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Perelló-Capó J, Estadella-Tarriel J, Gich-Saladich I, Bailón-Queiruga M, Llurba-Olivé E, Calaf-Alsina J. Health-related quality of life and satisfaction associated with 3-year use of a levonorgestrel 13.5 mg intrauterine device vs Nova T copper 380 mm 2 intrauterine device: Results of a phase 4 randomized controlled trial. Contraception 2024; 133:110367. [PMID: 38232939 DOI: 10.1016/j.contraception.2024.110367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 12/28/2023] [Accepted: 01/09/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVES This study aimed to investigate the impact of levonorgestrel 13.5 mg and Nova T copper 380 mm2 intrauterine devices (LNG13.5-IUD and Cu380-IUD, respectively) on health-related quality of life (HRQoL) and the satisfaction with the method throughout 3 years of use. STUDY DESIGN We conducted a single-center, evaluator-masked, randomized controlled trial to compare the bleeding profile of LNG13.5-IUD and Cu380-IUD users. Secondary objectives included HRQoL and satisfaction throughout the study. We used the validated questionnaire of the Spanish Society of Contraception (SEC-QoL), which evaluates social, sexual/psychological well-being, and menstrual/breast symptoms, to assess HRQoL and a 5-point Likert scale for satisfaction. RESULTS These secondary outcomes were assessed in the whole population included in the study: 55 LNG13.5-IUD and 51 Cu380-IUD users. The mean overall SEC-QoL scores were similar at baseline (61.5 and 59.6, respectively; p = 0.570) and greater for LNG13.5-IUD after 3 years (69.2 vs 52.5, respectively; p = 0.002). All SEC-QoL domains scored also higher (p < 0.05 vs Cu380-IUD for all). At month 36, 20/30 (67%) and 8/28 (29%) users, respectively, had reached the MID (a 3.4-point increase) in SEC-QoL score (p = 0.004). At this time, 24/29 (82%) and 9/28 (32%) users, respectively, were "very satisfied" (p < 0.001). Willingness to continue the method was similar (22/28 [79%] vs 17/28 [61%] users, respectively; p = 0.170). CONCLUSIONS Among the use of LNG13.5-IUD was associated with better HRQoL vs Cu380-IUD throughout the 3 years. Satisfaction with the method was higher with LNG13.5-IUD. IMPLICATIONS People considering having an LNG13.5-IUD or a Cu380-IUD inserted may now benefit from the information regarding the impact of these devices on HRQoL and satisfaction with the method as reported in our study conducted in Spain.
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Affiliation(s)
- Josep Perelló-Capó
- Department of Obstetrics and Gynecology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Pediatrics, Obstetrics and Gynecology, Preventive Medicine and Public Health, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Josep Estadella-Tarriel
- Department of Obstetrics and Gynecology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Pediatrics, Obstetrics and Gynecology, Preventive Medicine and Public Health, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ignasi Gich-Saladich
- Clinical Epidemiology and Public Health Service, IIB Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Spain
| | - Marta Bailón-Queiruga
- Department of Obstetrics and Gynecology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Elisa Llurba-Olivé
- Department of Obstetrics and Gynecology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Pediatrics, Obstetrics and Gynecology, Preventive Medicine and Public Health, Universitat Autònoma de Barcelona, Barcelona, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - Joaquim Calaf-Alsina
- Department of Obstetrics and Gynecology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Department of Pediatrics, Obstetrics and Gynecology, Preventive Medicine and Public Health, Universitat Autònoma de Barcelona, Barcelona, Spain
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Doty N, Beckley E, Garg B, Maristany S, Erikson DW, Jensen JT. Changes in hair cortisol concentration in intrauterine device initiators: A prospective cohort study. Contraception 2023; 128:110142. [PMID: 37633589 PMCID: PMC10842525 DOI: 10.1016/j.contraception.2023.110142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/28/2023]
Abstract
OBJECTIVES Prior studies found increased hair cortisol concentration (a surrogate marker for hypothalamic-pituitary-adrenal axis activation) in users of the levonorgestrel intrauterine device (LNG 52 mg IUD). We evaluated change in hair cortisol and psychometric tests in women initiating a copper (CuT380 IUD) or LNG 52 mg IUD. STUDY DESIGN We prospectively enrolled healthy women initiating an LNG 52 mg IUD or CuT380 IUD. Participants provided hair and blood samples and completed psychometric inventories (Patient Health Questionnaire-9, Positive and Negative Affect Schedule, and Psychological General Well-Being Index) after IUD insertion and at 6 and 12 months. We used liquid chromatography with tandem mass spectrometry to measure hair cortisol concentrations. We compared hair cortisol concentrations and psychometric test changes from baseline to 6 and 12 months using independent two-sample t tests. RESULTS We enrolled 39 of our targeted 86 participants (LNG 52 mg IUD 26, CuT380 IUD 13). Thirty-eight subjects (LNG 52 mg IUD 25, CuT380 IUD 13) completed 6 months of follow-up. We found no difference between cohorts in the mean change in hair cortisol concentrations at 6 months (LNG 52 mg IUD n = 21 [-0.01 pg/mg (95% CI -1.26, 1.23); CuT380 IUD n = 13 [-1.31 pg/mg (-3.36, 0.73)]). While psychometric inventory results remained within normal ranges, LNG 52 mg IUD users reported a trend toward more favorable changes over time. CONCLUSIONS We did not find clinically important differences in hair cortisol concentrations following initiation of a CuT380 IUD or LNG 52 mg IUD; psychometric inventories demonstrated no adverse effect of hormonal IUDs on mood. IMPLICATIONS Our findings of similar hair cortisol concentrations following the initiation of either the LNG 52 mg IUD or CuT380 IUD suggest that hormonal IUDs do not increase cortisol concentrations or alter stress reactivity, and favorable effects on psychometric inventories provide further reassurance that the LNG 52 mg IUD has no adverse impact on mood. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT03499379.
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Affiliation(s)
- Nora Doty
- Department of Obstetrics and Gynecology, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, United States.
| | - Ethan Beckley
- Department of Psychiatry, Oregon Health and Science University, Portland, OR, United States
| | - Bharti Garg
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, United States
| | - Sumiko Maristany
- The University of Chicago Pritzker School of Medicine, Chicago, IL, United States
| | - David W Erikson
- Endocrine Technologies Core, Oregon National Primate Research Center, Beaverton, OR, United States
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology and Division of Reproductive Sciences, Oregon Health and Science University, Portland, OR, United States
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FSRH Guideline (March 2023) Intrauterine contraception. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:1-142. [PMID: 37188461 DOI: 10.1136/bmjsrh-2023-iuc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
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Fanse S, Bao Q, Burgess DJ. Long-acting intrauterine systems: Recent advances, current challenges, and future opportunities. Adv Drug Deliv Rev 2022; 191:114581. [PMID: 36270490 PMCID: PMC10302114 DOI: 10.1016/j.addr.2022.114581] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/13/2022] [Accepted: 09/27/2022] [Indexed: 01/24/2023]
Abstract
Levonorgestrel intrauterine systems (LNG-IUSs) are complex drug-device combination products designed to release a hormonal contraceptive drug for up to 7 years. These drug delivery systems offers a great promise as a modern method of long-acting reversible contraceptives (LARCs) to improve women's health. Unfortunately, there are some scientific challenges associated with the development of these products which are among the major reasons contributing to the availability of relatively few IUS products on the market. This review summarizes the formulation considerations (drug and excipient attributes), manufacturing methods, advances in characterization and in vitro drug release testing of IUSs, as well as factors influencing drug release from IUSs. A critical discussion on the major challenges to IUS product development is presented. Specifically, insights on bioequivalence evaluation, in vitro-in vivo correlation (IVIVC) establishment, and regulatory challenges are detailed. Lastly, methodological tools to overcome some of these hurdles to product development are proposed. The knowledge furnished through this review will be helpful towards obtaining better product understanding. Such understanding will facilitate the development of these complex drug products, as well as their regulatory approval process.
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Affiliation(s)
- Suraj Fanse
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA
| | - Quanying Bao
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA
| | - Diane J Burgess
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA.
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Jensen JT, Lukkari-Lax E, Schulze A, Wahdan Y, Serrani M, Kroll R. Contraceptive efficacy and safety of the 52-mg levonorgestrel intrauterine system for up to 8 years: findings from the Mirena Extension Trial. Am J Obstet Gynecol 2022; 227:873.e1-873.e12. [PMID: 36096186 DOI: 10.1016/j.ajog.2022.09.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/25/2022] [Accepted: 09/03/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND The 52-mg levonorgestrel-releasing intrauterine system is an established, long-acting contraceptive option with approved use for up to 7 years. OBJECTIVE The Mirena Extension Trial evaluated the efficacy and safety of the 52-mg levonorgestrel-releasing intrauterine system during extended use beyond 5 and up to 8 years. STUDY DESIGN This was a multicenter, single-arm study in the United States, enrolling existing users of the 52-mg levonorgestrel-releasing intrauterine system, aged 18 to 35 years, who have had the system for 4.5 to 5 years. We assessed the contraceptive efficacy (Pearl Index) and cumulative failure rate (using the Kaplan-Meier method) of the 52-mg levonorgestrel-releasing intrauterine system during extended use. We also evaluated bleeding outcomes and adverse events. RESULTS Of the 362 participants starting year 6, 243 entered and 223 completed 8 years of 52-mg levonorgestrel-releasing intrauterine system use. Just more than half the participants were parous. The mean (standard deviation) age was 29.2 (±2.9) years, and all participants were aged ≤36 years at the end of year 8. Two pregnancies occurred, both with the device in situ. The year 6 pregnancy was of undetermined location and resolved spontaneously. The pregnancy in year 7 was ectopic and resolved with methotrexate treatment. In both cases, the 52-mg levonorgestrel-releasing intrauterine system was removed and the participants left the trial. For years 6 to 8, the 3-year Pearl Index (95% confidence interval) was 0.28 (0.03-1.00) with a 3-year cumulative failure rate of 0.68% (0.17-2.71). Pearl Indexes for years 6, 7, and 8 were 0.34 (0.01-1.88), 0.40 (0.01-2.25), and 0.00 (0.00-1.90), respectively. The 3-year (years 6-8) ectopic pregnancy Pearl Index was 0.14 (0.00-0.77). We found treatment-emergent adverse events in 249 of 362 participants (68.8%), with 65 (18.0%) events considered to be related to the 52-mg levonorgestrel-releasing intrauterine system. The discontinuation rate was 38.4% (139/362), most commonly because of desire for pregnancy (12.2%, 44/362). During extended use beyond 5 years and up to 8 years, participants reported a decrease in the mean number of bleeding or spotting days with approximately half of the women experiencing amenorrhea or infrequent bleeding. We did not enroll a sufficient number of women using the 52-mg levonorgestrel-releasing intrauterine system for contraception and heavy menstrual bleeding to assess extended use for that indication. At the end of year 8, most (98.7%, 220/223) of the participants who completed the study remained satisfied with the continued use of the 52-mg levonorgestrel-releasing intrauterine system. Of the 31 women who discontinued early because of desire for pregnancy with evaluable data for return-to-fertility analysis, 24 reported a posttreatment pregnancy within 1 year, giving a 12-month return-to-fertility rate of 77.4%. CONCLUSION The 52-mg levonorgestrel-releasing intrauterine system, initially approved for 5 years, maintains high contraceptive efficacy, user satisfaction, and a favorable safety profile through 8 years of use. Participants reported 26 posttreatment pregnancies in total, of which 24 occurred in women who had discontinued the 52-mg levonorgestrel-releasing intrauterine system because of a desire for pregnancy. Of note, among women who elected to continue use through 8 years, bleeding patterns remained highly favorable. These findings support continued 52-mg levonorgestrel-releasing intrauterine system use for up to 8 years in women who wish to continue treatment.
