Correlates of use of long-acting reversible methods of contraception among adolescent and young adult women

Background

Most pregnancies among adolescent and young adult women are unintended, and adolescent birth rates have risen. Use of long-acting reversible contraception may be an effective strategy to reduce the rate of unintended pregnancy.

Study Design

We conducted a secondary data analysis of nationally representative, cross-sectional data from the 2002 National Survey of Family Growth. Our sample included 1722 sexually active women aged 15-24 years. We used multivariable logistic regression to identify correlates of ever-use of depot-medroxyprogesterone acetate (DMPA) or the intrauterine device (IUD).

Results

One-quarter of our sample had ever used DMPA, and less than 2% had ever used the IUD. In multivariable analysis, increasing parity was associated with ever-use of DMPA (OR 2.07, 95% CI 1.55-2.77) and ever-use of the IUD (OR 4.57, 95% CI 1.60-13.03), but age and measures of socioeconomic status were not. Having ever been married (OR 5.54, 95% CI 1.23-24.82) and current cohabitation (OR 4.89, 95% CI 1.10-21.71) were associated with ever-use of the IUD. A history of an adolescent pregnancy was associated with ever-use of DMPA (OR 1.79, 95% CI 1.19-2.70) but not of the IUD.

Conclusions

While similarities exist between the correlates of use of DMPA and the IUD, we discovered important differences, some of which may reflect provider biases regarding IUD provision.     

Emergency contraception with a copper IUD or oral levonorgestrel: an observational study of 1-year pregnancy rates

Objective

We investigated the 1-year pregnancy rates for emergency contraception (EC) users who selected the copper T380 intrauterine device (IUD) or oral levonorgestrel (LNG) for EC.

Study Design

This prospective study followed women for 1 year after choosing either the copper T380 IUD or oral LNG for EC. The study was powered to detect a 6% difference in pregnancy rates within the year after presenting for EC.

Results

Of the 542 women who presented for EC, agreed to participate in the trial and met the inclusion criteria, 215 (40%) chose the copper IUD and 327 (60%) chose oral LNG. In the IUD group, 127 (59%) were nulligravid. IUD insertion failed in 42 women (19%). The 1-year follow-up rate was 443/542 (82%); 64% of IUD users contacted at 1 year still had their IUDs in place. The 1-year cumulative pregnancy rate in women choosing the IUD was 6.5% vs. 12.2% in those choosing oral LNG [hazard ratio (HR) 0.53, 95% confidence interval (CI): 0.29–0.97, p=.041]. By type of EC method actually received, corresponding values were 5.2% for copper IUD users vs. 12.3% for oral LNG users (HR 0.42, 95% CI: 0.20–0.85, p=.017). A multivariable logistic regression model controlling for demographic variables demonstrates that women who chose the IUD for EC had fewer pregnancies in the following year than those who chose oral LNG (HR 0.50, 95% CI: 0.26–0.96, p=.037).

Conclusion

One year after presenting for EC, women choosing the copper IUD for EC were half as likely to have a pregnancy compared to those choosing oral LNG.

Implications

Compared to EC users who choose oral levonorgestrel, those who select the copper IUD have lower rates of pregnancy in the next year. Greater use of the copper IUD for EC may lower rates of unintended pregnancy in high-risk women.     

Copper-containing, framed intrauterine devices for contraception: a systematic review of randomized controlled trials

BACKGROUND: Intrauterine devices (IUDs) are safe and effective methods of long-term reversible contraception. The design and copper content as well as placement of the copper on IUDs could affect their effectiveness and side effect profile. We compared different copper IUDs for their effectiveness and side effects. STUDY DESIGN: We searched multiple electronic databases with appropriate keywords and names of the IUDs known to be on the market. We searched the reference lists of papers identified and contacted authors when possible. There was no language restriction. Randomized controlled trials comparing different IUDs that reported on clinical outcomes were considered for inclusion. Two reviewers independently extracted data on outcomes and trial characteristics. We combined the trial results in meta-analyses and expressed results as rate difference (RD) using a fixed-effects model with 95% confidence interval (CI). In the presence of significant heterogeneity, a random-effects model was applied. RESULTS: We included 35 trials, resulting in 18 comparisons of 10 different IUDs in approximately 48,000 women. TCu380A was more effective in preventing pregnancy than MLCu375 (RD 1.70%, 95% CI 0.07-2.95% after 4 years of use). TCu380A was also more effective than MLCu250, TCu220 and TCu200. There tended to be fewer pregnancies with TCu380S compared to TCu380A after the first year of use, a difference which was statistically significant in the fourth year (RD -1.62%, 95% CI -3.00% to -0.24%). This occurred despite more expulsions with TCu380S (RD 3.50%, 95% CI 0.36-6.63% at 4 years). MLCu375 was no more effective than TCu220 at 1 year of use, or MLCu250 and NovaT up to 3 years. Compared to TCu380A or TCu380S, none of the IUDs showed any benefits in terms of bleeding or pain or any of the other reasons for early discontinuation. None of the trials that reported events at insertion found one IUD easier to insert than another or caused less pain at insertion. There is no evidence that uterine perforation rates vary by type of device. There are minimal randomized data on IUD use in nulliparous women. CONCLUSIONS: TCu380A and TCu380S appear to be more effective than other IUDs. No IUD showed consistently lower removal rates for bleeding and pain in comparison to other IUDs. There is no evidence that any particular framed copper device is better suited to women who have not had children.     

