4
The Whole Truth About IUDs Nurses are perfectly positioned to offer women accurate information about an often-neglected contraceptive method. M any women spend most of their reproductive years trying to avoid pregnancy, and they do so for a variety of reasons. For instance, a busy young mother of two de- sires more children—but in the future, after life settles down a bit; a graduate student intends to marry her fiancé and start a family—but not for a few years; a high-powered career woman is pursuing her professional goals before starting a family. Modern contraception options provide women with the oppor- tunity to plan when they attempt to have children. Choosing a con- traceptive method that’s both ef- fective and safe is an important decision for every woman of child- bearing age. There are many per- sonal variables that a woman must consider in making her de- cision, but convenience and ease of use will be high on any wom- an’s list of priorities in picking a contraceptive method that fits her lifestyle. Although health care providers usually suggest oral contracep- tives for family planning, 1 women should also be provided with in- formation about an overlooked and misunderstood contraceptive method—the intrauterine device (IUD). It’s up to nurses to provide the public with accurate facts to facilitate educated choices. A BLEMISHED PAST According to Family Planning Worldwide: 2008 Data Sheet from the Population Reference Bureau (available at www.prb. org/pdf08/fpds08.pdf), only 2% of married American women use IUDs, compared with 7% in Latin America and the Carib- bean, 11% in northern Europe (use ranges widely throughout the European continent, from 0.4% in Macedonia to 6% in the United Kingdom to nearly 26% in Belarus), and 18% overall in Asia. Misinformation about IUDs appears to be one of the main reasons that it isn’t more popular. Although evidence shows that IUDs are safe and effective, old fears and misconceptions often steer women toward other meth- ods. A historical view of IUDs sheds some light. IUDs became available to U.S. women in the 1960s. Their popu- larity plummeted, however, in the late 1970s after adverse events involving the Dalkon Shield were reported. When the device was in place, a multifilament tail string leading from the uterus to the va- gina wasn’t sealed on either end, creating an open portal for bac- teria to ascend into the uterus, which put women at higher risk for serious pelvic infection. The Dalkon Shield was responsible, according to some sources, for more than “200,000 infections, miscarriages, hysterectomies, and other gynecological complica- tions and led to an untold num- ber of birth defects,” as well as 18 deaths. 2 Media coverage ex- posed the adverse events, as well as shoddy premarketing research in the case of the Dalkon Shield, and contributed to the end of the manufacturing of almost all the IUDs in the United States by the 1980s. In spite of this, a few U.S. com- panies continued to develop and improve IUDs. The copper T 380A (ParaGard) was introduced in the United States in 1988 (Figure 1). The levonorgestrel-releasing By Ruth Monchek, MSN, CNM [email protected] AJN t June 2010 t Vol. 110, No. 6 53 Copper wire Copper band Monofilament threads Figure 1. The Copper T 380A (ParaGard) Intrauterine Device. LifeART image. © 2008 Lippincott Williams and Wilkins. All rights reserved.

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Page 1: The Whole Truth About IUDs - CEConnection€¦ · The Whole Truth About IUDs Nurses are perfectly positioned to offer women accurate information ... tunity to plan when they attempt

The Whole Truth About IUDsNurses are perfectly positioned to offer women accurate information about an often-neglected contraceptive method.

M any women spend most of their reproductive years trying to avoid

pregnancy, and they do so for a variety of reasons. For instance, a busy young mother of two de­sires more children—but in the future, after life settles down a bit; a graduate student intends to marry her fiancé and start a family—but not for a few years; a high­powered career woman is pursuing her professional goals before starting a family.

Modern contraception options provide women with the oppor­tunity to plan when they attempt to have children. Choosing a con­traceptive method that’s both ef­fective and safe is an important decision for every woman of child­bearing age. There are many per­sonal variables that a woman must consider in making her de­cision, but convenience and ease of use will be high on any wom­an’s list of priorities in picking a contraceptive method that fits her lifestyle.

Although health care providers usually suggest oral contracep­tives for family planning,1 women should also be provided with in­formation about an overlooked and misunderstood contraceptive method—the intrauterine device (IUD). It’s up to nurses to provide the public with accurate facts to facilitate educated choices.