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Affiliation(s)
- Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR.
| | | | | | | | | | - Robin Kroll
- Seattle Clinical Research Center, Seattle, WA
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Saloranta TH, Gyllenberg FK, But A, Gissler M, Heikinheimo O, Laine MK. Use of reproductive health services among women using long- or short-acting contraceptive methods - a register-based cohort study from Finland. BMC Public Health 2022; 22:1185. [PMID: 35701805 PMCID: PMC9199191 DOI: 10.1186/s12889-022-13581-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 05/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Long-acting reversible contraceptives (LARCs) have superior contraceptive efficacy compared to short-acting reversible contraceptives (SARCs) and choosing LARCs over SARC methods reduces the need for abortion care. However, little is known how initiating these methods associates with the subsequent overall need of reproductive health services including family planning services, and visits for gynecological reasons in primary and specialized care. METHODS We followed altogether 5839 non-sterilized women aged 15-44 years initiating free-of-charge LARC methods (n = 1689), initiating or switching SARC methods (n = 1524), or continuing with the same SARC method (n = 2626) at primary care family planning clinics in the City of Vantaa, Finland, 2013-2014 for 2 years using Finnish national health registers. We assessed the use of reproductive health services, namely attending public primary or specialized health care for gynecological reasons or attending the family planning clinics by applying unadjusted and adjusted negative binomial regression models on visit counts. RESULTS A total of 11,290 visits accumulated during the two-year follow-up: 7260 (64.3%) at family planning clinics, 3385 (30.0%) for gynecological reasons in primary, and 645 (5.7%) in specialized health care. Altogether 3804 (52.4%) visits at the family planning clinics were for routine checkup, and 3456 (47.6%) for other reasons. Women initiating LARC methods used reproductive health services for reasons other than routine checkups similarly as women initiating or switching SARC methods (adjusted incidence rate ratio 0.93, 95% CI 0.82-1.05), while women continuing with SARC methods used the services less frequently (0.65, 0.59-0.72). Women initiating free-of-charge LARC and those continuing with the same SARC method used services less for abortion care than women initiating or switching SARC (adjusted incidence rate ratios 0.05, 95% CI 0.03-0.08 and 0.16, 95% CI 0.11-0.24, respectively). CONCLUSIONS While women initiating LARC methods have lower need for abortion care compared to women initiating SARC methods, women initiating both LARC and SARC methods have similar overall need for reproductive health services. In contrast, women continuing with their SARC method need reproductive health services less than women initiating LARC or a new SARC method. These service needs should be acknowledged when planning and organizing family planning services, and when promoting long-acting reversible contraception.
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Affiliation(s)
- Tuire Helene Saloranta
- Myyrmäki Health Center, Jönsaksentie 4, 01600, Vantaa, Finland.,Department of General Practice and Primary Care, University of Helsinki, Tukholmankatu 8 B, 00029 HUS, Helsinki, Finland
| | - Frida Katrin Gyllenberg
- Myyrmäki Health Center, Jönsaksentie 4, 01600, Vantaa, Finland.,Department of General Practice and Primary Care, University of Helsinki, Tukholmankatu 8 B, 00029 HUS, Helsinki, Finland.,Department of Obstetrics and Gynecology, University of Helsinki, Haartmaninkatu 2, 00029 HUS, Helsinki, Finland
| | - Anna But
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Tukholmankatu 8 B, 00029 HUS, Helsinki, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Mannerheimintie 166, 00271, Helsinki, Finland.,Research Centre for Child Psychiatry, University of Turku, Lemminkäisenkatu 3 (Teutori 3. krs), 20014, Turku, Finland.,Region Stockholm, Academic Primary Health Care Centre, Solnavägen 1 E, 113 65, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institute, Solnavägen 1, 17177, Stockholm, Sweden
| | - Oskari Heikinheimo
- Department of Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, PO Box 140, FI-00029 HUS, Helsinki, Finland.
| | - Merja Kristiina Laine
- Department of General Practice and Primary Care, University of Helsinki, Tukholmankatu 8 B, 00029 HUS, Helsinki, Finland.,Folkhälsan Research Center, Topeliuksenkatu 20, 00250, Helsinki, Finland
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Recommendations for standardization of bleeding data analyses in contraceptive studies. Contraception 2022; 112:14-22. [DOI: 10.1016/j.contraception.2022.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 11/17/2022]
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Abstract
IMPORTANCE Many women spend a substantial proportion of their lives preventing or planning for pregnancy, and approximately 87% of US women use contraception during their lifetime. OBSERVATIONS Contraceptive effectiveness is determined by a combination of drug or device efficacy, individual fecundability, coital frequency, and user adherence and continuation. In the US, oral contraceptive pills are the most commonly used reversible method of contraception and comprise 21.9% of all contraception in current use. Pregnancy rates of women using oral contraceptives are 4% to 7% per year. Use of long-acting methods, such as intrauterine devices and subdermal implants, has increased substantially, from 6% of all contraceptive users in 2008 to 17.8% in 2016; these methods have failure rates of less than 1% per year. Estrogen-containing methods, such as combined oral contraceptive pills, increase the risk of venous thrombosis from 2 to 10 venous thrombotic events per 10 000 women-years to 7 to 10 venous thrombotic events per 10 000 women-years, whereas progestin-only and nonhormonal methods, such as implants and condoms, are associated with rare serious risks. Hormonal contraceptives can improve medical conditions associated with hormonal changes related to the menstrual cycle, such as acne, endometriosis, and premenstrual dysphoric disorder. Optimal contraceptive selection requires patient and clinician discussion of the patient's tolerance for risk of pregnancy, menstrual bleeding changes, other risks, and personal values and preferences. CONCLUSIONS AND RELEVANCE Oral contraceptive pills are the most commonly used reversible contraceptives, intrauterine devices and subdermal implants have the highest effectiveness, and progestin-only and nonhormonal methods have the lowest risks. Optimal contraceptive selection incorporates patient values and preferences.
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Affiliation(s)
- Stephanie Teal
- Department of OB/GYN, University Hospitals Medical Center and Case Western Reserve University, Cleveland, Ohio
| | - Alison Edelman
- Department of OB/GYN, Oregon Health & Science University, Portland
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Brache V, Vieira CS, Plagianos M, Lansiaux M, Merkatz R, Sussman H, Cochon L, Tejada AS, Kumar N, Loeven D, Blithe DL, Aprem AS, Williams AR, Kannan A, Bagchi IC, Sitruk-Ware R. Pharmacodynamics and pharmacokinetics of a copper intrauterine contraceptive system releasing ulipristal acetate: A randomized proof-of-concept study. Contraception 2021; 104:327-336. [PMID: 34157312 DOI: 10.1016/j.contraception.2021.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess pharmacodynamic and pharmacokinetic outcomes of a novel copper (Cu) intrauterine system (IUS) releasing ulipristal acetate (UPA) in healthy women. STUDY DESIGN In this single-blinded, randomized proof-of-concept study, ovulatory women received one of three Cu-IUSs releasing low-dose UPA (5, 20 or 40 µg/d) for 12 weeks. The study included a baseline cycle, three 4-week treatment-cycles and 2 recovery cycles. Primary outcomes included effects of the IUS on bleeding profile, ovarian function, and the occurrence of progesterone receptor modulator associated endometrial changes (PAEC). Pharmacokinetics and safety profile were secondary outcomes. We compared outcomes in treatment-cycle 3 with baseline, using generalized linear mixed models with orthogonal contrasts. RESULTS We randomized 29 women (5 µg/d = 10, 20 µg/d = 10, 40 µg/d = 9). All had a successful IUS insertion; 27 completed the 12-week treatment period. Compared to baseline, the mean number of bleeding-only days at treatment-cycle 3 declined by 16.7% in the 5 µg/d group (3.6 vs 3.0, p = 0.66), 40.5% in the 20 µg/d group (4.2 vs 2.5, p = 0.14), and 77% in the 40 µg/d group (3.9 vs 0.9, p = 0.002). Most women reported reduction in the amount of bleeding: 4/8, 8/10, and 7/9 for the 5 µg/d, 20 µg/d, and 40 µg/d groups, respectively. During IUS use, ovulation occurred in most cycles [5 µg/d: 23/24 (96%), 20 µg/d: 26/30 (87%), 40 µg/d: 22/27 (81%)]. The frequency of PAEC at IUS removal was 1/10 (10%), 1/10 (10%) and 4/9 (44%) in the 5 µg/d, 20 µg/d, and 4 0 µg/d groups, respectively. No serious adverse events occurred. CONCLUSIONS Reduction in bleeding, low incidence of PAEC, and no serious adverse events are reassuring findings of the novel Cu-UPA-IUS. The 20 µg/d seems the lowest dose promoting a favorable bleeding profile and limiting PAEC. IMPLICATIONS The preliminary results of this short-term study of a novel copper intrauterine system (IUS) delivering ulipristal acetate showed reduction of bleeding, low incidence of progesterone receptor modulator associated endometrial changes, and absence of serious adverse events. By preventing copper-induced increase in bleeding, this IUS could provide a noncontraceptive benefit, especially for women with low hemoglobin.
