Editorial robert L. Barbieri, MD Editor in Chief FIrST OF 2 PArTS Let’s increase our use of IUDs and improve contraceptive effectiveness in this country The unintended pregnancy rate is too high in the United States, and the use of long-acting reversible contraceptives is too low. Expanding the patient population to which we prescribe intrauterine devices could help many women avoid unintended pregnancy. ost studies indicate that of depot medroxyprogesterone ac- The results of the study by Win- the three available long- etate (DMPA) is also highly effective. ner and colleagues, and other studies, M acting reversible contra- In a large cohort study, by Winner support the notion that we could im- ceptives (LARCs)— and colleagues, of 7,486 women who prove the effectiveness of our contra- • copper intrauterine device (IUD) were prescribed a reversible contra- ceptive interventions, and reduce the • levonorgestrel-releasing intrauter- ceptive, the contraceptive failure rate unplanned pregnancy rate, if we used ine system (LNG-IUS) among women using a contraceptive LARCs more often. In this editorial, I • etonogestrel-releasing implant pill, patch, or vaginal ring was 4.55 per focus on the expanding clinical indi- (Nexplanon) 100 woman-years.1 For women using cations for the use of the two available —are the most effective reversible an IUD or etonogestrel implant, the IUDs, the copper IUD (FIgUre 1) and contraceptive methods. The injection contraceptive failure rate was 0.27 per the LNG-IUS (FIgUre 2), and propose, 100 woman-years, and in women us- if you were asked to prescribe the ing DMPA, the contraceptive failure most effective reversible contraceptive Instant Poll rate was 0.22. After adjusting for dif- method in the three presented cases, ferences in age and education levels, what would you recommend? the investigators found that women In next month’s editorial, I will using the pill, patch, or vaginal ring focus on the expanding indica- were 21.8 times more likely to become tions for the use of the etonogestrel- What interesting cases or novel pregnant than women using an IUD or releasing implant and DMPA. applications of the IUD have etonogestrel implant. you discovered in your clinical As Drs. Rowen and Creinin note A common misperception is practice that you would like to in their “Update on Contraception” that the IUD should not be used share with the readers of on page 29 of this issue of OBG Man- routinely in nulliparous women OBG ManageMent? agement, approximately 49% of all pregnancies are reported to be unin- CASe 1 Tell us—at tended in the United States. A major A 30-year-old G0 woman was pre- [email protected]. contributing factor to this high rate of scribed a contraceptive estrogen- Please include your name and unintended pregnancy is that LARC progestin pill. Following a 14-hour city and state. methods are used at a low rate in the international airplane flight she devel- United States, compared with other oped a lower extremity deep venous developed countries. thrombosis (DVT). A thrombophilia obgmanagement.com Vol. 24 No. 8 | August 2012 | OBG Management 5 Editorial been very pleased with this method of FIgURE 1 Paragard® FIgURE 2 Mirena® Figure 1 title contraception. 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 faith- fully taking an estrogen-progestin contraceptive pill when she became pregnant. She wonders why her con- traception “did not work.” Owned by Teva Pharmaceuticals Published with the permission of Bayer Industries, Ltd. HealthCare Pharmaceuticals Inc. Would you place an IUD in this adolescent? evaluation revealed that she carried IUD could cause tubal infection and Arguments for IUD use in adoles- a factor V Leiden allele. She has just infertility, which could be a more cents. Among women younger than completed a 6-month course of warfa- devastating adverse effect of infec- age 21, contraceptive failure rates are rin and is requesting that you place an tion among nulliparous women than higher for OCs, the patch, and the LNG-IUS. among women who have had one or vaginal ring than they are for LARC Would you recommend an IUD in more children. Among women at av- methods.1 Adolescents contribute this nulliparous woman? erage risk for pelvic infection, there disproportionately to the high num- is a slight increase in the risk of pel- ber of unintended pregnancies in the evidence for IUD use in nullipa- vic infection in the first 20 days after United States. Clinically, it is not sur- rous women. Although IUDs are insertion. After this time, the risk of prising that a 16-year-old who was widely used in many developed pelvic infection among IUD users is prescribed an estrogen-progestin countries, they are only used in the same as that among nonusers.3 contraceptive became pregnant. about 6% of contracepting women Based on findings from a large