A BLEMISHED PASTAccording to Family Planning Worldwide: 2008 Data Sheet

from the Population Reference Bureau (available at www.prb. org/pdf08/fpds08.pdf), only 2% of married American wo men use IUDs, compared with 7% in Latin America and the Car i b­bean, 11% in northern Europe (use ranges widely throughout the European continent, from 0.4% in Macedonia to 6% in the United Kingdom to nearly 26% in Belarus), and 18% over all in Asia. Misinformation about IUDs appears to be one of the main reasons that it isn’t more popular. Although evidence shows that IUDs are safe and effective, old fears and miscon ceptions often steer women toward other meth­ods. A historical view of IUDs sheds some light.

IUDs became available to U.S. women in the 1960s. Their popu­larity plummeted, however, in the late 1970s after adverse events involving the Dalkon Shield were reported. When the device was in place, a multifilament tail string leading from the uterus to the va­gina wasn’t sealed on either end, creating an open portal for bac­teria to ascend into the uterus, which put women at higher risk for serious pelvic infection. The Dalkon Shield was responsible, according to some sources, for more than “200,000 infections, miscarriages, hysterectomies, and other gynecological complica­tions and led to an untold num­ber of birth defects,” as well as 18 deaths.2 Media coverage ex­posed the adverse events, as well

as shoddy premarketing research in the case of the Dalkon Shield, and contributed to the end of the manufacturing of almost all the IUDs in the United States by the 1980s.

In spite of this, a few U.S. com­panies continued to develop and improve IUDs. The copper T 380A (ParaGard) was introduced in the United States in 1988 (Figure 1). The levonorgestrel­releasing

By Ruth Monchek, MSN, CNM

[email protected] AJN t June 2010 t Vol. 110, No. 6 53

Copper wire Copper band

Monofilament threads

Figure 1. The Copper T 380A (ParaGard) Intrauterine Device. LifeART image. © 2008 Lippincott Williams and Wilkins. All rights reserved.

Page 2: The Whole Truth About IUDs - CEConnection€¦ · The Whole Truth About IUDs Nurses are perfectly positioned to offer women accurate information ... tunity to plan when they attempt

and the potential risks of pelvic infection, infertility, and ectopic pregnancy.

An IUD is a small plastic or plastic­and­metal object that’s inserted into the uterus using a sterile technique during a pelvic examination. It has a tail string that hangs down into the upper part of the vagina to facilitate removal. Once in place, the IUD provides immediate contraceptive protection and is 99% effective against preventing pregnancy, ac cording to the Centers for Dis ease Control and Prevention (http://bit.ly/9SoVtj). The copper­releasing T 380A IUD and the LNG­IUS are the only two IUDs available in the United States. Each is a T­shaped device that has a unique composition and a different means of providing con­traceptive protection. Both offer the user safe, long­lasting family planning benefits.3 In addition, a 2008 meta­analysis of 10 studies shows that all IUDs have a pro­tective effect against endometrial cancer.4

The T 380A. The polyethyl­ene T 380A has copper bands on both arms and copper wire wrapped around its vertical stem with a string attached to its base (see Figure 1). The device is thought to act by releasing cop­per ions into uterine and tubal fluids and impairing sperm mo­tility so fertilization doesn’t oc­cur. It can be used effectively for up to 10 years, possibly as long as 12 years as a 1991 study showed.5

The copper IUD can also be used for emergency contracep­tion. When inserted within five days of unprotected intercourse, it is 99% effective in protecting against pregnancy.6 The exact mechanism of action of this IUD as an emergency contraceptive hasn’t been clearly identified. It’s possible that when used in this capacity, copper IUDs may work

by disrupting a pregnancy after fertilization has occurred.7

The LNG-IUS. The LNG­IUS contains a reservoir core that over time releases a therapeutic level of the hormone levonorg­estrel, which thickens cervical mucus, inhibiting sperm from entering the uterine cavity (see Figure 2). It also impairs sperm function, suppresses endometrial growth, and may even inhibit ovulation in some women. The approved duration of use is five years.