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Affiliation(s)
- Vivian Brache
- Investigaciones Biomédicas de Profamilia, Clínica Profamilia. Santo Domingo, Dominican Republic
| | - Carolina Sales Vieira
- Department of Gynecology and Obstetrics, Ribeirao Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.
| | | | - Maud Lansiaux
- Population Council, New York City, NY, United States
| | - Ruth Merkatz
- Population Council, New York City, NY, United States
| | | | - Leila Cochon
- Investigaciones Biomédicas de Profamilia, Clínica Profamilia. Santo Domingo, Dominican Republic
| | - Ana S Tejada
- Investigaciones Biomédicas de Profamilia, Clínica Profamilia. Santo Domingo, Dominican Republic
| | | | - Daniel Loeven
- Population Council, New York City, NY, United States
| | - Diana L Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | | | - Alistair Rw Williams
- Department of Pathology, The University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh
| | | | - Indrani C Bagchi
- University of Illinois at Urbana-Champaign, Urbana, IL, United States
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Gemzell‐Danielsson K, Kubba A, Caetano C, Faustmann T, Lukkari‐Lax E, Heikinheimo O. Thirty years of mirena: A story of innovation and change in women's healthcare. Acta Obstet Gynecol Scand 2021; 100:614-618. [PMID: 33544887 PMCID: PMC8248365 DOI: 10.1111/aogs.14110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/14/2021] [Accepted: 01/28/2021] [Indexed: 12/12/2022]
Abstract
Since its introduction in 1990, the levonorgestrel-releasing intrauterine system (LNG-IUS) has played a key role in shaping the healthcare landscape of women. Here we explore the development of the first LNG-IUS (Mirena®) and the early clinical trials that demonstrated its potential. We highlight the contraceptive and therapeutic benefits of Mirena®, and discuss how clinical practice has been changed since the introduction of LNG-IUS and other long-acting reversible contraceptive methods. The history of Mirena® is rich in innovation and has also paved the way to the development of smaller intrauterine systems with lower hormone doses. Along with Mirena®, these newer LNG-IUS contribute to improving contraceptive choices for women, allowing them to select the option that is right for them and that meets their needs no matter their age, parity or circumstances.
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Affiliation(s)
| | - Ali Kubba
- Guy’s and St Thomas’ NHS Foundation TrustLondonUK
| | | | | | | | - Oskari Heikinheimo
- Department of Obstetrics and GynecologyUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
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Free-of-charge long-acting reversible contraception: two-year discontinuation, its risk factors, and reasons. Am J Obstet Gynecol 2020; 223:886.e1-886.e17. [PMID: 32562657 DOI: 10.1016/j.ajog.2020.06.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 05/07/2020] [Accepted: 06/10/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Since 2013, the residents of the city of Vantaa, Finland, have been offered their first long-acting reversible contraceptive method (levonorgestrel-releasing intrauterine system, implant, and copper intrauterine device) free of charge. OBJECTIVE The primary aim of this study was to assess the 2-year cumulative discontinuation rates of long-acting reversible contraceptive methods when provided free of charge for first-time users in a real-world setting. Additional aims were to describe factors associated with discontinuation and to evaluate the reasons for discontinuation. STUDY DESIGN This is a retrospective register-based cohort study of 2026 nonsterilized women aged 15 to 44 years, who initiated a free-of-charge long-acting contraceptive method in 2013-2014 in the city of Vantaa. Removals within 2 years after method initiation and reasons for discontinuation were obtained from electronic health records and from national registers. We calculated the 2-year cumulative incidence rates of discontinuation with 95% confidence intervals for each method. Furthermore, we assessed crude and adjusted incidence rate ratios of discontinuation with 95% confidence interval by Poisson regression models comparing implants and copper intrauterine device with levonorgestrel-releasing intrauterine systems. RESULTS During the 2 -year follow-up, 514 women discontinued, yielding a cumulative discontinuation rate of 28.3 per 100 women-years (95% confidence interval, 26.2-30.4). Among the 1199 women who initiated the levonorgestrel-releasing intrauterine system, the cumulative discontinuation rate was 24.2 per 100 women-years (95% confidence interval, 21.7-26.9); among the 642 implant users, 33.3 per 100 women-years (95% confidence interval, 29.5-37.4); and among the 185 copper intrauterine device users, 37.8 per 100 women-years (95% confidence interval, 31.0-45.7). Compared with women aged 30 to 44 years, women aged 15 to 19 years (adjusted incidence rate ratio, 1.58; 95% confidence interval, 1.17-2.14) and 20 to 29 years (adjusted incidence rate ratio, 1.35; 95% confidence interval, 1.11-1.63) were more likely to discontinue. We observed a higher discontinuation rate in women who had given birth within the previous year (adjusted incidence rate ratio, 1.36; 95% confidence interval, 1.13-1.65), spoke a native language other than Finnish or Swedish (adjusted incidence rate ratio, 1.31; 95% confidence interval, 1.06-1.63), and had a history of a sexually transmitted infection (adjusted incidence rate ratio, 1.62; 95% confidence interval, 1.07-2.46). No association was found in marital status, overall parity, history of induced abortion, socioeconomic status, education level, or smoking status. The most common reason for discontinuation was bleeding disturbances, reported by 21% of women who discontinued the levonorgestrel-releasing intrauterine system, by 71% who discontinued the implant, and by 41% who discontinued the copper intrauterine device. One in 4 women who discontinued the copper intrauterine device reported heavy menstrual bleeding, whereas only 1% who discontinued the levonorgestrel-releasing intrauterine system and none who discontinued implants reported this reason. Abdominal pain was the reported reason for discontinuation in 20% of both intrauterine device users and in only 2% who discontinued implants. CONCLUSION At 2 years, the use of implants and copper intrauterine devices was more likely to be discontinued than that of the levonorgestrel-releasing intrauterine system. Women younger than 30 years and those who gave birth in the preceding year, spoke a native language other than Finnish or Swedish, or had a history of sexually transmitted infections were more likely to discontinue. The levonorgestrel-releasing intrauterine system was least likely to be removed owing to bleeding disturbances.
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Long-acting reversible contraceptive (LARCs) methods. Best Pract Res Clin Obstet Gynaecol 2019; 66:28-40. [PMID: 32014434 DOI: 10.1016/j.bpobgyn.2019.12.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/04/2019] [Accepted: 12/10/2019] [Indexed: 02/06/2023]
Abstract
Unplanned pregnancy (UP) is a public health problem, which affects millions of women worldwide. Providing long-acting reversible contraceptive (LARC) methods is an excellent strategy to avoid or at least reduce UP, because the effectiveness of these methods is higher than other methods, and is indeed comparable to that of permanent contraception. As the initial introduction of the inert plastic intrauterine device (IUD) and of the six-rod implant, pharmaceutical companies have introduced a copper IUD (Cu-IUD), different models of levonorgestrel-releasing intrauterine system (LNG IUS), and one and two-rod implants, which certainly improved women's LARC options. The main characteristic of LARCs is that they provide high contraceptive effectiveness with a single intervention, and that they can be used for a long time. Emerging evidence from the last few years has demonstrated that it is possible to extend the use of the 52 mg LNG IUS and of the etonogestrel-implant beyond five- and three years, respectively, which adds new value to these LARCs.
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Rapkin AJ, Korotkaya Y, Taylor KC. Contraception counseling for women with premenstrual dysphoric disorder (PMDD): current perspectives. Open Access J Contracept 2019; 10:27-39. [PMID: 31572029 PMCID: PMC6759213 DOI: 10.2147/oajc.s183193] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 08/07/2019] [Indexed: 12/20/2022] Open
Abstract
Premenstrual Dysphoric Disorder (PMDD) is a severe form of premenstrual syndrome (PMS) affecting up to 7% of reproductive age women. Women with PMDD are of reproductive age; therefore, contraception and treatment of PMDD are important considerations. The disorder as described in the DSM-V is characterized by moderate to severe psychological, behavioral and physical symptoms beginning up to two weeks prior to menses, resolving soon after the onset of menstruation and significantly interfering with daily functioning. PMDD develops in predisposed individuals after they are exposed to progesterone at the time of ovulation. It has been hypothesized that PMDD is in part attributable to luteal phase abnormalities in serotonergic activity and to altered configuration of ℽ-aminobutyric acid subunit A (GABAA) receptors in the brain triggered by the exposure to the neuroactive steroid progesterone metabolite, allopregnanolone (Allo). A large body of evidence suggests that selective serotonin reuptake inhibitors (SSRIs) can be effective in the treatment of PMDD. Combined hormonal contraceptive (CHC) pills, specifically the 20 mcg ethinyl estradiol/3mg drospirenone in a 24/4 extended cycle regimen has been shown to significantly improve the emotional and physical symptoms of PMDD. Other combined monophasic, extended cycle hormonal contraceptive pills with less androgenic progestins may also be helpful, although not well studied. Copper intrauterine devices (IUDs) are recommended for those not seeking hormonal contraceptives. Progestin-only methods including the progestin-only pill (POP), levonorgestrel (LNG) IUD, etonorgestrel implant or depot medroxyprogesterone acetate (DMPA) have the potential to negatively affect mood symptoms for women with or without baseline mood disorders, including PMDD. Careful counseling and close follow-up is recommended for patients with PMDD seeking these contraceptive methods.
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Affiliation(s)
- Andrea J Rapkin
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Yelena Korotkaya
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Kathrine C Taylor
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Bachofner** M, Blickenstorfer** K, Hutmacher J, Wehrle L, Leeners B, Merki-Feld G. Intrauterine device continuation rates and reasons for discontinuation in a Central European clinic with a high standard of care and ultrasound follow-up: a retrospective cohort study. EUR J CONTRACEP REPR 2019; 23:407-414. [DOI: 10.1080/13625187.2018.1539164] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Marion Bachofner**
- Department of Reproductive Endocrinology, University Hospital Zürich, Zürich, Switzerland
| | | | - Juliane Hutmacher
- Department of Reproductive Endocrinology, University Hospital Zürich, Zürich, Switzerland
| | - Lucia Wehrle
- Department of Reproductive Endocrinology, University Hospital Zürich, Zürich, Switzerland
| | - Brigitte Leeners
- Department of Reproductive Endocrinology, University Hospital Zürich, Zürich, Switzerland
| | - Gabriele Merki-Feld
- Department of Reproductive Endocrinology, University Hospital Zürich, Zürich, Switzerland
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Bitzer J, Rapkin A, Soares CN. Managing the risks of mood symptoms with LNG-IUS: a clinical perspective. EUR J CONTRACEP REPR 2018; 23:321-325. [PMID: 30468396 DOI: 10.1080/13625187.2018.1521512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Lack of awareness of reproductive hormone-related mood changes in the general population or limited acknowledgement of their existence by health care providers regularly contribute to fears or misconceptions about the link between hormonal contraception and potential mood changes. Recent media discussion linked the levonorgestrel intrauterine system (LNG-IUS 20 µg/d) to elevated cortisol levels and the possibility of panic attacks, anxiety, mood changes, sleep disturbance and restlessness. Efficacy of the LNG-IUS is based primarily on local effects but systemic effects, including a potential increase in mood symptoms, are a known risk and reflected in the product labelling for all LNG-IUS products. OBJECTIVE There is a need to improve communication to the public and health care providers around potential risk of mood disorders in order to facilitate 'informed choice' amongst women considering an LNG-IUS as their contraceptive method and directly address the fears of women currently using an LNG-IUS. RESULTS We propose a simple and brief, step-by-step process that can be embedded within current counselling that explores and clarifies the potential risk of developing mood symptoms prior to placement of LNG-IUS. It also addresses concerns from women using an LNG-IUS who either present with mood symptoms or are concerned about potential onset. CONCLUSION Mood symptoms with use of LNG-IUS are uncommon; however, all women, including those who may experience an increased sensitivity to certain progestins, should be counselled appropriately to raise awareness of the potential risk within an informed discussion around effectiveness, benefits and possible adverse events.
