Use of long-term methods moving up How can you boost numbers?
(Editor's Note: Read the September 2011 edition of Contraceptive Technology Update for the second of our two-part special coverage of long-acting reversible contraceptives. Included in the upcoming issue is an in-depth look at the American College of Obstetricians and Gynecologists' new practice bulletin on the use of long-acting reversible contraceptives. The new recommendations offer guidance in selecting appropriate candidates for such methods and provide tips on managing clinical issues that might arise.)
T he tide might be turning when it comes to use of long-acting reversible contraceptive methods such as intrauterine devices (IUDs) and implants among American women. Results of a new study show use has increased from 2.4% in 2002 to 5.6% in 2006-2008.1
What might be leading to the increase? There are several possibilities, says Megan Kavanaugh, DrPH, senior research associate at the New York City-based Guttmacher Institute and lead author of the current paper.
The U.S. Medical Eligibility Criteria for Contraceptive Use and guidance on use of intrauterine devices from the American College of Obstetricians and Gynecologists indicate safe use of the IUD in younger women and nulliparous women.2-4 U.S.-based organizations, such as the Association of Reproductive Health Professionals and the Society of Family Planning, also have disseminated evidence-based information on the safety and efficacy of IUDs.5 Now that medical organizations are recognizing that IUDs are safe, effective, and are desired in these younger populations, epidemiologists are seeing an increase, Kavanaugh notes.
In the past, the Copper T380A IUD (ParaGard, Teva Women's Health, North Wales, PA) and the levonorgestrel intrauterine system (LNG IUS, Mirena, Bayer HealthCare Pharmaceuticals, Wayne, NJ) had listed parity as a criteria for using the method in their package labeling. This situation is no longer the case with the Copper T380A. The Food and Drug Administration in 2005 approved a change in its labeling, removing a section titled "recommended patient profile" and deleting language that stated, "T380A is recommended for women who have had at least one child...".5 The Mirena package insert states that the device "is recommended for women who have had at least one child."
When the LNG IUS was approved in the United States in 2000, its 2001 marketing launch began an era of heightened awareness about the device, says Kavanaugh. Researchers hypothesize that the large marketing emphasis has contributed to an overall increase in IUD use, as well as boosted use among younger populations.
Women like the IUD
New data from the Contraceptive Choice Project in St. Louis show that women who use intrauterine contraception have the highest rates of continuation and satisfaction at 12 months among women who chose oral contraceptives, contraceptive vaginal ring, transdermal contraceptive, intrauterine devices, contraceptive implant, and contraceptive injection.6 The project is designed to promote reversible long-term methods such as subdermal implants and intrauterine devices and to assess satisfaction and discontinuation rates with various contraceptive methods. In the study, 45% chose the levonorgestrel intrauterine system, 10% chose a copper IUD, and 13% chose the contraceptive implant. About 11% of participants chose oral contraceptive pills, 10% chose the vaginal ring, 8% chose the contraceptive injection, and 2% chose a transdermal patch.
The two IUDs had the highest 12-month continuation rates: 88% for the levonorgestrel intrauterine system and 84% for the Copper T380A, followed by the contraceptive implant at 83%. In comparison, oral contraceptive users recorded a 55% 12-month continuation rate.
Satisfaction mirrored continuation, researchers report. More than 80% of users were satisfied with the IUD, compared with 54% satisfied with oral contraceptives.6 "Given that long-acting reversible contraception methods have the highest contraceptive efficacy, these methods should be the first-line contraceptive methods offered to patients," the researchers conclude.
Many myths remain in the minds of clinicians when it comes to IUD use, says Jeffrey Peipert, MD, MPH, MHA, Robert J. Perry professor of obstetrics and gynecology and vice chair for clinical research at Washington University School of Medicine in St. Louis. Peipert is directing the Contraceptive Choice study.
Many clinicians continue to mistakenly believe that the IUD is inappropriate for young women and women who have not had children, Peipert says. A second myth revolves around concerns of infection; that risk is very low with current IUDs, Peipert states.7 Some clinicians still might harbor concerns about impaired future fertility with intrauterine contraception; again, research has shown its use to be safe in this respect, says Peipert.8
Training also has been a barrier, Peipert notes. Many clinicians trained in an era when IUDs were not commonly used and subsequently didn't learn to insert them. However, the push is on to train more clinicians. In 2011, the Office of Populations Affairs provided funding to the Kansas City, MO-based Clinical Training Center for Family Planning, in joint sponsorship with the Association of Reproductive Health Professionals (ARHP) in Washington, DC, for four intrauterine contraception trainings. The trainings were held in Portland; Kansas City, MO; Denver; and Baltimore. (ARHP plans a session on the ParaGard IUC at its 2011 Reproductive Health conference scheduled for Sept. 15-17. Visit the ARHP web page, www.arhp.org, and click on the 2011 Reproductive Health icon to obtain more information.)
Don't forget EC use
Clinicians need to remember another use of the Copper T380A IUD: as the first-line choice for emergency contraception, says Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at the Emory University School of Medicine in Atlanta.
When Hatcher began as a family planning clinician 45 years ago, 50% of all U.S. pregnancies were unintended, and that figure still stands today, Hatcher says. Long-acting reversible contraceptives (LARCs) such as the IUD offer the best hope for lowering that number, he states.
While many interventions might help increase use of long-acting contraceptive methods, Hatcher sees the insertion of a Copper T380A IUD as the most promising option. Provider use might be swinging that way. There are clinicians who have inserted over a hundred Copper T380A IUDs as emergency contraceptives, he states. In a recent study of women who had a Copper T380A inserted as an emergency contraceptive, no pregnancies were recorded in the 1,963 women who received the device.9
"Each clinician who is serious about increasing the use of LARC methods should move in the direction of recommending Copper T380A insertion as the method of choice for a woman who has had unprotected sex," says Hatcher.
Hatcher also recommends that insertion of IUDs be done immediately after first trimester abortions. This practice leads to higher continuation rates and lower pregnancy rates than delaying IUD insertion for 2-6 weeks post procedure. (Results of a just-published study will be discussed in detail in the next issue of Contraceptive Technology Update.)10
- Kavanaugh ML, Jerman J, Hubacher D, et al. Characteristics of women in the United States who use long-acting reversible contraceptive methods. Obstet Gynecol 2011; 117:1,349-1,357.
- Centers for Disease Control and Prevention (CDC). U S. medical eligibility criteria for contraceptive use, 2010. MMWR Recomm Rep 2010; 59(RR-4):1-86.
- American College of Obstetricians and Gynecologists. ACOG practice bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 59, January 2005. Intrauterine device. Obstet Gynecol 2005; 105:223-232.
- American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 392, December 2007. Intrauterine device and adolescents. Obstet Gynecol 2007; 110:1,493-1,495.
- Hubacher D, Finer LB, Espey E. Renewed interest in intrauterine contraception in the United States: evidence and explanation. Contraception 2011; 83:291-294.
- Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol 2011; 117:1,105-1,113.
- Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet 2000; 356:1,013-1,019.
- Hubacher D, Lara-Ricalde R, Taylor DJ, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. NEJM 2001; 345:561-567.
- Wu S, Godfrey EM, Wojdyla D, et al. Copper T380A intrauterine device for emergency contraception: a prospective, multicentre, cohort clinical trial. BJOG 2010; 117:1,205-1,210.
- Bednarek PH, Creinin MD, Reeves MF, et al; Post-Aspiration IUD Randomization (PAIR) Study Trial Group. Immediate versus delayed IUD insertion after uterine aspiration. NEJM 2011; 364:2,208-2,217.