Because of its hormonal fea­tures, the LNG­IUS may be the treatment of choice for select gynecologic problems. For exam­ple, women with heavy menses or dysmenorrhea find relief after the first few months after inser­tion, when the IUD suppresses the monthly growth of endometrial tissue and reduces menstrual flow some 70% to 90%.8 Some women—as many as 23.9%, ac­cording to the device’s prescrib­ing information—will experience amenorrhea within one year of use.9 Both perimenopausal and postmenopausal women have also found symptom relief when this IUD is used as part of hor­mone replacement therapy.10 Al­though more research is needed, current studies show promising results for the treatment of en­dometriosis, adenomyosis, and chronic pelvic pain with use of the LNG­IUS.11

Mechanism of action. Women considering an IUD need an ac­curate explanation of how the IUD prevents fertilization rather than disrupts an established preg­nancy. It was originally thought that an IUD acted as a foreign body, causing an inflammatory response in the lining of the uterus that made the implantation of a fertilized ovum impossible. Ac­cording to the prescribing infor­mation for the T 380A, that’s

intrauterine system, or LNG­IUS (Mirena), was made available for use in the United States in 2001 (Figure 2).

Because of the Dalkon Shield events, many women have been afraid to use IUDs, and health care providers have hesitated to insert them for fear of litiga­tion, a fear that persists. It’s time for health professionals to sort through the fallacies and examine the facts about the IUDs avail­able today.

IUD BASICS FOR NURSESTo provide accurate informa­tion to patients, nurses need to know the facts about the modern IUD—how it works and the kinds that are available. Clarify­ing the misinformation that sur­rounds IUDs can enable nurses to help women to make informed decisions about using this con­traceptive method. Some of the most troublesome concerns for women are how the IUD works

54 AJN t June 2010 t Vol. 110, No. 6 ajnonline.com

Figure 2. The Levonorgestrel-Releasing Intrauterine System, or LNG-IUS (Mirena). LifeART image. © 2009 Lippincott Williams and Wilkins. All rights reserved.

Monofilamentthreads

HormonecylinderHormone cylinder

Monofilament threads

Page 3: The Whole Truth About IUDs - CEConnection€¦ · The Whole Truth About IUDs Nurses are perfectly positioned to offer women accurate information ... tunity to plan when they attempt

After an IUD is removed, the risk of ectopic implantation in future pregnancies remains low.23

PATIENT EDUCATIONNurses are often a patient’s first and best source of current evidence­based information on health care issues. Women are constantly bombarded with pop­ular media reports and advertis­ing about contraception. With knowledge of the IUDs available today, a nurse can educate women who are considering their family planning options. A discussion of the different types of IUDs, how they work, and the risks and ben­efits associated with their use can be very useful to women who are trying to determine whether the method would be right for them. Nurses come into contact with women of reproductive age in

many different clinical settings and can empower them to make educated decisions about their birth control method.

Nurses can point out to pa­tients that the modern IUD has a number of benefits as an effective method of contraception. It’s easy to use and maintain; a woman just has to perform a monthly check to ensure that the string is still in place. The IUD provides reversible contraception with no systemic adverse effects.

In the public sector, the cost for the T 380A is about $225 plus the insertion fee; the cost for the LNG­IUS is about $450 plus the insertion fee.8 In the private sectors, costs for the T 380A and the LNG­IUS are approximately $494 and $585, respectively,

associated with IUD use and prove that both types of IUD can be safely used by nulliparous women.17, 18 Research has demon­strated that there’s no causal rela­tionship between infertility and the past use of a copper­containing IUD.19 Although the same is thought to be true for the LNG­IUS, there hasn’t yet been enough research. For most women, there is a rapid return to fertility after they discontinue the use of the IUD.20 The IUD is being touted as an efficacious alternative to permanent sterilization because both are comparably effective in preventing pregnancy.21 And because the sterilization caused by the device is reversible, the IUD may be a pleasing option for women who are not 100% cer­tain that they want to end their reproductive capability.