Temporal and regional trends in IUD insertion: a population-based study in Ontario, Canada

Background

Intrauterine device (IUD) use is low in Canada and declined between 1985 and 1995. This study examines temporal and regional trends in IUD insertion in Ontario, Canada, from 1996 to 2006.

Study Design

We used physician billing data to determine annual age-adjusted IUD insertion rates for women aged 15-55 years and proportions inserted by gynecologists and family physicians (FPs). We used small area variation statistics to analyze variation in rates across the province.

Results

Annual insertion rates followed a U-shaped distribution and were lowest in 2001 and highest in 2006. From 1996 to 2006, the proportion inserted by FPs fell from 38.2% to 31.6% (p<.001). In 2006, women in regions with the highest rates were twice as likely to have an IUD inserted as those in the lowest-rate regions.

Conclusions

IUD insertion rates began to increase in 2001, the year of introduction of the levonorgestrel-releasing intrauterine system. Regional variation in rates suggests that access is not equal across the province and that strategies to support FPs to insert IUDs may be important to ensure adequate access.     

Comparison of two procedures for routine IUD exchange in women with positive Pap smears for actinomyces-like organisms

Background

In the female genital tract, up to 30% of Papanicolaou (Pap)-stained cervicovaginal smears of intrauterine device (IUD) users are positive for actinomyces-like organisms (ALOs). Many clinicians believe that no therapeutic intervention is necessary if women with ALOs are without symptoms. However, there are no recommendations for the procedure in ALO-positive women with need for a routine IUD exchange.

Study Design

In this retrospective study, the incidence of ALOs was compared in ALO-positive women with a routine IUD exchange according to two new procedures: Group 1 (n=19), insertion of a new IUD immediately after removal of the index device, and Group 2 (n=19) IUD removal and reinsertion after 3-5 days. A Pap smear was obtained at intervals of 6 weeks and 12, 24 and 36 months after reinsertion.

Results

The cytological examination carried out after 6 weeks proved to be negative for ALOs in all cases. After 36 months, smears were more often positive for ALOs in women with immediate IUD exchange (73% vs. 33%; p<.17).

Conclusion

Our results indicate that in ALO-positive women, IUD reinsertion immediately after removal or after an interval of 3-5 days is safe. The interval reinsertion might be of advantage on a long-term basis.     

TCu220C与TCu380A IUD体外细胞毒性研究

目的:评价两种含铜宫内节育器体外细胞毒性。方法:采用TCu220C和TCu380A,10%FBS-DMEM浸提后,与L929细胞接触培养,通过倒置相差显微镜观察其形态,采取MTT(四唑盐)比色法量化细胞毒性,计算相对增值率(RGR),并进行毒性评价。结果:TCu220C表现出轻度的细胞毒性(1～2级),TCu380A表现出明显的细胞毒性(4级)。结论:相同形状的两种含铜宫内节育器因含铜面积不同,其表现出来的细胞毒性也不同,含铜面积越大,细胞毒性越大。     

Menstrual problems and side effects associated with long-term TCu 380A IUD use in perimenopausal women

The study assessing menstrual problems and side effects associated with long-term TCu 380A intrauterine device (IUD) use in perimenopausal women is reported. Fifty perimenopausal TCu 380A IUD acceptors who had IUD inserted after age 40 and used IUD at least 36 months were recruited. The mean age of acceptors at time of insertion was 44.2 years with an average parity of two live births. The mean body weight at insertion was 62.13 kg. Most of the bleeding patterns were regular cycles. Intermenstrual bleeding and pelvic pain were the side effects most often reported. No pregnancies, pelvic inflammatory disease, or IUD expulsions occurred during the follow-up period. This study suggests that the use of TCu 380A IUD in perimenopausal women is safe and effective.     

