1. Educating Women About IUDs: Dispelling the Myths Linda Prine MD & Elaine Kang MD, Beth Israel Residency in Urban Family Practice, New York, NY IUDs can be an excellent option for nulliparous women. Though IUDs do have a slightly higher expulsion rate in nullips, risk of expulsion declines over time. Recent studies suggest that young nulliparous women continue IUD use at a greater rate than oral contraceptives. Evidence: Brockmeyer 2008, Nelson 2008, Prager 2007, Hubacher 2007, ACOG 2007, WHO 2004, Doll 2001, I heard you can only get an IUD if you’ve already had children. Isn’t it true that an IUD will increase my risk for STIs? And for PID? I want to have kids in the future. I heard the IUD causes sterility, is this true? I had an abnormal Pap smear last month. Can I still get the IUD? Studies show that there is a quick return to ovulation and fertility after IUD removal. Infertility is related to rates of infection caused by bacteria, not by IUDs. Evidence: Hubacher 2001, Doll 2001, Andersson 1992 Half of pregnancies in the United States are unintended. Women need more effective contraceptive methods and counseling, which family physicians can and should provide. Currently available copper and levonorgestrel intrauterine devices (IUDs) are among the safest and most effective contraceptives. Yet many patients (and physicians) are reluctant to use them because of longstanding myths about the risks. Recent research has debunked virtually all of the major concerns about IUDs. There is no direct evidence to oppose IUD insertion in a patient with an abnormal pap smear that is not cervical cancer. Clinical judgment should be used in these cases. According to WHO eligibility criteria, in the setting of CIN, both the copper and levonorgestrel IUD can be inserted and continued. Colposcopy can be performed with the IUD in place, though it may have to be removed if an excisional procedure is necessary. Evidence: WHO 2004 PID requires exposure to gonorrhea and chlamydia, and rates are equivalent among women with and without IUDs. IUD use alone is not associated with an increased risk of STI or PID. Over the life of an IUD, women are not predisposed to PID. For the first 20 days after IUD insertion, the risk of PID is elevated because of the insertion procedure itself. For this reason, the WHO recommends against IUDs for women who have had an STI in the previous 3 months. As an additional precaution, many providers screen for Gonorrhea and Chlamydia at the time of IUD insertion. The levonorgestrel IUD may actually decrease the risk of PID, by thickening cervical mucous. IUDs will not protect you from STIs, so you should always use condoms. If you develop an STI with the IUD in place, you can be treated without removing the IUD. Evidence: Mohllajee 2006, Steen 2004, Grimes 2000, Toivonen 1991 Yes, if your urine pregnancy test is negative today and you had unprotected sex less than 5 days ago, you can have the copper IUD placed today. The copper IUD is the most effective post-coital contraceptive. Evidence: Managing Contraception, 19th ed., WHO 2004 Will it make me bleed a lot? While bleeding and spotting may increase in the first few months following insertion, it generally decreases with long-term use. The levonorgestrel IUD actually decreases the frequency and length of menses, with 60% of all women becoming ammenorrheic by 5 years. In some women, the copper IUD may cause heavier periods and menstrual cramping. Taking ibuprofen or naproxen often helps. Evidence: Hidalgo 2002, Hubacher 2002 In 2007 the American College of Obstetricians and Gynecologists concluded that IUDs are appropriate for adolescents. Women of all ages can use IUDs. IUDs are a great method for teenagers because they allow women to finish high school and college, without an unintended pregnancy during a time when they may not have health insurance to buy their contraceptives. Studies have also shown higher continuation rates with contraceptive methods that are not user dependent, such as the IUD. Evidence: ACOG 2007, Tolymat 2007, Toma 2006, Chiun-Fang 2003 Background My last period was about a month ago and I had unprotected sex 3 days ago, can I get the IUD today? Copper-T IUD Levonorgestrel IUS IUDs are appropriate for young and nulliparous women IUDs do not increase women’s risk of contracting STIs or PID IUDs do not cause infertility. This poster should help providers respond to patients with concerns about IUDs. A 2005 ACOG Practice Bulletin provides a comprehensive review of these issues and more. I’m only 17. Can I still get the IUD? References ACOG Practice Bulletin. (2005). Intrauterine Device. No. 59: 2230232. ACOG Committee Opinion. (2007). Intrauterine device and adolescents. Obstetrics and Gynecology 2007; 110(6):1493-1495 Andersson, K., I. Batar, et al. (1992). "Return to fertility after removal of a levonorgestrel-releasing intrauterine device and Nova-T." Contraception 46(6): 575-84. Brockmeyer A, Kishen M, Webb A. (2008) Experience of IUD/IUS insertions and clinical performance in nulliparous women-a pilot study.Eur J Contracept Reprod Health Care. 2008 Sep;13(3):248-54. Chiun-Fang, C. (2003). "Economic analysis of contraceptives for women." Contraception 68(1): 3-10. Doll H, Vessey M, Painter R. (2001)”Return of fertility in nulliparous women after discontinuation of the intrauterine device: comparison with women discontinuing other methods of contraception.” BJOG 108(3):304-14. Hidalgo, M., L. Bahamondes, et al. (2002). "Bleeding patterns and clinical performance of the levonorgestrel-releasing intrauterine system (Mirena) up to two years." Contraception 65(2): 129-132. Hubacher, D. (2001). "Use of Copper Intrauterine Devices and the Risk of Tubal Infertility among Nulligravid Women." NEJM 345(8): 561-567. Hubacher, D. (2002). "Noncontraceptive Health Benefits of Intrauterine Devices: A Systematic Review." Obstetrical and Gynecological Survey 57(2): 120-128. Hubacher D. (2007) Copper intrauterine device use by nulliparous women: review of side effects. Contraception 75: S8-S11 Mohllajee AP, Curtis KM, Peterson HB. (2006). Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review. Contraception 73: 145-53. Nelson AL, Westhoff C, Schnare SM (2008). Real-world patterns of prescription refills for branded hormonal contraceptives: a reflection of contraceptive discontinuation. Obstet Gynecol. Oct;112(4):782-7. Prager S, Darney PD. (2007). The levonorgestrel IUS in nulliparous women. Contraception 75:S12-S15 Steen R, Shapiro K. (2004)”Intrauterine contraceptive devices and risk of pelvic inflammatory disease: standard of care in high STI prevalence settings.” Reprod Health Matters 12(23):136-43. Tolymat LL, Kaunitz AM. (2007). Long-acting contraceptives in adolescents. Curr Opin Obstet Gynecol. 19(5): 453-460. Toma A, Jamieson MA. (2006)”Revisiting the intrauterine contraceptive device in adolescents.” J Pediatr Adolesc Gynecol 19(4):291-6. ToivonenJ. Luukkainen T, Allonen H. (1991) “Protective effect of intrauterine release of levonorgestrel on pelvic infection:three years’ comparative experience of levonorgestrel- and copper-releasing intrauterine devices.” Obstet Gynecol 77(2):261-4. World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use. Third Edition. Geneva: World Health Organization, 2004. Available at www.who/int/reproductivehealth/publications/mec/mec.pdf