1. IUDs: Dispelling the Myths Linda Prine MD Noa’a Shimoni MD Beth Israel Residency in Urban Family Practice

2. Learning Objectives Participants in this seminar will be able to: List the indications and contraindication to IUD use Describe the pros and cons of hormonal vs non-hormonal IUD use Explain the role of higher efficacy, non- user dependent, contraceptive methods like the IUD in the prevention of unintended pregnancy

3. Contraceptive Users in the United States 43 million women – Of childbearing age – Heterosexually active – Not wanting to be pregnant 93% of them use contraception 6 million pregnancies per year Mosher WD et al., Use of contraception and use of family planning services in the United States: 1982-2002, Advance Data from Vital and Health Statistics, No. 350. 2004. Guttmacher Institute. Contraception Counts: Ranking State Efforts. 2006 Series, No. 1.

4. Unintended Pregnancy (n=3 million) Half of pregnancies unintended – 25% method failure – 25% imperfect use – 50% no contraception Half of unintended pregnancies end in abortion – 1.3 million per year National Survey Family Growth, 1995 Finer LB, Henshaw SK. Abortion Incidence and Services in the United States in 2000. Perspectives on Sexual and Reproductive Health, 2003, 35(1):6-15.

5. Methods of Birth Control Guttmacher Institute. Contraceptive method choice among U.S. women who practice contraception, 2002.

6. Shani is a 21 year old G2P2 single mother who returns for her 6 week post-partum visit, telling you that she wants to get her tubes tied Case: Shani

7. What about an IUD for Shani? Lower discontinuation rates in post-partum women 6 weeks postpartum is a good time to insert –Increased expulsion from 2 days to 6 weeks postpartum Non-patient-dependent method enhances adherence Chi, IC, et al, Performance of the copper T-380A intrauterine device in breastfeeding women, Contraception 39(6):603-18. 1989 Grimes, D et al. Immediate postpartum insertion of intrauterine devices. Cochrane Review, 2005

8. Sterilization by Education If graduated college, 13% had BTL If some college, 29% had BTL If graduated HS, 42% had BTL If no HS graduation, 55% had BTL National Survey of Family Growth, 2004

9. Young Women and Sterilization 20% of women selecting sterilization at age 30 years or younger later express regret Hillis, SD, et al. (1999) Poststerilization Regret: Findings From the United States Collaborative Review of Sterilization. Obstet Gynecol. 93:889-895.

10. Charges for Contraception for 5 years Tubal Ligation $2611 Oral contraceptive $2579 3-month injectable $2195 IUD –Copper$1646 –Levonorgestrel$1678 Chiun-Fang, Trussel, et al (2003). “Economic analysis of contraceptives for women.” Contraception. 68(1): 3-10.

11. Copper IUD Levonorgestrel IUD ParaGuard™ Mirena™ Copper IUD Levonorgestrel IUD ParaGuard™ Mirena™

12. Which do you choose? Copper IUD (ParaGuard™): –No hormone –Menses continues –Long lasting: 10 years (12 off label) Levonorgestrel IUD (Mirena™): –Progestin treats menorrhagia, anemia –Causes amenorrhea –Shorter term: 5 years (7 off label) Sivin, I (1991). Prolonged intrauterine contraception: a seven-year randomized study of the levonorgestrel 20 mcg/day (LNg 20) and the Copper T380 Ag IUDS. Contraception. 44(5): 473-480. UNDP. Long-term reversible contraception: Twelve years of experience with the TCu380A and TCu220C. (1997) Contraception. 56(6): 341-352.

13. Mechanism of Action IUDs are NOT abortifacients!

14. Mechanism of Action: Copper IUD Copper-releasing IUD (ParaGuard™): 380 mm 2 copper exposed on plastic T base  Interferes with sperm motility Causes spermicidal foreign-body reaction Rivera, R. (1999). "The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices." American Journal of Obstetrics & Gynecology 181(5): 1263-1269

15. Mechanism of Action: Levonorgestrel IUD Hormone-releasing IUD (Mirena™): 52 mg of levonorgestrel on its arms and stem released at a rate of 20 mcg /d  Thickens cervical mucus (acting as a sperm barrier) Inhibits sperm capacitation and survival Thins uterine lining Partial inhibition of ovulation Barbosa, I. (1995) Ovarian function after seven years' use of a levonorgestrel IUD. Advances in Contraception. 11(2):85-95.

