Authors

  1. Monchek, Ruth MSN, CNM

Abstract

Nurses are perfectly positioned to offer women accurate information about an often-neglected contraceptive method.

 

Article Content

Many 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 fiance 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 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 PAST

According to Family Planning Worldwide: 2008 Data Sheet from the Population Reference Bureau (available at http://www.prb.org/pdf08/fpds08.pdf), only 2% of married American women use IUDs, compared with 7% in Latin America and the Caribbean, 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 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 levonorgestrel-releasing intrauterine system, or LNG-IUS (Mirena), was made available for use in the United States in 2001 (Figure 2).

  
Figure 1 - Click to enlarge in new windowFigure 1.
 
Figure 2 - Click to enlarge in new windowFigure 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 NURSES

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

 

An IUD is a small plastic or plastic-and-metal 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, according to the Centers for Disease Control and Prevention (http://bit.ly/9SoVtj). The copper-releasing T 380A IUD and the LNG-IUS are the only two IUDs available in the United States. Each is a T-shaped device that has a unique composition and a different means of providing contraceptive protection. Both offer the user safe, long-lasting family planning benefits.3 In addition, a 2008 meta-analysis 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 LNG-IUS 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 LNG-IUS 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 LNG-IUS.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 still considered a possible mechanism of action.12 Current data consistently demonstrate that both the T 380A and the LNG-IUS 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 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 copper-containing IUD.19 Although the same is thought to be true for the LNG-IUS, 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 After an IUD is removed, the risk of ectopic implantation in future pregnancies remains low.23

 

PATIENT EDUCATION

Nurses are often a patient's first and best source of current evidence-based 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 LNG-IUS is about $450 plus the insertion fee.8 In the private sectors, costs for the T 380A and the LNG-IUS are approximately $494 and $585, respectively, 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 cost-effective 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. Menstrual disturbances are possible: users of the T 380A may experience heavy menstrual bleeding; users of the LNG-IUS 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 FUTURE

The IUD can provide long-term, 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 regardless 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 well-conducted 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 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.

 

REFERENCES

 

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