Ectopic pregnancy. Because of the confusion surrounding the IUD’s mechanism of action, it was believed that it could in­crease the risk of ectopic preg­nancy caused by interference with the movement of a fertilized ovum through the fallopian tubes. A recent study demonstrates that women using IUDs have a lower incidence of ectopic pregnancy than women who use no contra­ception at all.22 The IUD doesn’t protect against ectopic pregnancy as effectively as it prevents an in­trauterine pregnancy; if a woman with an IUD conceives, it’s pos­sible that it could be an ectopic pregnancy. However, because the IUD failure rate is less than 1%, its use reduces the absolute inci­dence of ectopic pregnancies.22

still considered a possible mecha­nism of action.12 Current data consistently demonstrate that both the T 380A and the LNG­IUS promote changes in the re­productive tract that are lethal to both sperm and ova and prevent the formation of embryos.13 The notion that an IUD might cause the abortion of a developing pregnancy may make this an un­acceptable method of birth con­trol for many women. Women need reassurance that the IUD averts pregnancy by inhibiting fertilization.

Risk of pelvic infection. One of the misconceptions most com­monly held by both patients and some providers is that IUDs cause pelvic inflammatory dis­ease (PID), a serious infection that spreads up into the uterus and fallopian tubes. Damage to these reproductive organs can often result in infertility. How­ever, the risk of pelvic infection among IUD users appears to be low.14 Clinical studies show that there is an increased risk of infec­tion during the first 20 days after insertion, which is most likely caused by uterine contamination from vaginal bacteria at the time of insertion.15 According to one 2007 review, after this initial pe­riod the incidence of PID appears to be low among IUD users and is likely similar to that of women in the general population.16 PID is caused primarily by sexually transmitted disease, most nota­bly gonorrhea and Chlamydia. Women who are sexually active and not using safer sex practices are at risk for PID regardless of the type of contraception they use.

Infertility. In the past, most women who had not yet had children were advised that IUD use could result in infertility be­cause of the risk of pelvic infec­tion. Many studies have disputed the increased incidence of PID

[email protected] AJN t June 2010 t Vol. 110, No. 6 55

The risk of pelvic infection among IUD users

appears to be low.

Page 4: The Whole Truth About IUDs - CEConnection€¦ · The Whole Truth About IUDs Nurses are perfectly positioned to offer women accurate information ... tunity to plan when they attempt

11. Bahamondes L, et al. Use of the levonorgestrel­releasing intrauterine system in women with endometriosis, chronic pelvic pain and dysmenorrhea. Contraception 2007;75(6 Suppl): S134­S139.

12. FEI Women’s Health LLC. ParaGard T 380A intrauterine copper contra­ceptive [Prescrib ing information]. 2005. http://www.accessdata.fda. gov/drugsatfda_docs/label/2005/ 018680s060lbl.pdf.

13. Ortiz ME, Croxatto HB. Copper­T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action. Contracep­tion 2007;75(6 Suppl):S16­S30.

14. Mohllajee AP, et al. Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmit­ted infection? A systematic review. Con­traception 2006;73(2):145­53.

15. Cheng D. The intrauterine device: still misunderstood after all these years. South Med J 2000;93(9):859­64.

16. Meirik O. Intrauterine devices—upper and lower genital tract infections. Con­traception 2007;75(6 Suppl):S41­S47.

17. Prager S, Darney PD. The levonor­gestrel intrauterine system in nullipa­rous women. Contraception 2007; 75(6 Suppl):S12­S15.

18. Hubacher D. Copper intrauterine device use by nulliparous women: review of side effects. Contraception 2007;75(6 Suppl):S8­S11.

19. Hubacher D, et al. Use of copper in­trauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345(8):561­7.

20. Hov GG, et al. Use of IUD and subse­quent fertility—follow­up after partic­ipation in a randomized clinical trial. Contraception 2007;75(2):88­92.

21. Grimes DA, Mishell DR, Jr. Intrauter­ine contraception as an alternative to interval tubal sterilization. Contracep­tion 2008;77(1):6­9.

22. Sivin I, et al. Prolonged intrauterine contraception: a seven­year random­ized study of the levonorgestrel 20 mcg/day (LNg 20) and the Cop­per T380 Ag IUDS. Contraception 1991;44(5):473­80.

23. Skjeldestad FE. The impact of in­trauterine devices on subsequent fertility. Curr Opin Obstet Gynecol 2008;20(3):275­80.