16. Maggie is a 35 year old G5P3 heavy smoker with a new partner who wants to have a child with her. She does not want to have more children and wants a method he won’t notice. Case: Maggie

17. Concerns with Maggie… and evidence for safety Age –No restriction for either IUD –WHO cautions with women <20 Consider expulsion risk and baseline STI risk Smoking: regardless of amount –No restriction for either IUD WHO. Medical eligibility criteria for contraceptive use - 3rd edition, 2004.

18. An IUD for Maggie Is discreet Patient and partner do not feel IUD body Although unlikely, partner may feel strings

19. WHO Categories of Safety 1 A condition for which there is no restriction for the use of the contraceptive method. Use method in any circumstances 2 A condition where the advantages of using the method generally outweigh the theoretical or proven risks. Generally use the method 3 A condition where the theoretical or proven risks usually outweigh the advantages of using the method. Use of method not usually recommended unless other more appropriate methods are not available or not acceptable 4 A condition which represents an unacceptable health risk if the contraceptive method is used. Method not to be used

20. W.H.O. Contraindications to IUD Use Pregnancy Puerperal sepsis Immediate use after septic abortion Distorted uterine cavity (fibroids, anatomy) Unexplained vaginal bleeding *** Cervical or endometrial cancer (awaiting treatment) *** Breast cancer (Progestin IUD only) Trophoblastic disease PID or STD (current or past 3 months) *** AIDS (not on antiretroviral therapy) Pelvic Tuberculosis *** Initiation is category 4, continuation is category 2

21. Case: Krystal Krystal is a 24 year old G2P1 who presents to the office requesting birth control. She had chlamydia twice as a teenager.

22. Sexually Transmitted infections and Pelvic Inflammatory Disease IUDs do not increase rates of STIs –STIs dependent on local prevalence –In high prevalence areas, reasonable to screen for STIs at IUD insertion –Do not remove IUD for STI treatment –No need for antibiotic prophylaxis at IUD insertion PID may be transiently higher for 20 days after IUD insertion, then back to baseline population levels –Even lower PID rates with good insertion technique and low baseline STI rate –Modern IUD strings do not facilitate ascent of infection –Do not remove IUD for PID treatment Farley, TM (1992). Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet. 339: 785-788. Grimes DA, et al (1999). Prophylactic antibiotics for intrauterine device insertion: a meta-analysis of the randomized controlled trials. Contraception. 60:57–63.

23. Sexually Transmitted infections Current or recent (past 3 months) STI is a contraindication to IUD insertion WHO. Medical eligibility criteria for contraceptive use - 3rd edition, 2004.

24. Kerry is a 19 year old who has had one abortion and who has type 1 diabetes. She is in a steady relationship and does not want to get pregnant. Case: Kerry

25. Medical Eligibility Levonorgestrel IUD does not alter glycemic control in patients with type 1 diabetes Copper IUD is approved for almost all medical conditions: cardiovascular disease, hypertension, migraines, smoking, lipid disorders, diabetes… Rogovskaya, S (2005). Effect of a levonorgestrel intrauterine system on women with type 1 diabetes: a randomized trial. Obstetrics and Gynecology. 105: 811-815. WHO. Medical eligibility criteria for contraceptive use - 3rd edition, 2004.

26. W.H.O. Contraindications Nulliparity is NOT a contraindication to IUD use! WHO. Medical eligibility criteria for contraceptive use - 3rd edition, 2004. Grimes, DA. “Intrauterine Devices”. Contraceptive Technology. NY: Ardent Media, 2004, pp. 495-530.

27. Tammy is a 24 y/o G8P3 with very heavy periods resulting in anemia, who is considering an IUD. She comes in today, LMP was 10 days ago. Case: Tammy

28. 1) Must IUDs be inserted during menses? 2) Can the IUD be used as emergency contraception? Questions about IUDs

29. Timing of IUD Insertion All IUDs can be inserted at any point in menstrual cycle Copper IUD can be used for emergency contraception within 5 days of unprotected sex-with nearly 100% efficacy Progestin IUD cannot be used for EC Fasoli M, Parazzini F, Cecchetti G, La Vecchia C. Post-coital contraception: an overview of published studies. Contraception 1989;39:459-468.