两种新型含铜IUD对宫颈沙眼衣原体阳性率影响的研究

本文报道了同期放置的TCu380A及GyneFix两种新型含铜宫内节育器在放置1年及2年时与对照组宫颈砂眼衣原体(CT)阳性率的比较。TCu380A组放置1年时阳性率为5.63％,2年时为4.92％;GyneFix组放置1年时阳性率为4.62％,2年时为5.08％,两组含铜IUD放置1年及2年时各组比较差别均无显著意义(P>0.05);对照组CT阳性率为15.18％,与上述各组比较差别均有显著意义(P<0.05)。本文结论认为含铜IUD对宫颈CT感染有抑制作用。     

Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors

Background

This study was conducted to determine the relationship between unintended pregnancy and maternal behaviors before, during and after pregnancy.

Study Design

Data were analyzed from a stratified random sample of 9048 mothers who delivered live born infants between 2001 and 2006 and completed the Pregnancy Risk Assessment Monitoring System (PRAMS) survey 2 to 9 months after delivery. Binary and ordinal logistic regression methods with appropriate survey weights were used to control for socio-demographic factors.

Results

Compared to women with intended pregnancies, mothers with unwanted pregnancies were more likely to consume less than the recommended amount of preconception folic acid [adjusted odds ratio (OR) 2.39, 95% confidence interval (CI) 1.7-3.2], smoke prenatally (OR 2.03, 95% CI 1.5-2.9), smoke postpartum (OR 1.86, 95% CI 1.35-2.55) and report postpartum depression (OR 1.98, 95% CI 1.48-2.64); they were less likely to initiate prenatal care during the first trimester (OR 0.34, 95% CI 0.3-0.5) and breastfeed for 8 or more weeks (OR 0.74, 95% CI 0.57-0.97). Compared to women with intended pregnancies, women with mistimed pregnancies were also more likely to consume inadequate folic acid, delay prenatal care and report postpartum depression.

Conclusion

Even after controlling for multiple socio-demographic factors, unwanted and mistimed pregnancies were associated with unhealthy perinatal behaviors.     

Continuation rates and reasons for discontinuing TCu380A IUD use in Tabriz, Iran

PURPOSE: The long-term effectiveness of copper-bearing intrauterine device (IUD) has been documented. This paper reports results from a 60-month study on the use of TCu380A IUD among 401 women in Tabriz, Iran. MATERIALS: In 2003, a 5% sample of women who had had an IUD inserted between May 1997 and May 1999 was taken. Analyses of discontinuation employed Tietze net rate life tables. RESULTS: Continuation of TCu380A IUD use by women at 1 month, 6 month, 1 year, 2 years, 3 years, 4 years and 5 years was 98.2, 89.3, 79.3, 68.3, 57.6, 49.5 and 45.0 per 100, respectively. Among women using the TCu380A IUD, the rate of termination due to pain/bleeding was significantly higher than the rate of termination due to other causes. Overall, two pregnancies were reported within 5 years after insertion. A third pregnancy occurred on Year 6. CONCLUSION: These findings indicate that family planning educators and health care providers should give more emphasis to counseling programs for women desiring IUD insertion and during follow-up.     

A comparative randomized study of three different IUDs in nulliparous Mexican women

With the aim to evaluate the clinical performance of intrauterine devices (IUDs) especially designed for nulliparous women (TCu 380 Nul and ML Cu 375 sl), a prospective randomized, single-blind study comparing them with standard TCu 380 A, was carried out. We included 1170 healthy nulliparous women randomly allocated to receive any of the three types of IUDs and conducted follow-up for 1 year of use. Continuation and termination rates were evaluated by gross cumulative life table analysis and compared by the log-rank test. Continuation rates (95% confidence interval) at the end of the study for TCu 380 A, TCu 380 Nul and ML Cu 375 sl were 29.5% (+/-12.9), 85.9% (+/-5.3) and 85.4% (+/-5.8), respectively (p < 0.001). There were six pregnancies during the first 3 months of use, for a failure rate of 1% (+/-0.6) in the TCu 380 A group, 0.5% (+/-0.3) in TCu 380 Nul, and no pregnancy in ML Cu 375 sl (p < 0.05). Especially designed IUDs for nulliparous women had a better clinical profile compared with the standard IUD. This may improve the use of IUD in this population.     

