CLINICAL PRACTICEIntrauterine devices and pelvic inflammatory disease: an international perspective
Abstract
The risk of pelvic inflammatory disease (PID) associated with use of an intrauterine device (IUD) has been an important concern that has dominated decisions on its use throughout the world, especially in the USA. Early research that suggested such an association led to both a dramatic decline in use of the method and its withdrawal from the US market by two manufacturers. However, factors other than use of an IUD are now thought to be major determinants of PID risk. To address these concerns, we have reviewed the World Health Organisation's IUD clinical trial data to explore the incidence and patterns of PID risk with use of an IUD. The overall rate of PID among 22 908 IUD insertions and during 51 399 woman-years of follow-up was 1·6 cases per 1000 woman-years of use. After adjustment for confounding factors, PID risk was more than six times higher during the 20 days after insertion than during later times (unadjusted rates, 9·7 vs 1 ·4 per 1000 woman-years, respectively); the risk was low and constant for up to eight years of follow-up. Rates varied according to geographical area (highest in Africa and lowest in China) and were inversely associated with age. PID rates were lower among women who had IUDs inserted more recently. Our findings indicate that PID among IUD users is most strongly related to the insertion process and to background risk of sexually transmissible disease. PID is an infrequent event beyond the first 20 days after insertion. Because of this increased risk with insertion, IUDs should be left in place up to their maximum lifespan and should not routinely be replaced earlier, provided there are no contraindications to continued use and the woman wishes to continue with the device. Lancet 1992; 339: 785-88.
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Cited by (588)
Society of Family Planning Clinical Recommendation: Emergency contraception
2023, ContraceptionEmergency contraception (EC) refers to several contraceptive options that can be used within a few days after unprotected or under protected intercourse or sexual assault to reduce the risk of pregnancy. Current EC options available in the United States include the copper intrauterine device (IUD), levonorgestrel (LNG) 52 mg IUD, oral LNG (such as Plan B One-Step, My Way, Take Action), and oral ulipristal acetate (UPA) (ella). These clinical recommendations review the indications, effectiveness, safety, and side effects of emergency contraceptive methods; considerations for the use of EC by specific patient populations and in specific clinical circumstances and current barriers to emergency contraceptive access. Further research is needed to evaluate the effectiveness of LNG IUDs for emergency contraceptive use; address the effects of repeated use of UPA at different times in the same menstrual cycle; assess the impact on ovulation of initiating or reinitiating different regimens of regular hormonal contraception following UPA use; and elucidate effective emergency contraceptive pill options by body mass indices or weight.
Evolution of contraceptive practices in France: An overview from 2014 to 2019
2022, Gynecologie Obstetrique Fertilite et SenologieNous avons étudié l’utilisation des différentes méthodes de contraception remboursées en France entre 2014 et 2019, avec une analyse des utilisatrices par tranches d’âge et une analyse selon le type de prescripteur.
Nous avons mené une étude descriptive nationale à partir des données issues de la base Open Data de l’Assurance Maladie portant sur l’utilisation des méthodes contraceptives remboursées en France entre le 1er janvier 2014 et le 31 décembre 2019. Nous avons fait une analyse par années du nombre d’utilisatrices par tranches d’âge (< 20 ans, 20–0) et par prescripteur (médecin généraliste libéral, gynécologue libéral, prescripteur hospitalier, sage-femme libérale).
En 2019, 5 893 343 femmes ont eu recours à une contraception orale (CO) remboursée. Le recours à la contraception orale combinée (COC) est en baisse depuis 2014 (–15,9 %) alors que la CO microprogestative est en hausse (+57 % depuis 2015). Le recours à la contraception intra-utérine est en hausse depuis 2014 (+12,6 %), et ce dans toutes les tranches d’âge. Le dispositif intra-utérin au cuivre (DIU) est le deuxième moyen de contraception toutes tranches d’âge confondues et son recours est en augmentation depuis 2014 (+25,4 %) alors que l’utilisation du système intra-utérin hormonal (SIU) est globalement stable (–0,7 %). L’implant contraceptif constitue la troisième méthode de contraception remboursée, son recours est globalement stable depuis 2014 (+6,1 %). Parmi les moins de 20 ans, il s’agit de la deuxième méthode de contraception remboursée. Le recours à la contraception par macroprogestatifs injectable est en hausse depuis 2014 (+7,3 %) et concerne 4836 femmes en 2019. Le préservatif remboursé depuis 2019 a été opté par 49 977 femmes. En 2019, 535 428 femmes ont eu recours à la CO d’urgence remboursée. En 2019, les médecins généralistes sont les prescripteurs majoritaires des trois méthodes de contraception remboursée (CO, contraceptifs intra-utérins, implant) (45 %, 10 685 861 boîtes prescrites), suivis par les gynécologues libéraux (35 %) (8 199 297 boites), les prescripteurs hospitaliers (16 %) (3 862 616 boîtes) puis les sages-femmes libérales (801 812 boîtes) (5 %). Les médecins généralistes ont prescrit dans 97 % des cas une CO remboursée. Les sages-femmes sont les principales prescriptrices des méthodes de contraception longue durée non injectables (contraception intra-utérine et implant).