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Affiliation(s)
- J Bitzer
- a Department of Obstetrics and Gynecology , University Hospital , Basel , Switzerland
| | - A Rapkin
- b Department of Obstetrics and Gynecology , David Geffen School of Medicine at UCLA , Los Angeles , CA , USA
| | - C N Soares
- c Department of Psychiatry , Queen's University School of Medicine Kingston , Kingston , Ontario , Canada
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Sonalkar S, Hunter T, Gurney EP, McAllister A, Schreiber C. A Decision Analysis Model of 1-Year Effectiveness of Intended Postplacental Compared With Intended Delayed Postpartum Intrauterine Device Insertion. Obstet Gynecol 2018; 132:1211-1221. [PMID: 30303909 PMCID: PMC6328318 DOI: 10.1097/aog.0000000000002926] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To compare, using decision analysis methodology, the 1-year probability of pregnancy after intended postplacental intrauterine device (IUD) insertion with intended delayed insertion at an outpatient postpartum visit (delayed postpartum placement). METHODS We developed an evidence-based decision model with the primary outcome of 1-year probability of pregnancy. We compared 1-year probability of pregnancy after intended postplacental or intended delayed postpartum IUD placement. We obtained estimates from the literature for the proportions of the following: mode of delivery, successful IUD placement, IUD type, postpartum visit attendance, IUD expulsion, IUD discontinuation, and contraceptive use, choice, and efficacy after IUD discontinuation. We performed sensitivity analyses and a Monte Carlo simulation to account for variations in proportion estimates. RESULTS One-year probabilities of pregnancy among a theoretical cohort of 2,500,000 women intending to receive a postplacental IUD after vaginal birth and 1,250,000 women intending to receive a postplacental IUD after cesarean birth were 17.3% and 11.2%, respectively; the 1-year probability of pregnancy among a theoretical cohort of 2,500,000 women intending to receive a delayed postpartum IUD was 24.6%. For delayed postpartum IUD placement to have effectiveness equal to postplacental placement, 91.4% of women delivering vaginally and 99.7% of women delivering by cesarean would need to attend postpartum care. Once placed, the effectiveness of postplacental IUDs was lower than that of delayed postpartum IUDs: 1-year probabilities of pregnancy after IUD placement at a vaginal birth, cesarean birth, and an outpatient postpartum visit were 15.4%, 6.6%, and 3.9%, respectively. CONCLUSION After accounting for factors that affect successful IUD placement and retention, this decision model indicates that intended postplacental IUD insertion results in a lower 1-year probability of pregnancy as compared with intended delayed postpartum IUD insertion.
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Affiliation(s)
- Sarita Sonalkar
- University of Pennsylvania Perelman School of Medicine, Department of Obstetrics and Gynecology
| | | | | | - Arden McAllister
- University of Pennsylvania Perelman School of Medicine, Department of Obstetrics and Gynecology
| | - Courtney Schreiber
- University of Pennsylvania Perelman School of Medicine, Department of Obstetrics and Gynecology
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Crawford M, Davy S, Book N, Elliott JO, Arora A. Oral Ketorolac for Pain Relief During Intrauterine Device Insertion: A Double-Blinded Randomized Controlled Trial. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:1143-1149. [DOI: 10.1016/j.jogc.2017.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/09/2017] [Accepted: 05/10/2017] [Indexed: 10/19/2022]
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Carvalho NM, Chou V, Modesto W, Margatho D, Garcia EAL, Bahamondes L. Relationship between user satisfaction with the levonorgestrel-releasing intrauterine system and bleeding patterns. J Obstet Gynaecol Res 2017; 43:1732-1737. [PMID: 28833891 DOI: 10.1111/jog.13441] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 05/11/2017] [Accepted: 05/28/2017] [Indexed: 11/29/2022]
Abstract
AIM Satisfaction with a contraceptive method constitutes an important factor in its acceptance and long-term use. The objective of this study was to assess the relationship between user satisfaction with the 20-μg/day levonorgestrel-releasing intrauterine system (LNG-IUS) and the bleeding patterns reported at two different time-points during follow-up. METHODS A total of 251 LNG-IUS users aged 18-45 years were invited to answer a questionnaire on their return to the clinic for a routine follow-up visit and again 1 year later. Data were collected face-to-face. RESULTS Twenty women discontinued prematurely; therefore, the analysis was performed on 231 women. Most users were either highly satisfied (66.6% and 66.2% at the first and second interviews, respectively) or satisfied (26.4% and 26.4% at the first and second interviews, respectively) with the LNG-IUS. Satisfaction was related to amenorrhea (P < 0.001) and duration of use (P < 0.001). Prolonged bleeding and spotting were the main causes of dissatisfaction with the device. CONCLUSION Most LNG-IUS users in this sample were satisfied with the device. The only two factors associated with satisfaction were amenorrhea and duration of use, while prolonged bleeding and spotting were the main causes of dissatisfaction. These findings could be useful for health-care professionals and policy-makers when developing information material for women. The study provides insight into the profile of satisfied LNG-IUS users; however, this information is not suitable for counseling women who are considering using an LNG-IUS.
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Affiliation(s)
- Nelsilene M Carvalho
- Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Campinas, São Paulo, Brazil
| | - Victoria Chou
- Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Campinas, São Paulo, Brazil
| | - Waleska Modesto
- Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Campinas, São Paulo, Brazil
| | - Deborah Margatho
- Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Campinas, São Paulo, Brazil
| | - Elaine A L Garcia
- Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Campinas, São Paulo, Brazil
| | - Luis Bahamondes
- Family Planning Clinic, Department of Obstetrics and Gynaecology, University of Campinas (UNICAMP) Medical School, Campinas, São Paulo, Brazil
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Merki-Feld GS, Apter D, Bartfai G, Grandi G, Haldre K, Lech M, Lertxundi R, Lete I, Lobo Abascal P, Raine S, Roumen F, Serfaty D, Shulman LP, Skouby S, Bitzer J. ESC expert statement on the effects on mood of the natural cycle and progestin-only contraceptives. EUR J CONTRACEP REPR 2017; 22:247-249. [PMID: 28728451 DOI: 10.1080/13625187.2017.1353075] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Hormonal fluctuations during the natural cycle, as well as progestins used for hormonal contraception, can exert effects on mood especially in vulnerable women. Negative effects of levonorgestrel-releasing intrauterine contraception on mood are rare.
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Affiliation(s)
- G S Merki-Feld
- a Department of Gynecology and Obstetrics, Clinic for Reproductive Endocrinology , University Hospital Zürich , Zürich , Switzerland
| | - D Apter
- b VL-Medi Oy Clinical Research Center , Helsinki , Finland
| | - G Bartfai
- c Department of Obstetrics and Gynaecology , University of Szeged , Szeged , Hungary
| | - G Grandi
- d Department of Medical and Surgical Sciences for Mother, Child and Adult , University of Modena, and Reggio Emilia, Azienda Ospedaliero-Universitaria Policlinico , Modena , Italy
| | - K Haldre
- e Sexual Health Clinic of the Estonian Sexual Health Association , Tallinn , Estonia
| | - M Lech
- f AD REM Fertility and Sterility Research Centre , Warsaw , Poland
| | - R Lertxundi
- g Department of Sexual and Reproductive Health , Clinica Euskalduna , Bilbao , Spain
| | - I Lete
- h Araba University Hospital , Vitoria , Spain
| | - P Lobo Abascal
- i Infanta Sofía University Hospital, San Sebastián de los Reyes , Madrid , Spain
| | - S Raine
- j Nurse Specialist in Contraception , Bournemouth , UK
| | - F Roumen
- k Zuyderland Medical Centre , Heerlen-Sittard , The Netherlands
| | - D Serfaty
- l Saint-Louis Hospital , Paris , France
| | - L P Shulman
- m Department of Obstetrics and Gynecology , Feinberg School of Medicine of Northwestern University , Chicago , IL , USA
| | - S Skouby
- n Endocrinological and Reproductive Unit, Department of Obstetrics and Gynaecology , Herlev/Gentofte Hospital, Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen , Denmark
| | - J Bitzer
- o University Hospital , Basel , Switzerland
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Continuation of copper and levonorgestrel intrauterine devices: a retrospective cohort study. Am J Obstet Gynecol 2017; 217:57.e1-57.e6. [PMID: 28315664 DOI: 10.1016/j.ajog.2017.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 03/04/2017] [Accepted: 03/08/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Studies conflict on whether the duration of use of the copper intrauterine device is longer than that of the levonorgestrel intrauterine device, and whether women who continue using intrauterine devices differ from those who discontinue. OBJECTIVE We sought to assess continuation rates and performance of levonorgestrel intrauterine devices compared with copper intrauterine devices over a 5-year period. STUDY DESIGN We performed a retrospective cohort study of 1164 individuals who underwent intrauterine device placement at an urban academic medical center. The analysis focused on a comparison of continuation rates between those using levonorgestrel intrauterine device and copper intrauterine device, factors associated with discontinuation, and intrauterine device performance. We assessed the differences in continuation at discrete time points, pregnancy, and expulsion rates using χ2 tests and calculated hazard ratios using a multivariable Cox model. RESULTS Of 1164 women who underwent contraceptive intrauterine device insertion, 956 had follow-up data available. At 2 years, 64.9% of levonorgestrel intrauterine device users continued their device, compared with 57.7% of copper intrauterine device users (P = .11). At 4 years, continuation rates were 45.1% for levonorgestrel intrauterine device and 32.6% for copper intrauterine device (P < .01), and at 5 years continuation rates were 28.1% for levonorgestrel intrauterine device and 23.8% for copper intrauterine device (P = .33). Black race, primiparity, and age were positively associated with discontinuation; education was not. The hazard ratio for discontinuation of levonorgestrel intrauterine device compared with copper intrauterine device >4 years was 0.71 (95% confidence interval, 0.55-0.93) and >5 years was 0.82 (95% confidence interval, 0.64-1.05) after adjusting for race, age, parity, and education. Copper intrauterine device users were more likely to experience expulsion (10.2% copper intrauterine device vs 4.9% levonorgestrel intrauterine device, P < .01) over the study period and to become pregnant in the first year of use (1.6% copper intrauterine device vs 0.1% levonorgestrel intrauterine device, P < .01). CONCLUSION We found a difference in continuation rates between levonorgestrel and copper intrauterine device users at 4 years but not at 5 years. Copper intrauterine device users were more likely to experience expulsion and pregnancy.
