Making a Dent in Teen Pregnancy Rates

Abstract & Commentary

By Alison Edelman, MD, MPH, Associate Professor, Assistant Director of the Family Planning Fellowship, Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, is Associate Editor for OB/GYN Clinical Alert.

Dr. Edelman reports no financial relationship to this field of study.

Synopsis: Intrauterine devices appear safe in teenagers and provide highly effective reversible contraception for a group that often faces challenges with medication adherence.

Source: Godfrey E, et al. Intrauterine contraception for adolescents aged 14-18 years. Contraception 2010;81:123-127.

This is a small U.S.-based clinical trial of 23 adolescent women (ages 14-18) randomized to levonorgestrel-releasing vs Copper T intrauterine device (IUD). Teens were followed for a total of 6 months and the main outcomes included method continuation, adverse events, side effects, and satisfaction. Continuation rates were higher at 6 months for teens using the levonorgestrel-releasing IUD (75% vs 45%), but sample sizes were too small to demonstrate a significant difference. Two Copper T users experienced partial expulsions. The most frequently reported side effects in both groups were bleeding and pain. The majority of subjects reported they were "happy" or "very happy" with their IUD.

Commentary

Teens have sex, high fecundity, and often inconsistent use of less effective forms of contraception6 — yet we are surprised when they become pregnant "unexpectedly." Some may even scold teens for their irresponsible behavior, but how can we expect teens to be consistent contraceptive users when many adults cannot comply with a daily medication?2 This group is screaming out for a "forgettable"3 contraceptive method, or one that does not rely on compliance. However, many providers restrict the use of these methods in teenagers.

What is this restriction based on? Adolescents and nulliparity are not listed as contraindications or precautions in the package inserts for either the levonorgestrel-releasing or the Copper T380A IUD.4,5 In fact, the Copper T380A even states that "safety and efficacy have been established in women over 16 years old."5

Are there any technical issues involved with IUD insertion in adolescents? These are the most common concerns that I have heard:

  • The uterus is too small:An IUD study of approximately 200 young women revealed a median uterine sound depth of 7 mm which is more than adequate to place an IUD.6
  • The os looks too small to place an IUD: There is no evidence that appearance of the os correlates with IUD insertion difficulty.
  • Teens won't tolerate the insertion: Teens seem "no pain," 65% "mild to moderate," and 21% "severe" pain.6,7
  • IUDs cause PID: There is extensive published literature showing that PID rates are similar in non-users and users of IUDs.8

Is there any evidence to support IUD use in teens? Yes, and although there are fewer studies than we have for adult IUD users, the evidence is consistently positive,6,9 echoing the results of Godfrey et al. Expulsion rates may be slightly higher, but it is unknown if this is related to age, nulliparity, or both. However, the contraceptive continuation rate of 73%-85% is almost twice that of contraceptive pills or injections, thus offsetting the expulsion rate. This recent study by Godfrey et al also demonstrates a positive experience for teen users of IUDs. With the U.S. teen pregnancy rate increasing for the first time in the last decade,10 we need to expand the type of highly effective contraceptive options offered to teens, like the IUD.

References

  1. Abma JC, et al. Teenagers in the United States: Sexual activity, contraceptive use, and childbearing, 2002. Vital Health Stat 2004;(24):1-48.
  2. Potter L, Oakley D. Measuring compliance among oral contraceptive users. Fam Plann Perspect 1996;28:154-158.
  3. Grimes DA. Forgettable contraception. Contraception 2009;80:497-499.
  4. Mirena® Package Insert. Available at: http://berlex.bayerhealthcare.com/html/products/pi/Mirena_PI.pdf. Accessed April 28, 2010.
  5. Paragard® Package Insert. Available at: www.paragard.com/health_care_professional/global/pdf/Prescribing-Info.pdf. Accessed April 28, 2010.
  6. Suhonen S, 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.
  7. Allen RH, et al. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev 2009;(3):CD007373.
  8. Hubacher D, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345:561-567.
  9. Paterson H, et al. A nationwide cohort study of the use of the levonorgestrel intrauterine device in New Zealand adolescents. Contraception 2009;79:433-438.
  10. Kost K, et al. U.S. Teenage Pregnancies, Births and Abortions: National and State Trends and Trends by Race and Ethnicity. New York, NY: Guttmacher Institute; January 2010. Available at: www.guttmacher.com/pubs/USTPtrends.pdf. Accessed April 28, 2010.