L’offre contraceptive en France se diversifie bien que la CO reste prédominante. Des disparités existent selon les tranches d’âge et il existe une hétérogénéité des pratiques entre les différents prescripteurs de contraception. Les efforts doivent être poursuivis en termes de politique de santé puisque les prescripteurs ont pour rôle de guider les utilisateurs dans le choix d’une méthode contraceptive adaptée au mieux à leurs besoins.
To study the use of reimbursed contraceptive methods in France between 2014 and 2019, with an analysis of the profile of users by age group and an analysis by type of prescriber.
We conducted a national descriptive study using data from the Assurance Maladie Open Data database on the use of contraceptive methods reimbursed in France from January 1, 2014, to December 31, 2019. We analyzed the number of users by year, by age group (< 20 years, 20–60 years), and by prescriber (liberal general practitioner, liberal gynecologist, hospital practitioner, liberal midwife).
In 2019, 50.1% (5,345,122) of women of childbearing age used a reimbursed contraceptive method. Hormonal oral contraception was the leading contraceptive method used (42.3%), followed by the intrauterine device (6.2%) and the implant (1.6%). Use of combined estrogen-progestogen oral contraception had been declining since 2015 (–8.1 points), to the benefit of the micro progestin pill (+9.1 points) and the copper intrauterine device (+1.4 points). Among women under 20, the hormonal implant was the second most popular contraceptive method (1.2%), followed by the copper intrauterine device (0.8%) and the hormonal intrauterine system (0.2%). Among women over 20 years of age of childbearing age, the copper IUD was the second most-reimbursed contraceptive method (2.4%), followed by the hormonal intrauterine system (1.6%) and the hormonal implant (1.2%). There are disparities in prescribing practices: in 2019, 51% of prescribers were general practitioners and 97% of them prescribed hormonal oral contraception.
The contraceptive supply in France is diversifying, although oral contraception remains predominant. Disparities exist between age groups of users and there is great heterogeneity in practices among contraceptive prescribers.
Feasibility evaluation of a Zn-Cu alloy for intrauterine devices: In vitro and in vivo studies
2022, Acta BiomaterialiaThe comprehensively adopted copper-containing intrauterine devices (Cu-IUDs) present typical adverse effects such as bleeding and pain at the initial stage of post-implantation. The replacement of Cu material is demanded. Zinc and its alloys, the emerging biodegradable materials, exhibited contraceptive effects since 1969. In this work, we evaluated the feasibility of bulk Zn alloys as IUD active material. Using pure Cu and pure Zn as control groups, we investigated the contraceptive performance of Zn-0.5Cu and Zn-1Cu alloys via in vitro and in vivo tests. The results showed that the main corrosion product of Zn-Cu alloys is ZnO from both in vitro and in vivo studies. CaZn2(PO4)2·2H2O is formed atop after long-term immersion in simulated uterine fluid, whereas CaCO3 is generally formed atop after implantation in the rat uterine environment. The cytocompatibility of the Zn-1Cu alloy was significantly higher than that of the pure Zn and pure Cu to the human endometrial epithelial cell lines. Furthermore, the in vivo results showed that the Zn-1Cu alloy presented much improved histocompatibility, least damage and the fastest recovery on endometrium structure in comparison to pure Zn, Zn-0.5Cu and pure Cu. The systematic and comparing studies suggest that Zn-1Cu alloy can be considered as a possible candidate for IUD with great biochemical and biocompatible properties as well as high contraceptive effectiveness.
The existing adverse effects with the intrinsic properties of copper materials for copper-containing intrauterine devices (Cu-IUD) are of concerns in their employment. Such as burst release of cupric ions (Cu2+) at the initial stage of the Cu-IUD. Zinc and its alloys which have been emerging as a potential biodegradable material exhibited contraceptive effects since 1969. In this study, Zn-1Cu alloys displayed significantly improved biocompatibility with human uterus cells and a decreased inflammatory response within the uterus. Therefore, high antifertility efficacy of the Zn-1Cu alloy was well maintained, while the adverse effects are significantly eased, suggesting that the Zn-1Cu alloy is promising for IUD.
Levonorgestrel Intrauterine Device Use for Medical Indications in Nulliparous Adolescents and Young Adults
2021, Journal of Adolescent HealthIntrauterine devices (IUDs) are highly effective at preventing pregnancy. Levonorgestrel (LNG) IUDs also have beneficial effects on menstrual bleeding and abdominal and pelvic pain. Although there are increasing data on use of IUDs for contraception in adolescents and for medical indications in adults, there are extremely limited data on LNG IUD use for medical indications in adolescents. Our objective is to describe the characteristics and experiences of LNG IUD use in nulliparous adolescents and young women using IUDs for medical indications.