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Melo J, Tschann M, Soon R, Kuwahara M, Kaneshiro B. Women's willingness and ability to feel the strings of their intrauterine device. Int J Gynaecol Obstet 2017; 137:309-313. [PMID: 28218963 DOI: 10.1002/ijgo.12130] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 12/26/2016] [Accepted: 02/16/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine how many intrauterine device (IUD) users are willing and able to palpate their IUD strings. METHODS A cross-sectional survey was conducted among IUD users presenting for their 6-week follow-up visit after insertion at the University of Hawaii, USA, between January 2011 and January 2012. Participants were asked whether they had previously felt the strings and whether they were willing to do so during the visit. Bivariate analyses and multiple logistic regression were performed. RESULTS Previous attempts to palpate IUD strings were reported by 74 (58.7%) of 126 participants, of whom 49 (66.2%) could feel the strings. At the study visit, 60 (47.6%) participants were willing to try to feel their strings; 33 (55.0%) were successful. Overall, 58 (46.0%) participants were willing and able to palpate their IUD strings at home and/or at the study visit. Fewer women who self-identified as native Hawaiian than women of other races reported previous attempts (P=0.005). Previous instruction to check IUD strings was associated with willingness to palpate them before and after controlling for native Hawaiian race (odds ratio 8.78, 95% CI 3.43-22.43; adjusted odds ratio 9.64, 95% CI 3.57-26.04). CONCLUSION Approximately half the participants were willing and able to palpate their IUD strings. Routinely counseling women to check their IUD strings could have limited clinical utility.
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Affiliation(s)
- Juliana Melo
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Mary Tschann
- Department of Obstetrics, Gynecology and Women's Health, University of Hawaii, Honolulu, HI, USA
| | - Reni Soon
- Department of Obstetrics, Gynecology and Women's Health, University of Hawaii, Honolulu, HI, USA
| | - Melissa Kuwahara
- Department of Obstetrics, Gynecology and Women's Health, University of Hawaii, Honolulu, HI, USA
| | - Bliss Kaneshiro
- Department of Obstetrics, Gynecology and Women's Health, University of Hawaii, Honolulu, HI, USA
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Mandle HB, Cahill KE, Fowler KM, Hauser WA, Davis AR, Herzog AG. Reasons for discontinuation of reversible contraceptive methods by women with epilepsy. Epilepsia 2017; 58:907-914. [PMID: 28369748 DOI: 10.1111/epi.13734] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To report the reasons for discontinuation of contraceptive methods by women with epilepsy (WWE). METHODS These retrospective data come from a web-based survey regarding the contraceptive practices of 1,144 WWE in the community, ages 18-47 years. We determined the frequencies of contraceptive discontinuations and the reasons for discontinuation. We compared risk ratios for rates of discontinuation among contraceptive methods and categories. We used chi-square analysis to test the independence of discontinuation reasons among the various contraceptive methods and categories and when stratified by antiepileptic drug (AED) categories. RESULTS Nine hundred fifty-nine of 2,393 (40.6%) individual, reversible contraceptive methods were discontinued. One-half (51.8%) of the WWE who discontinued a method discontinued at least two methods. Hormonal contraception was discontinued most often (553/1,091, 50.7%) with a risk ratio of 1.94 (1.54-2.45, p < 0.0001) compared to intrauterine devices (IUDs), the category that was discontinued the least (57/227, 25.1%). Among all individual methods, the contraceptive patch was stopped most often (79.7%) and the progestin-IUD was stopped the least (20.1%). The top three reasons for discontinuation among all methods were reliability concerns (13.9%), menstrual problems (13.5%), and increased seizures (8.6%). There were significant differences among discontinuation rates and reasons when stratified by AED category for hormonal contraception but not for any other contraceptive category. SIGNIFICANCE Contraception counseling for WWE should consider the special experience profiles that are unique to this special population on systemic hormonal contraception.
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Affiliation(s)
- Hannah B Mandle
- Harvard Neuroendocrine Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A
| | - Kaitlyn E Cahill
- Harvard Neuroendocrine Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A
| | - Kristen M Fowler
- Harvard Neuroendocrine Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A
| | - W Allen Hauser
- Gertrude H. Sergievsky Center, Mailman School of Public Health, Columbia University, New York, New York, U.S.A
| | - Anne R Davis
- Department of OBGYN, Columbia University Medical Center, New York, New York, U.S.A
| | - Andrew G Herzog
- Harvard Neuroendocrine Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A
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Long-acting reversible contraception in adolescents: a systematic review and meta-analysis. Am J Obstet Gynecol 2017; 216:364.e1-364.e12. [PMID: 28038902 DOI: 10.1016/j.ajog.2016.12.024] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 11/24/2016] [Accepted: 12/19/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Among adolescent pregnancies, 75% are unintended. Greater use of highly-effective contraception can reduce unintended pregnancy. Although multiple studies discuss adolescent contraceptive use, there is no consensus regarding the use of long-acting reversible contraception as a first-line contraception option. OBJECTIVE We performed a systematic review of the medical literature to assess the continuation of long-acting reversible contraceptives among adolescents. STUDY DESIGN Ovid-MEDLINE, Cochrane databases, and Embase databases were searched using key words relevant to the provision of long-acting contraception to adolescents. Articles published from January 2002 through August 2016 were selected for inclusion based on specific key word searches and detailed review of bibliographies. For inclusion, articles must have provided data on method continuation, effectiveness, or satisfaction of at least 1 long-acting reversible contraceptive method in participants <25 years of age. Duration of follow-up had to be ≥6 months. Long-acting reversible contraceptive methods included intrauterine devices and the etonogestrel implant. Only studies in the English language were included. Guidelines, systematic reviews, and clinical reviews were examined for additional citations and relevant points for discussion. Of 1677 articles initially identified, 90 were selected for full review. Of these, 12 articles met criteria for inclusion. All studies selected for full review were extracted by multiple reviewers; inclusion was determined by consensus among authors. For studies with similar outcomes, forest plots of combined effect estimates were created using the random effects model. The meta-analysis of observational studies in epidemiology guidelines were followed. Primary outcomes measured were continuation of method at 12 months, and expulsion rates for intrauterine devices. RESULTS This review included 12 studies, including 6 retrospective cohort studies, 5 prospective observational studies, and 1 randomized controlled trial. The 12 studies included 4886 women age <25 years: 4131 intrauterine device users and 755 implant users. The 12-month continuation of any long-acting reversible contraceptive device was 84.0% (95% confidence interval, 79.0-89.0%). Intrauterine device continuation was 74.0% (95% confidence interval, 61.0-87.0%) and implant continuation was 84% (95% confidence interval, 77.0-91.0%). Among postpartum adolescents, the 12-month long-acting reversible contraceptive continuation rate was 84.0% (95% confidence interval, 71.0-97.0%). The pooled intrauterine device expulsion rate was 8.0% (95% confidence interval, 4.0-11.0%). CONCLUSION Adolescents and young women have high 12-month continuation of long-acting reversible contraceptive methods. Intrauterine devices and implants should be offered to all adolescents as first-line contraceptive options.
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Bateson D, Harvey C, Trinh L, Stewart M, Black KI. User characteristics, experiences and continuation rates of copper intrauterine device use in a cohort of Australian women. Aust N Z J Obstet Gynaecol 2016; 56:655-661. [PMID: 27704541 DOI: 10.1111/ajo.12534] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 08/16/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Copper intrauterine device (Cu-IUD) use in Australia is low despite being a highly effective, cost effective non-hormonal contraceptive with reported 12-month continuation rates of 85% compared to 59% for oral contraception. AIMS To describe the characteristics of Cu-IUD users in the Australian context, their experiences of side effects, continuation rates and reasons for discontinuation. METHODS Between August 2009 and January 2012 we undertook a prospective cohort study of consecutive women presenting for Cu-IUD insertion to three family planning clinics in Queensland and New South Wales. We used survival analysis for continuation rates and univariate and multivariable analyses to characterise users, their experiences up to three years and reasons for discontinuation. RESULTS Of the 211 enrolled women, a third (36.0%) were aged under 30 and a third were nulliparous (36.5%). Efficacy and lack of hormones were the most frequently cited reasons to choose the method. Four women were lost to follow-up. Overall continuation rates were 79.1% at one year and 61.3% at three years. Early discontinuation was reduced in those with two or more children (adjusted hazards ratio 0.22, 95% CI 0.09-0.50). Heavy menstrual bleeding was the commonest reason for removal in 28 of 59 (47.5%) discontinuations due to complications or side effects. One uterine perforation and one method failure resulting in an ectopic pregnancy occurred. CONCLUSIONS Cu-IUDs were chosen for their efficacy and lack of hormones by a range of Australian women, including young and nulliparous women. While bleeding-related side effects were relatively common, overall continuation rates were high. Serious complications and failures were rare.
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Affiliation(s)
- Deborah Bateson
- Family Planning NSW, Sydney, New South Wales, Australia.,Discipline of Obstetrics, Gynaecology and Neonatology, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Caroline Harvey
- Family Planning Queensland (now called True Relationships and Reproductive Choice), Brisbane, Queensland, Australia
| | - Lieu Trinh
- Family Planning NSW, Sydney, New South Wales, Australia
| | - Mary Stewart
- Family Planning NSW, Sydney, New South Wales, Australia
| | - Kirsten I Black
- Discipline of Obstetrics, Gynaecology and Neonatology, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Sitruk-Ware R, Inki P. The Levonorgestrel Intrauterine System: Long-Term Contraception and Therapeutic Effects. WOMENS HEALTH 2016; 1:171-82. [DOI: 10.2217/17455057.1.2.171] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The levonorgestrel intrauterine system (Mirena®) has been developed as a long-acting method of contraception. This medicated device, inserted into the uterus, delivers a small daily dose of a progestin, levonorgestrel, into the uterine cavity. It is one of the most effective methods of contraception and is approved in more than 100 countries for 5 years of use.
