a study that suggests offering same-day IUD insertion to women who seek walk-in pregnancy testing or EC is an effective strategy for promoting contraception.1
To date, few clinicians have offered IUDs to women seeking emergency contraception.2 One barrier for many clinicians is lack of training in IUD insertion, says Schwarz. [Editor's note: The Association of Reproductive Health Professionals (ARHP) sponsors a continuing medical education program, "A Clinical Update on Intrauterine Contraception." Select sessions offer a hands-on insertion practicum on Copper T IUD and levonorgestrel intrauterine system (LNG IUS, Mirena, Bayer HealthCare Pharmaceuticals; Wayne, NJ). For more information, visit the ARHP web site, www.arhp.org. Select "Professional Education," then the program title.]
Many women would be interested in same-day insertion of an IUD. Schwarz and associates surveyed 412 women and adolescent girls who requested EC or pregnancy testing at four Pittsburgh family planning clinics. Twelve percent of those surveyed expressed interest in same-day insertion, and 22% wanted more information about IUDs.1
Alisa Weber, MSN, FNP-BC, a nurse practitioner with Carolinas HealthCare System Mecklenburg County Health Department in Charlotte, NC, has been using IUDs for EC for about six years. Weber says women often do not know about intrauterine contraception or even EC. Since Plan B went over the counter, a few more people are inclined to know about EC, she observes, but most are unaware of the practice.
To determine if a woman is a candidate for EC use of an IUD, Weber reviews the patient's contraceptive history, checks whether she is currently using birth control, and then talks about long-term family planning goals. Weber then discusses the two options for EC and checks the date of the last act of intercourse to confirm that it was unprotected. If the unprotected sex was within the last five days, Weber offers the patient a choice in EC: the levonorgestrel pill, along with its effectiveness rate, then the IUD, accompanied by its effectiveness rate. If the woman has been leaning more toward a long-term method of contraception, Weber then presents further information on the IUD to allow the woman to make an informed decision on the method.
Since Weber's agency is a Title X-funded agency, it is able to purchase IUDs at a discounted rate. Women pay on a sliding-fee scale, which expands financial access to the method. While she is unsure of total numbers, Weber estimates she has placed more than 100 IUDs for post-coital contraception for women who have been candidates for intrauterine contraception. "It is more effective than the pill," she says. "Then if the person is a candidate for an IUD, she has ongoing contraception, and it's long-term contraception."
How do efficacy rates vary between the EC use of levonorgestrel-only pills and the IUD? Eight studies of the levonorgestrel regimen that encompass more than 9,500 women report estimates of effectiveness between 59% and 94%.3 About 13,000 post-coital insertions of copper-bearing IUDs have been performed since the practice was introduced in 1976; with 13 failures reported, the approach lists a pregnancy rate of 0.1%.3
If a woman is able to continue using the IUD for contraception for the next year, she benefits from an effective form of birth control, points out Robert Hatcher, MD, MPH, professor of obstetrics and gynecology at Emory University. Efficacy computations in Contraceptive Technology show 0.8% of women using a Copper T IUD experience an unintended pregnancy within the first year of typical use; if the method is used perfectly, just 0.6% (six women in 1,000) have an unintended pregnancy in the first year of use.4
While insertion of a Copper T IUD is not cost-saving when used solely as an EC, data indicate high contraceptive effectiveness as long as 12 years.5 If used as an ongoing method of contraception for as little as four months after emergency insertion, it can provide cost savings, an analysis indicates.6
How about use of a LNG IUS for EC? This question may arise when a patient's history of severe menstrual cramps or heavy menses might preclude use of the Copper T IUD, says Hatcher. Although it is believed that the LNG IUS probably is effective as a post-coital contraceptive, there are no data regarding its efficacy in an EC setting, he says. Women who are seeking EC and are open to IUS insertion could receive Plan B for EC and have an LNG IUS insertion at the same time, Hatcher notes.
"Bottom line: If you insert a ParaGard IUD or a Mirena IUS — backing it up with Plan B simply because we don't have data — you not only gain better protection against pregnancy from that one act of unprotected intercourse, but if the woman is able to tolerate using an IUD, she has a superb reversible contraceptive in utero," says Hatcher.