Tuesday, May 21, 2013

Are IUDs a reasonable option for birth control in adolescents?

- Jennifer Middleton, MD, MPH

What kind of contraception options do you discuss with adolescents?

A study by Rubin, Davis, and McKee from the Annals of Family Medicine's last issue explored the views of family physicians, pediatricians, and OB/GYNs on this issue.  Some might be tempted to dismiss this study because the n only equaled 28 docs, but this study was a qualitative study, not a numbers-crunching quantitative study.  The researchers used a semi-structured interview guide and interviewed as many physicians as it took to reach saturation, or the point where they were not recording any new themes.  (Low ns are fairly typical of qualitative studies.)

Although this study discussed both the intrauterine device (IUD) and implantable contraception (Implanon), I'm going to focus on the IUD findings for today's post.

It turns out that only about half of these physicians were recommending IUDs to their teenage patients.  The researchers found that this was due to "knowledge gaps" and "limited access to the device."

The "knowledge gaps" mostly related to the suitability of an IUD for a teen.  We know that 1 in 4 teens get a sexually transmitted infection (STI) each year.  IUDs were previously thought to increase the risk for pelvic inflammatory disease following an STI, but more recent research disputes that assumption with the current IUD devices available in the US.(1,2) And, despite all of the levonorgestrel-releasing intrauterine system (Mirena) commercials stating that it's only for women who have "had at least one child," the American College of Obstetrics and Gynecology reasonably asserts that IUDs are safe and reasonable to use in nulliparous women of all ages.

The "limited access to the device" is exactly what it sounds like; only 60% of the family docs, and none of the pediatricians, were providing this service in their offices.  Pediatricians, especially, were uncomfortable with any type of birth control besides oral contraceptive pills.  Long-acting contraception like the IUD, though, is a perfect fit for many teens who may be less than reliable at remembering to pop a pill every day. (Let's face it - many adults aren't any better at remembering to take daily meds.)

A look at the recent evidence regarding IUD use in adolescents shows that IUDs are easily inserted in most teens and nulliparous women, though the insertion process can be more uncomfortable. (3)  NSAIDs are a reasonable option for controlling this discomfort. Adolescents may be at slightly higher risk for IUD expulsion than older women, but current data suggests that the difference is probably not very large. (4,5)

There is a useful AFP By Topic collection on family planning and contraception available at http://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=71.  The IUD article does date to 2005, so please take its recommendations in the context of the evidence cited above, but the collection has many helpful resources to assist busy family doctors regarding this increasingly complex topic.

What are your thoughts about the IUD for teens?  If you are recommending it, what spurred you to do so?  If not, what is making you hesitate?

  1. Faundes A, Telles E, Cristofoletti ML, Faundes D, Castro S, Hardy E. The risk of inadvertent intrauterine device insertion in women carriers of endocervical Chlamydia trachomatis. Contraception 1998;58:105–9.
  2. Skjeldestad FE, Halvorsen LE, Kahn H, Nordbo SA, Saake K. IUD users in Norway are at low risk for genital C. trachomatis infection. Contraception 1996;54:209–12.
  3. Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception 1994;49:56–72.
  4. Deans EI, Grimes DA. Intrauterine devices for adolescents: a systematic review. Contraception 2009;79:418–23.
  5. Lyus R, Lohr P, Prager S. Use of the Mirena LNG-IUS and Paragard CuT380A intrauterine devices in nulliparous women. Board of the Society of Family Planning. Contraception 2010;81:367–71.