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Acog committee opinion, number 392, december 2007

Intrauterine Device and Adolescents
Committee on
ABSTRACT: The intrauterine device (IUD) is highly effective and widely used by Adolescent Health
women throughout the world. Data support the safety of IUDs for most women, includ- ing adolescents. This document addresses the major benefits of IUD use in adolescents,a population at particular risk of unintended pregnancy.
The committee would like to thankNicole Zidenberg, MD,Nirupama DeSilva, MD, gitis in IUD users, and inability to control for the effects of sexual behavior, leading to an exaggeration of risk estimates (8). Ongoing pelvic inflammatory disease (PID), sexually research continues to demonstrate the safety transmitted diseases (STDs), infertility, and difficult insertion have limited the use of the IUD in adolescents. Data support the safety line only at the time of insertion. Among of IUDs for most women, including adoles- 22,908 IUD users, within the first 20 days of cents. The World Health Organization sup- ports the use of intrauterine contraception in woman-years; from 21 days to 8 years, the incidence of PID was 1.4 per 1,000 woman- women from menarche to age 20 years, stat- ing that the benefits of intrauterine contra- years, the same as that in the general popula- ception generally outweigh the risks (2).
controlled trials confirmed these findings (8, 10). The risk of PID with IUD placement is 0–2% when no infection is present at the time of insertion and 0–5% when insertion 62% of 12th graders have engaged in inter- occurred with a documented infection. The course (3). Sexual activity and inconsistent absolute risk of PID is very small in bothgroups (10). Case reports also have shown contraceptive use contribute to the high rate that women with positive chlamydia cultures of adolescent pregnancy in the United States, identified at the time of IUD insertion are which exceeds that of other industrialized unlikely to develop PID if the infection is countries (4, 5). Intrauterine devices offer the treated with the IUD retained (11, 12).
long-term, cost-effective, highly reliable, and thickening cervical mucus and thinning the endometrium (13). Studies have demonstrat-ed the reduced risk of PID using the lev- The Intrauterine Device Does Not
onorgestrel-releasing intrauterine system as Increase an Adolescent’s Risk of
compared with a copper IUD (14, 15).
Pelvic Inflammatory Disease and
Intrauterine Devices Do Not Affect
Sexually Transmitted Diseases
the Fertility of Adolescents
Past experiences with the Dalkon Shield have perpetuated the myth that IUDs cause pelvic was not higher after cessation of IUD use ver- The American College
infections. The studies that showed a causal sus cessation of other reversible methods of of Obstetricians
relationship between pelvic infection and contraception (8). In a case–control study and Gynecologists
IUDs were fraught with methodologic errors.
examining determinants of tubal infertility, Confounding factors included inappropriate the presence of chlamydial antibodies was comparison groups, overdiagnosis of salpin- associated with infertility in both users and nonusers of IUDs (16). Fecundity rapidly returns to nor- In many states, adolescents have the right to receive con- fidential contraceptive services without parental permis-sion (26). Confidential IUD insertion may be thwarted by the cost or consent issues. Preinsertion counseling about Adolescents are more likely than adult women to discon- the IUD is paramount. Goals of counseling include tinue a range of contraceptive methods, including pills awareness of the long-term nature of the contraceptive, and injectable contraception. In women younger than 25 side effects, risks, and benefits. Upon insertion of the years, discontinuation of the levonorgestrel-releasing IUD, self-examination to confirm the presence of strings intrauterine system at 12 months was slightly higher should be taught, and condom use for STD prevention compared with older women (19). Among copper IUD should be encouraged. It is important for adolescents users, pain and bleeding led to discontinuation (20). The using IUDs to be familiar with their anatomy and com- rate of amenorrhea with the levonorgestrel-releasing intrauterine system varies from 16.4% to 80% at 1 yearafter insertion and may alleviate bleeding concerns (21).