Intraoperative placement of the Copper T-380 intrauterine devices in women undergoing elective cesarean delivery: a pilot study

Background

The purpose of this pilot project was to test the feasibility of a technique designed to place a copper intrauterine device (IUD) through the hysterotomy incision of an elective cesarean delivery to minimize possible contamination and to guarantee that tailstrings were visible in the vagina for easy removal should complications occur.

Study Design

Women were monitored in the hospital for signs of infection or excessive blood loss. At the time of hospital discharge and at 2 and 6 weeks postpartum, they were examined to determine the status of the tailstrings. The position of the IUD was assessed by ultrasound at week 6.

Results

All seven of the subjects had successful placement. The sutures tied to the IUD strings were visible on vaginal examination in each case. The original tailstrings were visible in the vagina at 6 weeks and each IUD was fundally positioned.

Conclusion

Successful intraoperative placement of Copper T-380A IUDs through incision at the time of cesarean birth is possible.     

Variations in body mass index of users of depot-medroxyprogesterone acetate as a contraceptive

Background

Weight gain is a frequent reason for discontinuing the contraceptive with depot-medroxyprogesterone acetate (DMPA).

Study Design

This 3-year retrospective cohort study assessed body mass index (BMI; kg/m²) variations in 379 current or past DMPA users compared to TCu380A intrauterine device (IUD) users matched for age and BMI, categorized into G1 (normal weight), G2 (overweight) or G3 (obese) according to baseline BMI. Variations in weight and BMI were evaluated using analysis of variance.

Results

BMI increased progressively in all groups but significantly more in G1 and G2 DMPA users compared to nonusers and according to duration of use. In the G3 subgroup, weight trends were similar in the DMPA and IUD users.

Conclusions

Normal and overweight women increased BMI with DMPA use; however, obese women did not increase weight. Weight increase in DMPA users could be associated with metabolic alterations related to duration of use in normal and overweight women and to alterations already present in obese women. Prospective studies are required to determine triggering factors. DMPA use ≤3 years was not associated with weight increase in women with BMI (kg/m²) ≥30.     

TCu220C与TCu380AIVD体外细胞毒性研究

目的:评价两种含铜宫内节育器体外细胞毒性.方法:采用TCu220C和TCu380A,10?S-DMEM浸提后,与L929细胞接触培养,通过倒置相差显微镜观察其形态,采取MTT(四唑盐)比色法量化细胞毒性,计算相对增值率(RGR),并进行毒性评价.结果:TCu220C表现出轻度的细胞毒性(1～2级),TCu380A表现出明显的细胞毒性(4级).结论:相同形状的两种含铜宫内节育器因含铜面积不同,其表现出来的细胞毒性也不同,含铜面积越大,细胞毒性越大.     

Assessment of menstrual blood loss in Brazilian users of the frameless copper-releasing IUD with copper surface area of 330 mm2 and the frameless levonorgestrel-releasing intrauterine system

OBJECTIVE: This study was conducted to evaluate the effect of two types of IUDs on the amount of menstrual blood loss (MBL): the frameless copper-releasing intrauterine device (IUD) with copper surface area of 330 mm2 (GyneFix; Contrel Research, Ghent, Belgium) and the frameless levonorgestrel (LNG)-releasing intrauterine system (IUS) releasing 14 microg per day (FibroPlant-LNG; Contrel Research). Heavy and abnormal MBL is the main reason for discontinuation of intrauterine devices. METHODS: In 20 Brazilian women using GyneFix 330 and 32 using FibroPlant-LNG, respectively, MBL was measured by the quantitative alkaline hematin technique. In addition, ferritin levels were measured in GyneFix 330 and FibroPlant-LNG users. RESULTS: MBL with GyneFix 330, measured over a 24-month period, increased but was less when compared with TCu380A. Ferritin levels with GyneFix 330 were not affected in contrast with TCu380A. In FibroPlant-LNG users, mean MBL decreased by about 90% and ferritin levels increased significantly. CONCLUSIONS: The authors confirm earlier reports that, especially for women with low body iron stores and heavy menstrual bleeding, there is an order of preference for IUD use to minimize MBL. The choice should first be a progestin-releasing IUS, then a copper IUD, which has the least effect on menstrual bleeding, such as the frameless GyneFix IUD.     