24. Trussell J, et al. Cost effectiveness of contraceptives in the United States. Contraception 2009;79(1):5­14.

25. American College of Obstetricians and Gynecologists. ACOG practice bulle­tin. Clinical management guidelines for obstetrician­gynecologists. Num­ber 59, January 2005. Intrauterine de­vice. Obstet Gynecol 2005;105(1): 223­32.

26. Nelson AL. Contraindications to IUD and IUS use. Contraception 2007;75 (6 Suppl):S76­S81.

use is a high risk of contracting sexually transmitted infections.

Erroneous beliefs and fears— on the part of patients and providers—based on outdated information create barriers that prevent women from considering the IUD as a possible contracep­tive option. Working as patient advocates and educators, nurses can convey the facts about intra­uterine contraception and help women, such as those mentioned at the beginning of the article, to determine whether this method fits their lifestyle and meets their birth control needs. t

Ruth Monchek is a certified nurse mid­wife and an associate professor at the University of Medicine and Dentistry of New Jersey School of Nursing, Newark. Contact author: [email protected].

REFERENCES 1. Mosher WD, et al. Use of contracep­

tion and use of family planning ser­vices in the United States: 1982­2002. Adv Data 2004(350):1­36.

2. Tone A. Devices and desires: a history of contraceptives in America. 1st ed. New York: Hill and Wang; 2001.

3. Hubacher D, Cheng D. Intrauterine devices and reproductive health: American women in feast and famine. Contraception 2004;69(6):437­46.

4. Beining RM, et al. Meta­analysis of intrauterine device use and risk of endometrial cancer. Ann Epidemiol 2008;18(6):492­9.

5. World Health Organization, Depart­ment of Reproductive Health and Re­search. Medical eligibility criteria for contraceptive use: a WHO family planning cornerstone. Geneva, Swit­zerland; 2009. 4th edition. http://whqlibdoc.who.int/publications/2009/ 9789241563888_eng.pdf.

6. Trussell J, Ellertson C. Efficacy of emergency contraception. Fertility control reviews 1995;4(2):8­11.

7. Zhou L, Xiao B. Emergency contra­ception with Multiload Cu­375 SL IUD: a multicenter clinical trial. Con­traception 2001;64(2):107­12.

8. Morgan KW. The intrauterine device: rethinking old paradigms. J Midwifery Womens Health 2006;51(6):464­70.

9. Casey PM, Pruthi S. The latest contra­ceptive options: what you must know. J Fam Pract 2008;57(12):797­805.

10. Sitruk­Ware R. The levonorgestrel intrauterine system for use in peri­ and postmenopausal women. Contracep­tion 2007;75(6 Suppl):S155­S160.

not including the insertion fee.24 Although the initial cost of an IUD may seem relatively high, because it lasts so long it’s very cost­effective and, in the long run, is one of the least expensive contraceptives available.

Nurses must also inform their patients of the disadvantages of IUDs. IUD insertion must be per­formed by a health care provider and an office visit is required. Men strual disturbances are pos­sible: users of the T 380A may experience heavy menstrual bleed­ing; users of the LNG­IUS may have irregular bleeding initially, and overall they may have a re­duced menstrual flow. Cramping and pain are possible at the time of insertion, and T 380A users may have increased menstrual pain. Finally, nurses must remind patients that the IUD offers no protection against sexually trans­mitted infections.

INTO THE FUTUREThe IUD can provide long­term, highly effective contraception to most women of reproductive age. Medical groups such as the World Health Organization (WHO) and the American Congress of Obste­tricians and Gynecologists pro­pose that eligibility for use of the IUD includes all healthy women of any age re gardless of whether or not they have had children.5, 25 According to the WHO’s analysis of the available research, “There are conflicting data regarding whether IUD use is associated with infertility among nulliparous women, although well­conducted studies suggest no increased risk.”5 Although there are some medical conditions that preclude its use, among the most common being uterine abnormalities, uterine or cervical neoplasia, unexplained genital bleeding, and hypersensi­tivity to components of the IUD,26 the main contraindication to IUD

56 AJN t June 2010 t Vol. 110, No. 6 ajnonline.com