Let’s increase our use of IUDs and improve contraceptive effectiveness in this country

OCs, the patch, and the ring fail more often among adolescents than among women aged 21 and older

CASE 2

A 16-year-old G1P0 female adolescent had a therapeutic abortion 4 weeks ago. She reports that she was faithfully taking an estrogen-progestin contraceptive pill when she became pregnant. She wonders why her contraception “did not work.”

Would you place an IUD in this adolescent?

Arguments for IUD use in adolescents. Among women younger than age 21, contraceptive failure rates are higher for OCs, the patch, and the vaginal ring than they are for LARC methods.¹ Adolescents contribute disproportionately to the high number of unintended pregnancies in the United States. Clinically, it is not surprising that a 16-year-old who was prescribed an estrogen-progestin contraceptive became pregnant.

A committee opinion given by the American Congress of Obstetricians and Gynecologists concluded that the use of an IUD by a sexually active adolescent does not increase her risk of pelvic infection or infertility.⁵ Sexually active adolescents are at high risk for developing a chlamydial infection, and diligence in screening and treating chlamydial infections is important in this high-risk group regardless of their contraceptive choice.⁶

Compared with women aged 21 and older, adolescents may have more IUD expulsions or removals due to troubling bleeding or pain.^7,8 As noted by Drs. Braaten and Goldberg in their article, “Malpositioned IUDs: When you should intervene (and when you should not),” on page 38 of this issue, for a woman with an IUD and pelvic pain, performing a physical examination, testing for sexually transmitted disease, and using ultrasonography to identify the IUD’s position may help you develop an effective plan for resolving the patient’s symptoms.

CASE 2: Conclusion

The patient agreed that an IUD was an excellent contraceptive for her. She has not become pregnant since the IUD was placed approximately 18 months ago.

Copper IUDs can serve a dual purpose

CASE 3

A 21-year-old G1P1 woman calls your office at 8 AM on Monday morning and reports that on Saturday night she had sexual relations and the condom broke. She thinks she is at midcycle and asks for your advice about her emergency contraception options.

Would you place a copper IUD in this woman?

Evidence for IUDs as emergency contraception. In the United States, available emergency contraceptives include the copper IUD, ulipristal, and levonorgestrel and estrogen-progestin contraceptives. Many authorities believe that, around the time of ovulation, the copper IUD is the most effective emergency contraceptive.⁹ The copper IUD can be placed up to 5 days after unprotected intercourse. For this young woman who has used condoms as her contraception, placement of a copper IUD would be both an effective emergency contraceptive and provide up to 10 years of contraception.

CASE 3: Conclusion

The woman was counseled about emergency contraceptive options, and she selected the copper IUD. She expressed that she had expected to receive a pill and that she did not realize IUD placement was an option. She came to the office later in the day for an expedited single-visit that included pregnancy and chlamydia testing and copper IUD placement.

As ObGyns, let’s lead the way

Increasing the use of LARC contraceptive methods is likely to result in a significant improvement in the reproductive health of women. Internists, pediatricians, and family medicine specialists have other priorities and are not likely to lead the effort of increasing LARC use in the United States. That task will be borne by the few, the proud, the ObGyns.