Intrauterine device use does not increase the incidence of anti-hepatitis C seropositivity among monogamous women in Turkey

Background

The relationship between intrauterine device (IUD) use and anti-hepatitis C virus (HCV) status has not been investigated yet. The aims of this study were to compare anti-HCV seropositivity between IUD users and nonusers and to determine whether IUD use is an independent risk factor for anti-HCV seropositivity.

Study Design

This cross-sectional study included 302 married women who used either an IUD (n=164) or did not use any form of modern contraception (n=138). Statistical analysis was carried out using multiple logistic regression models.

Results

Most women were housewives and all indicated their husbands as the one and only lifetime sexual partner. None of the women have ever used intravenous drugs. There were no statistically significant differences between groups in any of the major risk factors for HCV exposure such as invasive dental procedures, parenteral injections, surgery and blood or blood product transfusions. Twenty-seven (8.9%) of the participants were anti-HCV-positive. Of these, 14 were IUD users and 13 were nonusers and there were no statistically significant differences between the two groups (p=.472). The most important risk factors for anti-HCV seropositivity were the number of deliveries (OR=1.41; 95% CI 1.07-1.86) and invasive dental procedures (OR=2.39; 95% CI 1.07-5.39).

Conclusions

IUD use is not associated with an increased incidence of anti-HCV seropositivity among monogamous women. The IUD may be an appropriate contraceptive option for women in stable monogamous partnership with HCV carriers and condom use should not be specifically recommended in this situation.     

Identifying appropriate IUD candidates in areas with high prevalence of sexually transmitted infections

Background

The IUD is a highly effective, safe, inexpensive and long-lasting contraceptive. However, IUDs may increase PID risk during the early postinsertion period when inserted in women with cervical infections. We developed a simple algorithm to identify women at low risk of current sexually transmitted infection (STI) who are appropriate IUD candidates in regions with moderate or high STI prevalence.

Methods

We used data sets from family planning populations in Kenya, Zimbabwe, Jamaica and the United States to develop optimum algorithms. We then validated these algorithms using data sets from family planning populations in Thailand and Uganda.

Results

A simple unweighted algorithm based on age, living with partner, education, bleeding between periods and a behavioral risk score (number of sex partners, condom use) was the most useful. Adding clinical signs did not improve algorithm performance. Women categorized at low risk by this algorithm were at substantially reduced risks of cervical infection. Women identified at high STI risk had at least twice the risk as the overall clinic populations. Women in the moderate-risk group had STI risks similar to the overall clinic populations.

Conclusion

Women categorized as low risk by the algorithm can be referred for IUD insertion while women categorized at high risk should not receive an IUD without further testing or treatment. Women in the moderate-risk group should be triaged based on the STI prevalence of the overall clinic population. A simple checklist has been developed to help providers estimate a client's risk of current STI and to guide appropriate triage.     

Six-week retention after postplacental copper intrauterine device placement

Objectives

We sought to evaluate the 6-week clinical outcomes (intrauterine device [IUD] retention, recognized expulsions, ability to visualize or palpate strings, and need for ultrasound evaluation) in women who received a TCu380A postplacental IUD (PPIUD) after vaginal (VD) or cesarean delivery (CD).

Efficacy and safety of a low-dose combined oral contraceptive containing drospirenone 3 mg and ethinylestradiol 20 mcg in a 24/4-day regimen

Objective

The study was conducted to assess the efficacy of a low-dose combined oral contraceptive (COC) containing drospirenone (drsp) 3 mg/ethinylestradiol (EE) 20 mcg administered for 24 days of active treatment followed by a 4-day hormone-free interval (24/4 regimen).

Study Design

In this open-label uncontrolled study conducted in 50 European centers, healthy females aged 18-35 years with a body mass index of less than 30 kg/m² received drsp 3 mg/EE 20 mcg 24/4 over 13 cycles. The primary efficacy variable was the number of unintended pregnancies.

Results

Five pregnancies occurred among 1101 women over 13,248 treatment cycles, resulting in a Pearl Index (PI) of 0.49 with an upper two-sided 95% CI limit of 1.14. Of these pregnancies, three were attributed to noncompliance with tablet use resulting in an adjusted PI for ‘perfect use’ of 0.22 (upper limit of two-sided 95% CI: 0.80) based on 11,755 cycles.

Conclusion

Drospirenone 3 mg/EE 20 mcg 24/4 is a highly effective COC in nonobese women.