ob- A committee opinion given by in the United States.2 Many factors servational study, investigators have the American Congress of Obstetri- contribute to their limited use in reported that chlamydial infection is cians and Gynecologists concluded this country, including beliefs about the most common cause of tubal in- that the use of an IUD by a sexually patient characteristics (nulliparity, fection and infertility, not the IUD.4 active adolescent does not increase adolescent age) that are relative con- Based on this study, my conclu- her risk of pelvic infection or infertil- traindications to use. Yet recent evi- sion is that IUDs do not cause tubal ity.5 Sexually active adolescents are dence strongly supports expanding damage and infertility, rather unde- at high risk for developing a chla- the number of patients eligible for tected and untreated chlamydial mydial infection, and diligence in IUDs. For instance, until relatively infections are the primary cause of screening and treating chlamydial recently, the FDA labeling for IUDs tubal damage and infertility.4 infections is important in this high- recommended limiting their use to risk group regardless of their contra- women who had at least one child. In CASe 1 Conclusion ceptive choice.6 2005, however, the FDA changed its Given this patient’s history of DVT Compared with women aged guidance and approved the copper while taking an estrogen-progestin 21 and older, adolescents may IUD for use in nulliparous women. I contraceptive, she is no longer eli- have more IUD expulsions or re- believe the same guidance should be gible to use the estrogen-progestin movals due to troubling bleeding used for the LNG-IUS. pill, patch, or vaginal ring. I placed an or pain.7,8 As noted by Drs. Braat- A theoretical concern is that an LNG-IUS in this woman and she has en and Goldberg in their article, 6 OBG Management | August 2012 | Vol. 24 No. 8 obgmanagement.com Editorial evidence for IUDs as emergency references 1. Winner B, Peipert JF, Zhao Q, et al. Effectiveness Contraindications to contraception. In the United States, of long-acting reversible contraception. N Engl J available emergency contraceptives Med. 2012;366(21):1998–2007. IUD placement 2. Mosher WD, Jones J. Use of contraception in the include the copper IUD, ulipristal, United States: 1982-2008. Vital Health Stat 23. These clinical situations preclude any and levonorgestrel and estrogen− 2010;23(29):1–44. IUD insertion, most experts agree: 3. Farley TM, Rosenberg MJ, Rowe PJ, Chen JH, progestin contraceptives. Many au- Meirik O. Intrauterine devices and pelvic inflam- • Active pelvic infection thorities believe that, around the matory disease: an international perspective. • Known or suspected pregnancy Lancet. 1992;339(8796):785–788. time of ovulation, the copper IUD is • Uterine bleeding that has not been 4. Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra- the most effective emergency con- Infante F, Guzman-Rodriguez R. Use of copper evaluated or diagnosed 9 intrauterine devices and the risk of tubal infer- • Severe distortion of the uterus, traceptive. The copper IUD can be tility among nulligravid women. N Engl J Med. including severe fibroid disease or placed up to 5 days after unprotected 2001;345(8):561–567. certain Müllerian anomalies 5. Committee on Adolescent Health Care. intercourse. For this young woman ACOG Committee Opinion No. 392. Intrauter- who has used condoms as her con- ine device and adolescents. Obstet Gynecol. Contraindications to the copper IUD: traception, placement of a cop- 2007;110(6):1493–1495. • Wilson’s disease 6. Miller WC, Ford CA, Morris M, et al. Preva- • Copper allergy per IUD would be both an effective lence of chlamydia and gonococcal infections emergency contraceptive and pro- among young adults in the United States. JAMA. Contraindication to the LNG-IUS: 2004;291(18):2229–2236. vide up to 10 years of contraception. 7. Zhang J, Feldblum PJ, Chi IC, Farr MG. Risk fac- • Current breast cancer tors for copper I IUD expulsion: an epidemiologic analysis. Contraception. 1992;46(5):427–433. CASe 3 Conclusion 8. Diaz J, Pinto Neto AM, Bahamondes L, Diaz M, “Malpositioned IUDs: When you The woman was counseled about Espejo Arce X, Castro S. Performance of the copper T 200 in parous adolescents: are copper should intervene (and when you emergency contraceptive options, IUDs suitable for these women? Contraception. should not),” on page 38 of this is- and she selected the copper IUD. She 1993;48(1):23–28. 9. Glasier A, Cameron ST, Blithe D, et al. Can we sue, for a woman with an IUD and expressed that she had expected to identify women at risk of pregnancy despite using pelvic pain, performing a physical receive a pill and that she did not real- emergency contraception? Data from random- ized trials of ulipristal acetate and levonorgestrel.