Discomfort with IUD insertion is common. In one study,86% of adolescents reported mild to severe pain with Expulsion contributes to IUD failure with a risk of 1 in 20 insertion (13). Misoprostol may soften a nulliparous (22). Younger age and previous IUD expulsion may con- cervix before insertion (27). Studies of use of non- fer the greatest risk of failure (23). Prior expulsion should steroidal antiinflammatory drugs for analgesia yielded not be considered a contraindication for a new IUD pro- mixed results but they may be used (28). Less studied vided that patients undergo appropriate counseling and methods of analgesia include paracervical blocks or pre- insertion narcotics. Little data suggest that IUD insertion is technically more difficult in adolescents.
Prophylactic antibiotics are not necessary for IUD Contraindications to IUD use include current pregnancy; insertion (29). Because adolescents have the highest num- PID or puerperal or postabortion sepsis that is current or ber of reported cases of chlamydia and coinfection with within the past 3 months; current STDs; purulent cervici- gonorrhea frequently occurs (30), all adolescents should tis; undiagnosed abnormal vaginal bleeding; malignancy be screened for gonorrhea and chlamydia before IUD of the genital tract; known uterine anomalies or leiomy- insertion (27, 31). Screening at the time of insertion expe- omata distorting the uterine cavity in a way incompatible dites contraceptive use. Patients with positive test results with IUD insertion; or allergy to any component of the have no adverse effects if treated promptly (10–12).
IUD or Wilson’s disease (for copper-containing IUDs)(24). An asymptomatic patient may use an IUD within 3 months of a treated pelvic infection or septic abortion The IUD is a highly effective method of contraception that is underused in the United States. Because adoles- cents contribute disproportionately to the epidemic of unintended pregnancy in this country, top tier methodsof contraception, including IUDs and implants, should be The copper IUD may be used for emergency contracep- considered as first-line choices for both nulliparous and tion within 5 days of unprotected intercourse (24). The parous adolescents. After thorough counseling regarding IUD confers the additional benefit of serving as a long- contraceptive options, health care providers should term contraceptive. One study found that 86% of parous strongly encourage young women who are appropriate women and 80% of nulliparous women maintained the IUD for long-term contraception after use as emergencycontraception (25).
In addition to providing contraception, the lev- 1. Mosher WD, Martinez GM, Chandra A, Abma JC, Willson onorgestrel-releasing intrauterine system reduces men- SJ. Use of contraception and use of family planning servic- strual blood loss by 75% at 3 months. It offers the most es in the United States: 1982-2002. Adv Data 2004;350:1–36.
favorable side effect profile of the progesterone-only 2. World Health Organization. Intrauterine devices. In: methods. The levonorgestrel-releasing intrauterine system Medical eligibility criteria for contraceptive use. 3rd ed.
offers an alternative to birth control pills for cycle control.
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Retrieved August 16, 2007.
3. Eaton DK, Kann L, Kinchen S, Ross J, Hawkins J, Harris Practitioners must be familiar with federal, state, and WA, et al. Youth risk behavior surveillance—United States, institutional guidelines governing consent by adolescents.
2005. MMWR Surveill Summ 2006;55(5):1–108.
4. Zibners A, Cromer BA, Hayes J. Comparison of continua- 19. Luukkainen T, Allonen H, Haukkamaa M, Holma P, Pyorala tion rates for hormonal contraception among adolescents.
T, Terho J, et al. Effective contraception with the lev- J Pediatr Adolesc Gynecol 1999;12:90–4.
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Available at: http://guttmacher.org/pubs/fb_ATSRH.html.
20. Rivera R, Chen-Mok M, McMullen S. Analysis of client characteristics that may affect early discontinuation of theTCu-380A IUD. Contraception 1999;60:155–60.
6. Trussell J, Vaughan B. Contraceptive failure, method-relat- ed discontinuation and resumption of use: results from the 21. Toma A, Jamieson MA. Revisiting the intrauterine contra- 1995 National Survey of Family Growth. Fam Plann ceptive device in adolescents. J Pediatr Adolesc Gynecol 7. Chiou CF, Trussell J, Reyes E, Knight K, Wallace J, Udani J, 22. FFPRHC Guidance (April 2004). The levonorgestrel-releas- et al. Economic analysis of contraceptives for women.