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Affiliation(s)
- Regine Sitruk-Ware
- Population Council, 1230 York Avenue, New York 10021, USA, Tel.: +1 212 327 7045; Fax: +1 212 327 7678
| | - Pirjo Inki
- Schering Oy, PO Box 415 20101 Turku, Finland, Tel.: +358 405 501 519; Fax: +358 2 333 2648
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Chiles DP, Roberts TA, Klein DA. Initiation and continuation of long-acting reversible contraception in the United States military healthcare system. Am J Obstet Gynecol 2016; 215:328.e1-9. [PMID: 27005514 DOI: 10.1016/j.ajog.2016.03.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 03/09/2016] [Accepted: 03/14/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Long-acting reversible contraception is more effective for pregnancy prevention than shorter-acting contraceptive methods and has the potential to reduce healthcare disparities and costs. However, long-acting reversible contraception is underused in the United States. One population of interest is beneficiaries of the United States military healthcare system who have access to universal healthcare, including no-cost, no-copay contraception with unlimited method switching, and comprise a large, actual use cohort. Efforts to increase long-acting reversible contraception initiation and continuation in this population may improve health outcomes and mitigate the profound consequences of unintended or mistimed pregnancy on readiness and cost to the military. OBJECTIVE We aimed to determine long-acting reversible contraception initiation and continuation rates among the diverse population with universal healthcare who are enrolled in the US military healthcare system. STUDY DESIGN This study is a retrospective cohort of >1.7 million women, aged 14-40 years, who were enrolled in the US military healthcare system, TRICARE Prime, between October 2009 and September 2014. Individuals were assessed for long-acting reversible contraception initiation and continuation with the use of medical billing records. Method continuation and factors that were associated with early method discontinuation were evaluated with the Kaplan-Meier estimator and Cox proportional hazard models. RESULTS During the study dates, 188,533 women initiated long-acting reversible contraception. Of these, 74.6% women selected intrauterine contraceptives. Method initiation rates remained relatively stable (41.7-50.1/1000 women/year) for intrauterine methods, although the rate for subdermal implants increased from 6.1-23.0/1000 women/year. In analysis of women who selected intrauterine contraceptives, 61.2% continued their method at 36 months, and 48.8% continued at 60 months. Among women who selected the implant, 32.0% continued their method at 36 months; however, 45.8% continued until 33 months (ie, 3 months before the currently recommended expiration date). Compared with intrauterine contraceptive users, implant users were more likely to discontinue their method during the 36 months after insertion (hazard ratio, 1.59; 95% confidence interval, 1.56-1.62; P < .001). Adolescents aged 14-19 years were the least likely age group to discontinue the implant before 36 months; women aged 35-40 years were the least likely to discontinue an intrauterine contraceptive before 60 months. In multivariable analysis that controlled for demographic factors and contraceptive type, early contraceptive method discontinuation was most likely among women aged 20-24 years, implant users, and women with method initiation in military clinics. CONCLUSION In the US military healthcare system, TRICARE Prime, the initiation of long-acting reversible contraception is low but increasing, and continuation rates are high. This evidence supports long-acting reversible contraception as first-line recommendations for women of all ages who seek contraception.
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Affiliation(s)
- Daniel P Chiles
- Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX; Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Timothy A Roberts
- Department of Pediatrics, San Antonio Military Medical Center, San Antonio, TX; Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - David A Klein
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD; Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD.
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Rowe P, Farley T, Peregoudov A, Piaggio G, Boccard S, Landoulsi S, Meirik O. Safety and efficacy in parous women of a 52-mg levonorgestrel-medicated intrauterine device: a 7-year randomized comparative study with the TCu380A. Contraception 2016; 93:498-506. [PMID: 26916172 PMCID: PMC5357727 DOI: 10.1016/j.contraception.2016.02.024] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 02/17/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare rates of unintended pregnancy, method continuation and reasons for removal among women using the 52-mg levonorgestrel (daily release 20 microg) intrauterine device (LNG-IUD) or the copper T 380 A IUD (TCu380A). STUDY DESIGN This was an open-label 7-year randomized controlled trial in 20 centres, 11 of which in China. Data on 1884 women with interval insertion of the LNG-IUD and 1871 of the TCu380A were analysed using life tables with 30-day intervals and Cox proportional hazards models. RESULTS The cumulative 7-year pregnancy rate of the LNG-IUD was 0.5 (standard error 0.2) per 100, significantly lower than 2.5 (0.4) per 100 of the TCu380A, cumulative method discontinuation rates at 7 years were 70.6 (1.2) and 40.8 (1.3) per 100, respectively. Dominant reasons for discontinuing the LNG-IUD were amenorrhea (26.1 [1.3] per 100) and reduced bleeding (12.5 [1.1] per 100), particularly in Chinese women and, for the TCu380A, increased bleeding (9.9 [0.9] per 100), especially among non-Chinese women. Removal rates for pain were similar for the two intrauterine devices (IUDs). Cumulative rates of removal for symptoms compatible with hormonal side effects were 5.7 (0.7) and 0.4 (0.2) per 100 for the LNG-IUD and TCu380A, respectively, and cumulative losses to follow-up at 7 years were 26.0 (1.4) and 36.9 (1.3) per 100, respectively. CONCLUSION The LNG-IUD and the TCu380A have very high contraceptive efficacy, with the LNG-IUD significantly higher than the TCu380A. Overall rates of IUD removals were higher among LNG-IUD users than TCu380A users. Removals for amenorrhea appeared culturally associated. IMPLICATIONS The 52-mg LNG-IUD and the TCu380A have very high contraceptive efficacy through 7 years. As an IUD, the unique side effects of the LNG-IUD are reduced bleeding, amenorrhea and symptoms compatible with hormonal contraceptives.
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Affiliation(s)
- Patrick Rowe
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland
| | - Tim Farley
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland
| | - Alexandre Peregoudov
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland
| | - Gilda Piaggio
- Medical Statistics Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Simone Boccard
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland
| | - Sihem Landoulsi
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Olav Meirik
- Instituto Chileno de Medicina Reproductiva (ICMER), Santiago, Chile.
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Abstract
INTRODUCTION Intrauterine devices (IUD) are viewed as important contraceptive methodologies to prevent unintended pregnancy. AREAS COVERED This expert opinion examines the place of frameless devices for use in young women in order to minimize side effect, improve patient comfort and maximize continuation of use to help reduce unintended pregnancies. EXPERT OPINION Frameless designed IUDs have the ability to be used in both small and large uterine cavities of varied shapes and can significantly reduce abnormal bleeding, pain, embedment and expulsion and likely account for higher continuation rates than that seen with framed IUDs.
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Affiliation(s)
- Dirk Wildemeersch
- a Gynecological Outpatient Clinic and IUD Training Center , Ghent , Belgium
| | - Norman D Goldstuck
- b Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences , Stellenbosch University and Tygerberg Hospital , Western Cape , South Africa
| | - Thomas Hasskamp
- c Klinik für Operativen Gynäkologie, GynMünster , Münster , Germany
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Intrauterine Contraception Among Women Living With Human Immunodeficiency Virus: A Randomized Controlled Trial. Obstet Gynecol 2016; 126:928-934. [PMID: 26444127 DOI: 10.1097/aog.0000000000001087] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare discontinuation rates of the levonorgestrel and copper intrauterine devices (IUDs) among women with human immunodeficiency virus. METHODS A double-masked randomized trial was conducted at Mulago Hospital, Uganda. Women received either a copper or levonorgestrel IUD. The primary outcome was discontinuation of intrauterine contraception within 1 year of placement. The secondary outcomes were incidence of side effects and severe adverse events. To discern a difference of 10% from a copper IUD discontinuation rate of 18%, power of 80%, and 95% confidence interval (CI), a sample size of 351 per arm was estimated. Analysis of the primary outcome was by intension-to-treat principle. RESULTS From September 2013 to December 2014, 979 were screened and 703 randomized as follows: 349 to the copper group and 354 to the levonorgestrel group. In total, 8.6% (29/338) women in the copper group compared with 8.1% (27/334) in the levonorgestrel group discontinued intrauterine conception within 1 year of placement (incidence rate ratio 1.1 [95% CI 0.64-1.96]). Overall, the incidence of heavy bleeding was higher in the copper group (37% [125/338]) than in the levonorgestrel group (19.5% [65/334]). However, the incidence of amenorrhea, which occurred in 3.3% (11/338) of women, was lower in the copper group than the 19.8% (66/334) of women who reported amenorrhea in the levonorgestrel group. CONCLUSION There was no difference in discontinuation rates between the copper and levonorgestrel devices. Women in the levonorgestrel group had reduced incidence of heavy bleeding and a higher incidence of amenorrhea compared with those in the copper group. CLINICAL TRIAL REGISTRATION Pan African Clinical Trial Registry, www.pactr.org, PACTR 201308000561212. LEVEL OF EVIDENCE I.
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Simonatto P, Bahamondes MV, Fernandes A, Silveira C, Bahamondes L. Comparison of two cohorts of women who expulsed either a copper-intrauterine device or a levonorgestrel-releasing intrauterine system. J Obstet Gynaecol Res 2016; 42:554-9. [PMID: 26817571 DOI: 10.1111/jog.12939] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 11/10/2015] [Accepted: 12/02/2015] [Indexed: 11/28/2022]
Abstract
AIM To assess if there is a difference in the characteristics of the women who expelled a copper-intrauterine device (TCu-IUD) or the levonorgestrel-releasing intrauterine system (LNG-IUS) and the frequency of expulsions over different periods of observation. METHODS We retrospectively analyzed 19 697 medical charts of women consulting between January 1980 and December 2013 who requested a TCu-IUD or a LNG-IUS. RESULTS The medical records of 17 644 Cu-IUD and 2053 LNG-IUS users returning to the clinic for a follow-up visit after insertion of an IUC were reviewed. Of these, 1532 Cu-IUD and 254 LNG-IUS parous users were found to have expelled the IUC for a first time. The mean age at insertion (± standard deviation) was 26.3 ± 6.6 years (range 16-49) for Cu-IUD users and 31.7 ± 7.6 years (range 18-48) for LNG-IUS users (P < 0.001). A total of 263 (13.4%) and 12 (4.3%) of the Cu-IUD and the LNG-IUS users were ≤19 years old, and 49.1% and 54.1% of the expulsions among the Cu-IUD and LNG-IUS users, respectively, were reported in the first six months after placement. A regression model showed that the variables significantly associated with an expulsion of either a Cu-IUD or LNG-IUS were age < 25 years, less than two deliveries and using a Cu-IUD. CONCLUSION Our findings showed that the characteristics associated with IUC expulsion were age under 25 years, having had less than two deliveries and being users of Cu-IUD.
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Affiliation(s)
- Paula Simonatto
- Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medical Sciences and the National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Maria Valeria Bahamondes
- Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medical Sciences and the National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Arlete Fernandes
- Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medical Sciences and the National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Carolina Silveira
- Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medical Sciences and the National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Luis Bahamondes
- Human Reproduction Unit, Department of Obstetrics and Gynaecology, School of Medical Sciences and the National Institute of Hormones and Women's Health, University of Campinas (UNICAMP), Campinas, SP, Brazil
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Abstract
Permanent methods of contraception are used by an estimated 220 million couples worldwide, and are often selected due to convenience, ease of use and lack of side effects. A variety of tubal occlusion techniques are available for female permanent contraception, and procedures can be performed using a transcervical or transabdominal approach. This article reviews currently available techniques for female permanent contraception and discusses considerations when helping patients choose a contraceptive method and tubal occlusion technique.
