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Update your practice when it comes to IUDs
What is your approach when it comes to discussing intrauterine contraception? It may be time to update your practice, based on information presented at the recent clinical meeting of the Washington, DC-based American College of Obstetricians and Gynecologists (ACOG) and newly published research.1
Consider this fact: In the 1970s, about 10% of U.S. women used intrauterine contraception; today, less than 1% do.2 More than 25 years have passed since the era of the Dalkon Shield, an intrauterine contraceptive whose manufacture was halted in the mid-1980s due to product liability issues. However, new information on intrauterine devices (IUDs) has been slow to disseminate, says Lee Shulman, MD, Northwestern Memorial Hospital distinguished physician and professor in the department of obstetrics and gynecology at the Feinberg School of Medicine, Northwestern University, both in Chicago.
This trend is about to change, though: The Washington, DC-based Association of Reproductive Health Professionals (ARHP) has organized a visiting faculty program on intrauterine contraception to update providers on the method. Shulman presented information on the Copper T IUD (ParaGard IUD, FEI Women’s Health, North Tonawanda, NY) at the ACOG meeting as part of the ARHP program. (See the resource box below for information on the ARHP program.)
Women in the United States have two choices when it comes to intrauterine contraception: the ParaGard and the levonorgestrel intrauterine system (IUS), marketed as Mirena by Berlex Laboratories, Montville, NJ. (See resource box below for contact information for both devices.) The ParaGard is approved in the United States for 10 years of effectiveness. The Mirena is approved for five years.2
The Copper T IUD is safe and effective for the vast majority of women, says Shulman. A 2001 case control study helps to refute the myths that IUDs cause pelvic inflammatory infection, increase ectopic pregnancy and infertility, and are inappropriate for young or never-pregnant women, he notes.3
More than half of unintended pregnancies in the United States are a result of contraceptive failure or misuse4; such statistics could be lowered with use of the IUD, says Shulman. While U.S. providers tend to place IUDs in multiparous women, the experience with IUDs in other countries continue to show that intrauterine contraception is well accepted by many women, he notes. In a comparative study of five European countries (Italy, Spain, Poland, Germany, and Denmark), the IUD accounted for 9%-24% of all contraceptive use.5 Shulman says he has nulliparous patients who have successfully used intrauterine contraception.
"I think it is important that we need to understand not only the IUD, but our patients, and try to get the patient to use the method she is likely to use consistently and correctly," he says.
Check new research
Just-published research on the levonorgestrel IUS indicates the device is safe and effective when used by nulliparous women.1 In the study, 200 nulliparous women were randomized to use the IUS or a monophasic oral contraceptive (OC). Twelve-month continuation rates were higher in the IUS group (80% vs. 73%). The most common reason for discontinuation in the IUS group was pain, while hormonal side effects were the predominant medical reason named by pill users. About 20% of IUS users had become amenorrheic, compared to 1% of pill users.
While no pregnancies were noted in the study, the typical-use annual failure rate for pill users is approximately 8%, compared to lower than 1% for IUD users,6,7 notes Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/Jacksonville. While many clinicians think that IUDs are not appropriate for nulliparous women, the new findings indicate that the IUS is a safe and effective option for those nulliparous women who prefer the convenience of the IUS or menstrual-suppression effect, he states.
1. Suhonen S, Haukkamaa M, Jakobsson T, et al. Clinical performance of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: A comparative study. Contraception 2004; 69:407-412.
2. Hubacher D. The checkered history and bright future of intrauterine contraception in the United States. Perspect Sex Reprod Health 2002; 34:98-103.
3. 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.
4. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect, 1998; 30:24-29, 46.
5. Spinelli A, Talamanca IF, Lauria L. Patterns of contraceptive use in 5 European countries. Am J Public Health 2000; 90:1,403-1,408.
6. Fu H, Darroch JE, Haas T, et al. Contraceptive failure rates: New estimates from the 1995 National Survey of Family Growth. Fam Plann Perspect 1999; 31:56-63.
7. New estimates of contraceptive failure rates. Contraception Report 1999; 10:10-11, 14.