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23. Thonneau P, Almont T, de La Rochebrochard E, Maria B.
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24. Intrauterine device. ACOG Practice Bulletin No. 59.
10. Mohllajee AP, Curtis KM, Peterson HB. Does insertion and American College of Obstetricians and Gynecologists.
use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually trans- 25. Zhou L, Xiao B. Emergency contraception with Multiload mitted infection? A systematic review. Contraception Cu-375 SL IUD: a multicenter clinical trial. Contraception 11. Skjeldestad FE, Halvorsen LE, Kahn H, Nordbo SA, Saake K.
26. Guttmacher Institute. State policies in brief: minors’ access IUD users in Norway are at low risk for genital C. tra- to contraceptive services. New York (NY): GI; 2007.
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Available at: http://www.guttmacher.org/statecenter/spibs/ 12. Faundes A, Telles E, Cristofoletti ML, Faundes D, Castro S, spib_MACS.pdf. Retrieved September 6, 2007.
Hardy E. The risk of inadvertent intrauterine device inser- 27. McNaught J. Adolescents and IUCDs—Not a contraindica- tion in women carriers of endocervical Chlamydia tra- tion. J Pediatr Adolesc Gynecol 2006;19:303–5.
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28. Grimes DA, Hubacher D, Lopez LM, Schulz KF. Non- 13. Suhonen S, Haukkamaa M, Jakobsson T, Rauramo I. Clinical steroidal anti-inflammatory drugs for heavy bleeding or performance of a levonorgestrel-releasing intrauterine sys- pain associated with intrauterine-device use. Cochrane tem and oral contraceptives in young nulliparous women: a Database of Systematic Reviews 2006, Issue 4. Art. No.: comparative study. Contraception 2004;69:407–12.
CD006034. DOI: 10.1002/14651858.CD006034.pub2.
14. Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing 29. Grimes DA, Schulz FK. Antibiotic prophylaxis for intrauter- and copper-releasing (Nova T) IUDs during five years of ine contraceptive device insertion. Cochrane Database of use: a randomized comparative trial. Contraception 1994; Systematic Reviews 1999, Issue 3. Art. No.: CD001327. DOI: 15. Toivonen J, Luukkainen T, Allonen H. Protective effect of 30. Centers for Disease Control and Prevention. Sexually trans- intrauterine release of levonorgestrel on pelvic infection: mitted disease surveillance 2005. Atlanta (GA): CDC; 2006.
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16. Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra-Infante F, J Pediatr Adolesc Gynecol 2006;19:301–3.
Guzman-Rodriguez R. Use of copper intrauterine devicesand the risk of tubal infertility among nulligravid women.
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Copyright December 2007 by the American College of Obstet- ricians and Gynecologists, 409 12th Street, SW, PO Box 96920, 17. Hov GG, Skjeldestad FE, Hilstad T. Use of IUD and subse- Washington, DC 20090-6920. Al rights reserved. No part of this pub- quent fertility—follow-up after participation in a random- lication may be reproduced, stored in a retrieval system, posted on ized clinical trial. Contraception 2007;75:88–92.
the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior 18. Penney G, Brechin S, de Souza A, Bankowska U, Belfield T, written permission from the publisher. Requests for authorization to Gormley M, et al. FFPRHC Guidance (January 2004). The make photocopies should be directed to: Copyright Clearance Center, copper intrauterine device as long-term contraception.
222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400.
Faculty of Family Planning and Reproductive Health Care Intrauterine device and adolescents. ACOG Committee Opinion No.
Clinical Effectiveness Unit [published erratum appears in J 392. American College of Obstetricians and Gynecologists. Obstet Fam Plann Reprod Health Care 2004;30:134]. J Fam Plann Reprod Health Care 2004;30:29–41; quiz 42.

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