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Affiliation(s)
- Elizabeth A Micks
- Department of Obstetrics & Gynecology, University of Washington, 1959 NE Pacific St, Box 356460, Seattle, WA 98195-6460, USA
| | - Jeffrey T Jensen
- Department of Obstetrics & Gynecology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
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Diedrich JT, Madden T, Zhao Q, Peipert JF. Long-term utilization and continuation of intrauterine devices. Am J Obstet Gynecol 2015; 213:822.e1-6. [PMID: 26409157 DOI: 10.1016/j.ajog.2015.08.077] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 08/19/2015] [Accepted: 08/28/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We compared the 48 and 60 month continuation rates of levonorgestrel (LNG) and copper (Cu) intrauterine devices (IUDs) among women enrolled in the Contraceptive CHOICE Project (CHOICE). Our primary outcome was continuation at 48 months. STUDY DESIGN This is a prospective cohort study of women who received an IUD through CHOICE. We randomly selected women who had either LNG or Cu IUDs inserted between January 2008 and June 2009 and contacted them by telephone. Once contacted and consented, they were asked whether they were still using their IUD. Women who reported discontinuation of the IUD were asked for the reasons and subsequent contraceptive use. Survival analysis using Cox proportional hazards was performed to assess for factors associated with discontinuation and to calculate hazard ratios. RESULTS Of the 460 women we attempted to contact, 321 (70%) were reached for interviews. Continuation data on the remaining 139 women were available from CHOICE and its substudies. Continuations at 48 and 60 months were 62.3% and 51.7% for LNG IUD and 64.2% and 55.9% for the Cu IUD, respectively. Continuation at 48 months was highest among women older than 29 years of age at insertion (LNG IUD, 72.5%; Cu IUD, 77.1%). Women younger than 24 years of age had the lowest 48 month continuation (LNG IUD, 55.4%, and Cu IUD, 53.2%). In univariable and multivariable analysis, demographic characteristics, menstrual profile, and pregnancy history were not associated with discontinuation. Age older than 29 years was associated with less discontinuation than those 24-29 years of age (hazard ratio, 0.67, 95% confidence interval, 0.47-0.96). CONCLUSION IUD continuation remains high (> 60%) at 48 months with no difference between Cu and LNG IUDs.
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Affiliation(s)
- Justin T Diedrich
- Divisions of Family Planning and Clinical Research, Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St Louis, MO
| | - Tessa Madden
- Divisions of Family Planning and Clinical Research, Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St Louis, MO
| | - Qiuhong Zhao
- Divisions of Family Planning and Clinical Research, Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St Louis, MO
| | - Jeffrey F Peipert
- Divisions of Family Planning and Clinical Research, Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, St Louis, MO.
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Patil E, Bednarek PH. Immediate Intrauterine Device Insertion Following Surgical Abortion. Obstet Gynecol Clin North Am 2015; 42:583-91. [DOI: 10.1016/j.ogc.2015.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Woo I, Seifert S, Hendricks D, Jamshidi RM, Burke AE, Fox MC. Six-month and 1-year continuation rates following postpartum insertion of implants and intrauterine devices. Contraception 2015; 92:532-5. [DOI: 10.1016/j.contraception.2015.09.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 09/19/2015] [Accepted: 09/21/2015] [Indexed: 10/23/2022]
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Diedrich JT, Zhao Q, Madden T, Secura GM, Peipert JF. Three-year continuation of reversible contraception. Am J Obstet Gynecol 2015; 213:662.e1-8. [PMID: 26259905 PMCID: PMC5292132 DOI: 10.1016/j.ajog.2015.08.001] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/20/2015] [Accepted: 08/02/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this analysis was to estimate the 3-year continuation rates of long-acting reversible contraceptive (LARC) methods and to compare these rates to non-LARC methods. STUDY DESIGN The Contraceptive CHOICE Project (CHOICE) was a prospective cohort study that followed 9256 participants with telephone surveys at 3 and 6 months, then every 6 months for 2-3 years. We estimated 3-year continuation rates of baseline methods that were chosen at enrollment. The LARC methods include the 52-mg levonorgestrel intrauterine device; the copper intrauterine device, and the subdermal implant). These were then compared to rates to non-LARC hormonal methods (depot medroxyprogesterone acetate, oral contraceptive pills, contraceptive patch, and vaginal ring). Eligibility criteria for this analysis included participants who started their baseline chosen method by the 3-month survey. Participants who discontinued their method to attempt conception were censored. We used a Cox proportional hazard model to adjust for confounding and to estimate the hazard ratio for risk of discontinuation. RESULTS Our analytic sample consisted of 4708 CHOICE participants who met inclusion criteria. Three-year continuation rates were 69.8% for users of the levonorgestrel intrauterine device, 69.7% for copper intrauterine device users, and 56.2% for implant users. At 3 years, continuation was 67.2% among LARC users and 31.0% among non-LARC users (P < .001). After adjustment for age, race, education, socioeconomic status, parity, and history of sexually transmitted infection, the hazard ratio for risk of discontinuation was 3-fold higher among non-LARC method users than LARC users (adjusted hazard ratio, 3.08; 95% confidence interval, 2.80-3.39). CONCLUSION Three-year continuation of the 2 intrauterine devices approached 70%. Continuation of LARC methods was significantly higher than non-LARC methods.
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Affiliation(s)
- Justin T Diedrich
- Divisions of Family Planning and Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Qiuhong Zhao
- Divisions of Family Planning and Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Tessa Madden
- Divisions of Family Planning and Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Gina M Secura
- Divisions of Family Planning and Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jeffrey F Peipert
- Divisions of Family Planning and Clinical Research, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO.
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The new LNG-releasing IUS: a new opportunity to reduce the burden of unintended pregnancy. Eur J Obstet Gynecol Reprod Biol 2015; 190:58-64. [DOI: 10.1016/j.ejogrb.2015.04.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 04/23/2015] [Accepted: 04/27/2015] [Indexed: 11/30/2022]
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Use of the etonogestrel implant and levonorgestrel intrauterine device beyond the U.S. Food and Drug Administration-approved duration. Obstet Gynecol 2015; 125:599-604. [PMID: 25730221 DOI: 10.1097/aog.0000000000000690] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of the contraceptive implant and the 52-mg hormonal intrauterine device (IUD) in women using the method beyond the current U.S. Food and Drug Administration (FDA)-approved duration of 3 and 5 years, respectively. METHODS Women willing to continue using their implant or 52-mg levonorgestrel IUD beyond the FDA-approved duration were followed prospectively for contraceptive effectiveness. Unintended pregnancy rate per 100 women-years was calculated. Implant users are offered periodic venipuncture for analysis of serum etonogestrel levels. The Kruskal-Wallis test was used to compare the etonogestrel levels across body mass index (BMI) groups. RESULTS Implant users (n=237) have contributed 229.4 women-years of follow-up, with 123 using the etonogestrel implant for 4 years and 34 using it for 5 years. Zero pregnancies have been documented, for a failure rate of 0 (one-sided 97.5% confidence interval [CI] 0-1.61) per 100 women-years. Among 263 levonorgestrel IUD users, 197.7 women-years of follow-up have been completed. One pregnancy was confirmed, for a failure rate of 0.51 (95% CI 0.01-2.82) per 100 women-years. Among implant users with serum etonogestrel results, the median and range of etonogestrel level at 3 years of use was 188.8 pg/mL (range 63.8-802.6 pg/mL) and 177.0 pg/mL (67.9-470.5 pg/mL) at 4 years of use. Etonogestrel levels did not differ by BMI at either time point (3 years: P=.79; 4 years: P=.47). CONCLUSION Preliminary findings indicate the contraceptive implant and 52-mg hormonal IUD continue to be highly effective for an additional year beyond the FDA-approved 3 and 5 years. Serum etonogestrel levels indicate the implant contains adequate hormone for ovulation suppression at the end of both 3 and 4 years of use. LEVEL OF EVIDENCE II.
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Heinemann K, Reed S, Moehner S, Do Minh T. Comparative contraceptive effectiveness of levonorgestrel-releasing and copper intrauterine devices: the European Active Surveillance Study for Intrauterine Devices. Contraception 2015; 91:280-3. [DOI: 10.1016/j.contraception.2015.01.011] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 01/08/2015] [Accepted: 01/12/2015] [Indexed: 10/24/2022]
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Kaneshiro B, Salcedo J. Contraception for Adolescents: Focusing on Long-Acting Reversible Contraceptives (LARC) to Improve Reproductive Health Outcomes. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015; 4:53-60. [PMID: 27635305 PMCID: PMC5021306 DOI: 10.1007/s13669-015-0112-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Adolescent pregnancy rates in the U.S. have reached an all-time low from their peak in the 1980s and 1990s. However, the U.S. maintains the highest rate of teenage pregnancy among developed nations. Adolescents experience higher typical use failure rates for user-dependent contraceptives compared to their adult counterparts. Long-acting reversible contraception (LARC), IUDs and implants, have failure rates that are both very low and independent of user age. In settings where the most effective methods are prioritized and access barriers are removed, the majority of adolescents initiate LARC. Use of LARC by adolescents significantly reduces rates of overall and repeat teen pregnancy. All methods of contraception are safe for use in teens, including IUDs and DMPA. Dual use of LARC and barrier methods to reduce risk of sexually transmitted infection, is the optimal contraceptive strategy for most adolescents. Adolescent access to evidence-based and confidential contraceptive services, provided in a manner that respects autonomy, is a vital public health goal.
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Affiliation(s)
- Bliss Kaneshiro
- Department of Obstetrics, Gynecology and Women’s Health University of Hawaii John A. Burns School of Medicine, 1319 Punahou Street #824, Honolulu, HI 96826, Phone: (808) 203-6500, Fax: (808) 955-2175
| | - Jennifer Salcedo
- Department of Obstetrics, Gynecology and Women’s Health University of Hawaii John A. Burns School of Medicine, 1319 Punahou Street #824, Honolulu, HI 96826, Phone: (808) 203-6500, Fax: (808) 955-2175
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Abstract
OBJECTIVE To investigate whether age 14 to 19 years and nulliparity are associated with expulsion of levonorgestrel and copper intrauterine devices (IUDs). METHODS This was a planned secondary analysis of the Contraceptive CHOICE Project. We used Kaplan-Meier survival analysis to estimate expulsion rates for the first levonorgestrel or copper IUD received during study participation. Cox proportional hazards regression models were used to investigate baseline characteristics associated with expulsion. RESULTS A total of 5,403 females were included; 4,219 (78%) used the levonorgestrel IUD and 1,184 (22%) used the copper IUD. There were 432 initial expulsions reported. The 36-month cumulative expulsion rate was 10.2 per 100 IUD users and did not vary by IUD type (levonorgestrel IUD 10.1 compared with copper IUD 10.7, P=.99). In the bivariate analysis, multiple characteristics including age, nulliparity, immediate postabortion insertion, and heavy menses were associated with expulsion. The cumulative rate of expulsion was lower in nulliparous women compared with parous women (8.4 compared with 11.4; P<.001) and higher in females aged 14 to 19 compared with older women (18.8 compared with 9.3; P<.001). After adjusting for confounders and stratifying by IUD type, the hazard ratio of expulsion for females aged 14 to 19 years was 2.26 (95% confidence interval [CI] 1.68-3.06) for the levonorgestrel IUD and 3.06 (95% CI 1.75-5.33) for the copper IUD. Compared to parous levonorgestrel IUD users, expulsion was lower for nulliparous levonorgestrel IUD users (adjusted hazard ratio 0.59, 95% CI 0.44-0.78). CONCLUSION IUD expulsions were not increased in nulliparous females. More expulsions were observed in females aged 14 to 19 compared with older women regardless of parity or IUD type. LEVEL OF EVIDENCE : II.