We conducted a retrospective chart review of all nulliparous patients aged 22 years and younger who underwent LNG IUD insertion at a tertiary care children's hospital between July 1, 2004 and June 30, 2014 primarily for noncontraceptive indications. Descriptive statistical analysis was performed.
We identified 231 LNG IUDs placed in 219 nulliparous women for medical indications during this time period. Mean patient age was 16.8 years (±2.2). Only 41% reported ever being sexually active. IUD continuation rate at 1 year was 86%. The amenorrhea rate at 1 year was 51%. Approximately 80% of women reported improvements in menstrual bleeding and abdominal and pelvic pain. Side effects and complications were low.
This study provides evidence that LNG IUDs are effective, well-tolerated, and safe menstrual management options in young nulliparous women, including younger adolescents and those who have never been sexually active. This method is an excellent first-line therapy option for adolescents and young women for both contraceptive and noncontraceptive indications, regardless of age, parity, or sexual activity.
Intrauterine Devices and Sexually Transmitted Infection among Older Adolescents and Young Adults in a Cluster Randomized Trial
2021, Journal of Pediatric and Adolescent GynecologyProvider misconceptions regarding intrauterine device (IUD) safety for adolescents and young women can unnecessarily limit contraceptive options offered; we sought to evaluate rates of Neisseria gonorrhoeae or Chlamydia trachomatis (GC/CT) diagnoses among young women who adopted IUDs.
Secondary analysis of a cluster-randomized provider educational trial.
Forty US-based reproductive health centers.
We followed 1350 participants for 12 months aged 18-25 years who sought contraceptive care.
The parent study assessed the effect of provider training on evidence-based contraceptive counseling.
We assessed incidence of GC/CT diagnoses according to IUD use and sexually transmitted infection risk factors using Cox regression modeling and generalized estimating equations.
Two hundred four participants had GC/CT history at baseline; 103 received a new GC/CT diagnosis over the 12-month follow-up period. IUDs were initiated by 194 participants. Incidence of GC/CT diagnosis was 10.0 per 100 person-years during IUD use vs 8.0 otherwise. In adjusted models, IUD use (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 0.71-2.40), adolescent age (aHR, 1.28; 95% CI, 0.72-2.27), history of GC/CT (aHR, 1.23; 95% CI, 0.75-2.00), and intervention status (aHR, 1.12; 95% CI, 0.74-1.71) were not associated with GC/CT diagnosis; however, new GC/CT diagnosis rates were significantly higher among individuals who reported multiple partners at baseline (aHR, 2.0; 95% CI, 1.34-2.98).
In this young study population with GC/CT history, this use of IUDs was safe and did not lead to increased GC/CT diagnoses. However, results highlighted the importance of dual sexually transmitted infection and pregnancy protection for participants with multiple partners.
Misconceptions and Beliefs Regarding the Use of Intrauterine Devices for Nulliparous Women Among Chinese Health Care Providers
2020, Journal of Pediatric and Adolescent GynecologyTo investigate the knowledge and beliefs regarding the use of intrauterine devices (IUDs) for nulliparous women among Chinese health care providers and assess the potential factors related to their misconceptions and conservative beliefs.
A self-administered survey was conducted at 2 Chinese national academic conferences in 2015. The questionnaire data obtained from 103 health care providers were analyzed to examine the providers’ knowledge regarding the safety and effectiveness of IUDs and the complications associated with IUD use, as well as their beliefs regarding the suitability of IUDs for nulliparous women. An ordinal logistic regression model was used to evaluate the potential factors related to their beliefs.
Misconceptions about the complications associated with IUD use were common among our respondents, and they were least likely to know that IUDs do not increase the risk of developing pelvic inflammatory disease (26/97) or ectopic pregnancy (23/102) (22.5%-26.8%). Only approximately 10% of the providers believed that adolescents (9/94) or unmarried nulliparas (10/95) could be candidates for IUDs. In contrast, they were more likely (37/96, 38.5%) to consider married nulliparous women as appropriate candidates (P < .001). Misconceptions about the complications of IUD use were associated with more conservative beliefs regarding IUD use for nulliparous women (adjusted odds ratio, 1.34; 95% confidence interval, 1.00-1.79).
The health care providers' insufficient knowledge regarding IUDs contributed to their outdated and conservative beliefs about the suitability of IUDs for nulliparous women. In addition, the difference in the providers’ beliefs regarding IUD use for married and unmarried nulliparous women might reflect the stigma associated with premarital sex in Chinese traditional culture.