30. Progestin IUD - Medical Advantages Cramps & menorrhagia improve 90% decrease in overall blood loss Decreases number of invasive treatments for DUB, fibroids Decreases risk of ectopic pregnancy May protect against endometrial cancer Decreases perimenopausal symptoms Hubacher D, Grimes DA. Obstet Gynecol Surv. 2002;57(2):120-8. Crosignani PG, Vercellini P, Mosconi P, et al. Obstet Gynecol. 1997;90(2):257-63. Hurskainen R, Teperi J, Rissanen P, et al. Lancet. 2001;357:273-7. Varila E, Wahlstrom T, Rauramo I. Fertil Steril. 2001;76(5):969-73. Chiou CF, Trussell J, Reyes E, et al. Contraception. 2003;68(1):3-10.

31. Noncontraceptive Benefits of the Levonorgestrel IUD Treatment of menorrhagia, including in women with uterine fibroid tumors and adenomyosis Treatment of pain in women with endometriosis Alternative to hysterectomy for women with menorrhagia Prevention of endometrial hyperplasia in menopausal women using estrogen therapy Prevention of endometrial proliferation and polyps in breast cancer survivors taking tamoxifen Kaunitz, AM (2005). Beyond the pill: New data and options in hormonal and intrauterine contraception. Am J Obst Gyn 192(4):998-1004.

32. Progestin IUD - Side Effects Spotting, bleeding, and cramping: Increased in 1 st 3 months Amenorrhea: 20% of users by 1 yr, 60% by 5 yrs Expulsion: 2-12% in 1 st yr Perforation: <.01% at time of insertion Headaches, acne, mastalgia: < 3% in 1 st months Grimes, DA. “Intrauterine Devices”. Contraceptive Technology. NY: Ardent Media, 2004, pp. 495-530. Managing Contraception

33. Lifetime Number of Menstrual Cycles Adapted from Coutinho EM. Is Menstruation Obsolete? 1999. Number of Cycles 50 0 100 150 200 250 300 350 400 450 Prehistoric 160 Colonial America 450 Modern 500

34. IUD Myths Debunked IUDs DO NOT cause Abortion: –IUDs thicken cervical mucus, suppress endometrium; progestin IUD has some anovulatory effect IUDs DO NOT increase risk of PID: –IUD itself carries no risk of infection. Transient risk w/ insertion. Progestin IUD: may protect against PID, 5-year PID associated removal risk 0.8. Grimes, DA. “Intrauterine Devices”. Contraceptive Technology. NY: Ardent Media, 2004, pp. 495-530. Andersson, K. (1994). "Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: A randomized comparative trial." Contraception 49: 56-72.

35. More IUD Myths Debunked IUDs DO NOT increase risk of ectopic pregnancy IUDs DO NOT increase rates of breast cancer May insert at any point in the menstrual cycle

36. More IUD Myths Debunked Okay to use in nulliparous women No need for prophylactic antibiotics OK to do STI testing at time of insertion (& treat infections w/ IUD in place)

37. The future… Levonorgestrel IUDs Mirena Femilis Femilis slim

38. Gynefix

39. Summarizing IUDs Most economic reversible contraceptive method on market The most effective reversible method, comparable to tubal ligation –Failure rate 0.6-0.8% CuT, 0.1% LNG-IUS –Decreases ectopic risk High continuation rates: 78% (Cu), 81% (LNG) Common side effects: increased spotting and cramping initially, then decreased –Amenorrhea common with LNG-IUS STI rates unaffected by IUD PID only transiently higher for 20 days

40. Proactive Contraception Rules for success Encourage prompt initiation Use patient-centered counseling to enhance adherence Inform about high-efficacy methods - don’t limit IUDs unnecessarily Don’t let systems issues interfere Educate about all contraceptive options: if she qualifies, let her decide

41. References and Resources Hatcher et al, Contraceptive Technology 2004 Managing Contraception – book online @ www.managingcontraception.org Medical Eligibility Criteria for Contraceptive Use 2004 by WHO http://www.who.int/reproductive-health/publications/mec/iuds.html Association of Reproductive Health Professionals www.arhp.org Alan Guttmacher Institute www.agi-usa.org www.contraceptiononline.org Planned Parenthood www.plannedparenthood.org The Cochrane Collaboration www.cochrane.org www.Not-2-Late.com Reproductive Health Access Project www.reproductiveaccess.org