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Contraception Corner

Underuse of Intrauterine Contraception in the United States

Barbara Clark, RN, MSN, MPH; Raquel D. Arias, MD

Challenging myths about intrauterine contraception and increasing awareness of evidence-based eligibility can give more women access to this underused form of birth control.

In the United States, women have two options for intrauterine contraception (IUC)—the levonorgestrel-releasing intrauterine system (LNG-IUS) and the copper-bearing intrauterine device (IUD). Both are highly effective, safe, and reversible. However, this contraceptive method is vastly underused in the United States: Only 2.1% of US women use IUC.1 Many women and health care providers have misconceptions about IUC, such as the belief that it causes pelvic inflammatory disease (PID), and it is contraindicated in nulliparous women.2

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CURRENT INTRAUTERINE CONTRACEPTION

The LNG-IUS releases 20 mcg/d of levonorgestrel directly into the uterine cavity, whereas the copper-bearing IUD releases copperions. Each provides long-term protection—the LNG-IUS and copper-bearing IUD for at least 5 and 10 years, respectively. Neither device protects against sexually transmitted infections, but both are associated with a lower risk of endometrial cancer.4 These devices differ in their effect on menstrual flow: The LNG-IUS can decrease menstrual bleeding and dysmenorrhea, while the copper-bearing IUD can increase menstrual flow and cramping.3,4 Like other hormonal contraceptives, the LNG-IUS is associated with changes in menstrual bleeding, especially for the first few months. Adverse events such as migraine, acne, weight gain, edema, and nausea have been reported.4 Rare yet serious side effects include spontaneous expulsion, infection, and uterine perforation.

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BARRIERS TO USE

Intrauterine contraception is underused in the United States because both female patients and health care providers have misconceptions about its safety and efficacy, and lack knowledge about the evidence regarding its appropriate use (Table 1). For example, many believe that IUC devices are abortifacients, cause ectopic pregnancies and pelvic infections, and decrease future fertility.2 Many of these beliefs originate from the early 1970s, when the Dalkon Shield IUD was associated with complications such as septic miscarriage and PID. Other beliefs arise from restrictive product labeling and lack of information regarding the evidence-based criteria for selecting IUC candidates.2,5

Table 1. Reasons for Underuse of Intrauterine Contraception Womenês lack of awareness about safety and efficacy Health care provider and public misconceptions Health care provider concerns about litigation Restrictions imposed by product labeling

Recent surveys support the need to educate women and health care providers about IUC. For instance, of 190 women aged 14 to 25 years presenting for prenatal or abortion care, only 50% had heard of IUC, 71% were unaware of its safety, and 58% did not know of its efficacy.6 A survey of more than 400 OB/GYNs found that 20% had not inserted an IUC device in the past year. Of those, 79% said they had inserted 10 or fewer.2 Physicians who feared litigation and believed that IUC causes PID were least likely to insert an IUC device. Furthermore, OB/GYNs who used less restrictive, more evidence-based criteria for selecting IUC candidates (eg, nulliparous and nonmonogamous women) inserted more IUC devices. Until recently, product labeling did not recommend that nulliparous women use IUC.

Another area requiring patient and provider education is the noncontraceptive health benefits of IUC. According to a 2002 review, many women and health care providers were unaware of these benefits (Table 1).3

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IMPROVING ACCESS

Physicians have been reluctant to provide IUC to women who are nulliparous or breast-feeding, even though evidence shows that IUC is safe and effective in these groups (Table 2).7 The World Health Organization (WHO) provides medical eligibility criteria for IUC. For example, according to WHO, the advantages of IUC outweigh the theoretical or proven risks in nulliparous women, and recent, well-conducted studies suggest no increased risk.

To improve IUC access, physicians should be knowledgeable about the WHO criteria and other evidence regarding the appropriate use of IUC.7 Simplified product labeling and updated practice guidelines could help to advance such knowledge.5 More information about IUC is available at the US Agency for International Developmentês –IUD Toolkit” Web site (http://www.iudtoolkit.org).

Women should be counseled about IUC as a contraceptive choice. Counseling topics include efficacy, how each device works, possible changes in menstrual flow, how the devices are inserted and removed, potential side effects and complications, and noncontraceptive benefits (Table 2).

Table 2. Appropriate Candidates for Intrauterine Contraception Nulliparous women Women with previous ectopic pregnancies Women receiving treatment for pelvic inflammatory disease Lactating women Women testing positive for human immunodeficiency virus omen immediately postpartum or postabortion

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CONCLUSION

Correcting misunderstandings about IUC is necessary to increase women’s access to this safe, effective, and easily reversible method of contraception. Educational programs about the appropriate use of IUC could dispel misconceptions held by physicians, who in turn can counsel women about the advantages and disadvantages of using IUC.

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Barbara Clark, RN, MSN, MPH, is a freelance writer in Arlington, Va; and Raquel D. Arias, MD, is associate dean for women and associate professor of obstetrics and gynecology, Keck School of Medicine, University of Southern California, Los Angeles.

References

1. Mosher WD, Martinez G, Chandra A, Abma J, Willson S. Use of Contraception and Use of Family Planning Services in the United States, 1982-2002: A Fact Sheet for Advance Data No. 350. Hyattsville, MD: National Center for Health Statistics; 2004.
   Available at: http://0-www.cdc.gov.mill1.sjlibrary.org/nchs/data/ad/ad350FactSheet.pdf. Accessed March 26, 2007.
2. Stanwood NL, Garrett JM, Konrad TR. Obstetrician-gynecologists and the intrauterine device: a survey of attitudes and practice. Obstet Gynecol. 2002;99(2):275-280.
3. Hubacher D, Grimes DA. Noncontraceptive health benefits of intrauterine devices: a systematic review. Obstet Gynecol Surv. 2002;57(2):120-128.
4. Varma R, Sinha D, Gupta JK. Non-contraceptive uses of levonorgestrel-releasing hormone system (LNG-IUS)—A systematic enquiry and overview. Eur J Obstet Gynecol Reprod Biol. 2006;125(1):9-28.
5. Grossman D, Ellertson C, Abuabara K, Blanchard K, Rivas FT. Barriers to contraceptive use in product labeling and practice guidelines. Am J Public Health. 2006;96(5):791-799.
6. Stanwood NL, Bradley KA. Young pregnant womenês knowledge of modern intrauterine devices. Obstet Gynecol. 2006;108(6):1417-1422.
7. World Health Organization. Medical Eligibility Criteria for Contraceptive Use. 3rd ed. Geneva, Switzerland: World Health Organization; 2004.
   Available at: http://www.who.int/reproductive-health/publications/mec/index.htm. Accessed March 26, 2007.

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