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Extended use of the intrauterine device: a literature review and recommendations for clinical practice. Contraception 2014; 89:495-503. [DOI: 10.1016/j.contraception.2014.02.011] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 02/15/2014] [Accepted: 02/17/2014] [Indexed: 11/17/2022]
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Abstract
This article summarizes the literature regarding the epidemiology and prevention of unintended pregnancy in the United States. Because of the Affordable Care Act and its accompanying contraceptive provision, there is a need for more primary care clinicians to provide family planning services. Office-based interventions to incorporate family planning services in primary care are presented, including clinical tools and electronic health record use. Special attention is paid to long-acting reversible contraceptive methods (the subdermal implant and intrauterine devices); these highly effective and safe methods have the greatest potential to decrease the rate of unintended pregnancy, but have been underused.
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Zhou J, Tan X, Song X, Zhang K, Fang J, Peng L, Qi W, Nie Z, Li M, Deng R, Yan C. Temporal Trends of Copper-Bearing Intrauterine Device Discontinuation. Asia Pac J Public Health 2014; 27:NP2433-42. [DOI: 10.1177/1010539513517259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Copper-bearing intrauterine device (IUD) insertion for long-term contraceptive use is high in China, but there has been evidence that first-year discontinuation rate of copper-bearing IUD has also increased rapidly in recent years especially among rural married women. To investigate long-term use of copper-bearing IUD, the authors examined the 7-year temporal trends of copper-bearing IUD discontinuation in a population-based birth-cohort study among 720 rural married women in China, from 2004 to 2012. Women requesting contraception were followed-up twice per year after the insertion of IUD. The gross cumulative life table discontinuation rates were calculated for each of the main reasons for discontinuation as well as for all reasons combined. By the end of 7 years, 384 discontinuations were observed. With a stepped-up trend, the gross cumulative life table rate for discontinuation increased from 10.06 (95% confidence interval = 7.86-12.27) per 100 women by the first year to 52.69 (95% confidence interval = 48.94-56.44) per 100 women by the end of 7 years, which increased rapidly in the first 2 years after copper-bearing IUD insertion, flattened out gradually in the following 2 years, then increased again in the last 3 years. Among reported method failure, expulsion and side effects were the main reasons for discontinuation of the copper-bearing IUD but not pregnancy. Personal reasons, such as renewal by personal will had influenced copper-bearing IUD use since the second year and should not be neglected. Based on this study, the temporal trends of copper-bearing IUD discontinuation was in a stepped-up trend in 7 years after insertion. Both reported method failure (expulsion and side effect) and personal reason had effect on the discontinuation of copper-bearing IUD, but pregnancy was no more the most important reason affecting the use of copper-bearing IUD.
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Affiliation(s)
- Jie Zhou
- Wuhan University, Wuhan, China
- Kunming Medical University, Kunming, China
| | | | - Xiangjing Song
- Yunnan Institute of Population and Family Planning Research, Kunming, China
| | | | - Jing Fang
- Kunming Medical University, Kunming, China
| | - Lin Peng
- Yunnan Institute of Population and Family Planning Research, Kunming, China
| | - Wencai Qi
- Family Planning Centre of Yuanmou County in Yunnan Province, Yuanmou, China
| | - Zonghui Nie
- Health Bureau of Yuanmou County, Yuanmou, China
| | - Ming Li
- Maternal and Child Care Service Centre of Yuanmou County, Yuanmou, China
| | - Rui Deng
- Kunming Medical University, Kunming, China
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Prescott GM, Matthews CM. Long-Acting Reversible Contraception: A Review in Special Populations. Pharmacotherapy 2013; 34:46-59. [DOI: 10.1002/phar.1358] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Gina M. Prescott
- Department of Pharmacy Practice; University at Buffalo School of Pharmacy and Pharmaceutical Sciences; Buffalo New York
| | - Christina M. Matthews
- Department of Pharmacy Practice; University at Buffalo School of Pharmacy and Pharmaceutical Sciences; Buffalo New York
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Dermish AI, Turok DK. The copper intrauterine device for emergency contraception: an opportunity to provide the optimal emergency contraception method and transition to highly effective contraception. Expert Rev Med Devices 2013; 10:477-88. [PMID: 23895075 DOI: 10.1586/17434440.2013.811865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Worldwide, 40% of all pregnancies are unintended. Widespread, over-the-counter availability of oral emergency contraception (EC) has not reduced unintended pregnancy rates. The EC visit presents an opportunity to initiate a highly effective method of contraception in a population at high risk of unintended pregnancy who are actively seeking to avoid pregnancy. The copper intrauterine device (IUD), the most effective method of EC, continues to provide contraception as effective as sterilization for up to 12 years, and it should be offered as the first-line method of EC wherever possible. Increased demand for and supply of the copper IUD for EC may have an important role in reducing rates of unintended pregnancy. The EC visit should include access to the copper IUD as optimal care but should ideally include access to all highly effective methods of contraception.
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Affiliation(s)
- Amna I Dermish
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
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Hubacher D, Masaba R, Manduku CK, Veena V. Uptake of the levonorgestrel intrauterine system among recent postpartum women in Kenya: factors associated with decision-making. Contraception 2013; 88:97-102. [DOI: 10.1016/j.contraception.2013.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 03/01/2013] [Accepted: 03/05/2013] [Indexed: 10/27/2022]
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Wildemeersch D, Pett A, Jandi S, Hasskamp T, Rowe P, Vrijens M. Precision intrauterine contraception may significantly increase continuation of use: a review of long-term clinical experience with frameless copper-releasing intrauterine contraception devices. Int J Womens Health 2013; 5:215-25. [PMID: 23658502 PMCID: PMC3645905 DOI: 10.2147/ijwh.s42784] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective The purpose of this paper is to review the experience with the frameless, anchored, GyneFix copper-releasing intrauterine contraceptive devices (IUCDs/IUDs) (Contrel Europe, Belgium), and to demonstrate their high acceptability and low rate of discontinuation of use, which could contribute to current efforts that aim to reduce radically the high number of unintended pregnancies and induced abortions, particularly in young women. Materials and methods This paper is based on studies that examined the differences in uterine volume and cavity size, related to age and parity, and on original clinical research data and practical experience with frameless copper IUDs, as well as on literature data on the IUD–endometrial cavity relationship of conventional IUDs, with special reference to side effects and user discontinuation. Results The mean transverse diameter in nulliparous and parous women is significantly less than the length of the transverse arm of the TCu380A IUD (ParaGard, Duramed, NY, USA) or the levonorgestrel intrauterine system (Mirena, Bayer, Germany). Small, frameless, flexible, and unidimensional copper IUDs appear to be well tolerated, with less impact on menstrual bleeding, resulting in low discontinuation rates when compared with standard-size conventional IUDs, which often result in increased expulsion rates, complaints of pain and erratic or increased menstrual bleeding, and subsequent high rates of discontinuation, particularly in young women. Conclusion The unidimensional GyneFix IUDs fit the majority of uterine cavities. An IUD that fits is likely to result in increased tolerance and continued use of the method. As this would appeal to women, the logical result should be greater use of the method and fewer unintended pregnancies and induced abortions. Recommending the standard TCu380A (ParaGard) IUD or the Mirena levonorgestrel intrauterine system, primarily developed for use in parous women, for general use in nulliparous and adolescent women should be done with caution in the light of current scientific evidence, except if 3-D sonography indicates that the uterine cavity is sufficiently large.
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Affiliation(s)
- Dirk Wildemeersch
- Gynecological Outpatient Clinic and IUD Training Center, Ghent, Belgium
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Santos ARG, Bahamondes MV, Hidalgo MM, Atti A, Bahamondes L, Monteiro I. Pain at insertion of the levonorgestrel-releasing intrauterine system in nulligravida and parous women with and without cesarean section. Contraception 2013; 88:164-8. [PMID: 23507169 DOI: 10.1016/j.contraception.2012.10.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Revised: 10/11/2012] [Accepted: 10/12/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Despite the high contraceptive effectiveness and noncontraceptive benefits of the levonorgestrel-releasing intrauterine system (LNG-IUS) in nulligravidas, there are still concerns related to the use of this device. Pain at insertion is one of the limitations to the increased use of intrauterine contraceptives. The aim of the study was to evaluate the ease of insertion and occurrence of pain at insertion of the LNG-IUS in nulligravidas (women who never became pregnant) compared to parous women with and without cesarean section (c-section). We also assessed the difficulty at insertion in each group. METHODS Three groups of new acceptors of the LNG-IUS were studied: one with 23 nulligravida women, one with 28 parous women who had undergone at least one c-section and one with 23 parous women who had no previous c-section. Pain at insertion was evaluated by using a pain visual analogue score (VAS). The ease of insertion was defined as easy or difficult by health care providers (HCPs) and classified according to the cause of difficulty: tight cervix, anatomically distorted uterus or pain. RESULTS Almost all women reported pain at insertion, regardless of parity and form of delivery. The mean VAS was 6.6 for nulligravida women, 5.2 for parous women with c-section and 5.9 for parous women with no c-section. Although 93% of the women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS again if needed. The most common difficulties were a tight cervix in nulligravidas, an anatomically distorted uterus in parous women with c-section and pain in parous women without c-section. There was no failure of insertion in any group. HCPs reported that it was easier to perform insertion in parous women who had undergone only vaginal deliveries than nulligravid women or parous women with a prior c-section. CONCLUSIONS Although almost all women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS if needed. This attitude reflects high satisfaction with the LNG-IUS. The type of difficulty at insertion was related to parity and type of delivery. The LNG-IUS was able to be inserted in all women; however, it was easier to do in parous women without c-section than nulligravid women or those with a prior C-section.
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Affiliation(s)
- Ana Raquel Gouvea Santos
- Human Reproduction Unit, Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
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