IUDs and adolescents--an under-utilized opportunity for pregnancy prevention

Long-acting contraception in adolescents and young women with type 1 and type 2 diabetes

Adolescent pregnancy is a major public health problem worldwide. Adolescents living with diabetes are not aware of the risks of unplanned pregnancy and the high rate of fetal and maternal complications when gestation occurs in women with significant hyperglycemia. These data highlight the significance of pregnancy prevention in young women with diabetes. Long-acting reversible contraceptives (LARCs), which include subdermal progestin implants and hormonal and nonhormonal intrauterine devices (IUDs), have been recommended by the American College of Obstetricians Gynecologists and the American Academy of Pediatrics as a first-line contraceptive option for adolescents and young women. This article reviews LARC options for adolescents and young women with type 1 (T1D) and type 2 (T2D) diabetes as well as the possible complications and side effects.

Comparative Efficacy of Vaginal Misoprostol vs Vaginal Dinoprostone Administered 3 Hours Prior to Copper T380A Intrauterine Device Insertion in Nulliparous Women: A Randomized Controlled Trial

STUDY OBJECTIVE

To compare the effectiveness of misoprostol and dinoprostone tablets administered vaginally 3 hours before copper intrauterine device (IUD) insertion vs placebo in reducing pain and increasing ease of insertion among nulliparous women.

DESIGN

Randomized controlled trial.

SETTING

Tertiary referral hospital.

PARTICIPANTS

A total of 129 nulliparous women requesting a Copper T380A IUD insertion.

INTERVENTIONS

Women were randomized to receive 200 μg misoprostol or 3 mg dinoprostone or placebo 3 hours before IUD insertion.

MAIN OUTCOME MEASURE(S)

Primary outcome was patient-reported pain during IUD insertion using a 10-cm visual analog scale (VAS). Secondary outcomes include provider ease of insertion, women satisfaction level, and side effects.

RESULTS

Participants' baseline characteristics were comparable between the study groups. Mean pain score during IUD insertion was lower with misoprostol than placebo (3.1 ± 2.3 vs 4.4 ± 2.2; P = .02) and dinoprostone compared to placebo (2.4 ± 1.8 vs 4.4 ± 2.2; P < .001). Clinicians reported easier IUD insertion with misoprostol than placebo (2.4 ± 1.7 vs 4.0 ± 2.4; P = .001) and dinoprostone compared to placebo (2.0 ± 1.5 vs 4.0 ± 2.4; P < .001). Women's satisfaction levels were higher with both misoprostol and dinoprostone than placebo (P < .001). Side effects did not differ among the 3 study groups.

CONCLUSIONS

Premedication with vaginal misoprostol or dinoprostone effectively lowered pain during copper IUD insertion. However, the reduction in pain scores was clinically significant only in women who received dinoprostone. In both the misoprostol and dinoprostone groups, clinicians found the procedure easier, and women were more satisfied with IUD insertion. Side effects and complications were similar in all groups.

Prophylactic vaginal dinoprostone administration six hours prior to copper-T380A intrauterine device insertion in nulliparous women: A randomized controlled trial

OBJECTIVE

To determine the effectiveness of 3 mg vaginal dinoprostone administered six hours prior to copper intrauterine device (IUD) insertion compared to placebo in increasing ease of insertion and reducing insertion pain among nulliparous women.

STUDY DESIGN

This was a single-center double-blinded randomized controlled trial (RCT). We randomly divided the two hundred nulliparous women requesting a copper T380A IUD to receive 3 mg vaginal dinoprostone or placebo six hours before IUD insertion. The primary outcome was provider ease of insertion. Patients reported their perceived insertion pain using a 10 cm visual analog scale (VAS). We also reported number of failed IUD insertions.

RESULTS

Baseline characteristics were similar between groups. Ease of insertion score was lower in dinoprostone group than placebo group (3.6 ± 2.5 vs. 5.4 ± 2.8; p < 0.01) denoting easier insertion for clinicians in dinoprostone group. Mean pain score during copper IUD insertion was lower in dinoprostone group (3.7 ± 2.3 vs. 5.0 ± 2.8; p < 0.01). Failed IUD insertion occurred in two cases of dinoprostone group (2%) versus four cases in control group (4%) (p-value; 0.68).

CONCLUSIONS

Although vaginal dinoprostone administration six hours prior to copper IUD insertion in nulliparous women leads to an easy IUD insertion, we do not routinely advise it as the reduction in IUD insertion pain scores with vaginal dinoprostone lacked clinical significance.

IMPLICATIONS

In settings where it is feasible to provide dinoprostone vaginally six hours before copper IUD insertion, clinicians will find insertion easier, and nulliparous women may experience somewhat less pain during the procedure. Where waiting six hours is practical, this may prove to be useful.

Practical Tips for Intrauterine Device Counseling, Insertion, and Pain Relief in Adolescents: An Update

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have endorsed intrauterine devices as first-line contraceptive choices for nulliparous and parous adolescents. Practical concerns about intrauterine devices might be barriers to use for teens and clinicians; this review is devoted to "practical tips" for clinicians, on the basis of an update of the available literature as well as the author's clinical experience. Counseling about contraceptive choices, preventive guidance about possible side effects, informed consent, and pain management are addressed to promote successful use of this long-acting reversible contraption option.

Pain Perception during Levonorgestrel-releasing Intrauterine Device Insertion in Nulliparous Women: A Systematic Review

STUDY OBJECTIVE

Intrauterine devices (IUDs) still remain underused in adolescents. Pain during insertion might prevent adolescents to opt for a levonorgestrel-releasing IUD. This study aimed to conduct a systematic review, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, and critically appraise published data with respect to the efficacy of various substances (analgesics or not) in preventing pain during levonorgestrel-releasing IUD insertion in nulliparous women as a proxy for adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A comprehensive computerized systematic literature search of all English language studies between 2006 and 2016 was performed in PubMed, EMBASE, Scopus, Evidence Based Medicine Reviews (Cochrane Database and Cochrane Central Register of Controlled Trials), and Google Scholar. Relevant article reference lists were manually searched.

RESULTS

The computerized database search revealed 31 citations of relevance, 9 of which with a total of 355 treated women and 345 controls fulfilled the inclusion/exclusion criteria. In women treated with misoprostol (n = 150) vs placebo (n = 145), the median visual analogue scale (VAS) score ± SD were 5.7 ± 2.1 vs 5.1 ± 2.2, respectively. In the previously mentioned population, there was a nonsignificant change in VAS score (odds ratio, 1.44; 95% confidence interval, 0.86-2.40). In women treated with lidocaine (n = 140) vs placebo (n = 136), the median VAS score ± SD were 4.6 ± 2.1 vs 5.8 ± 2, respectively. In the aforementioned population, there was a significant decrease in VAS score (odds ratio, 0.12; 95% confidence interval, 0.02-0.91).

CONCLUSION

In nulliparous women, lidocaine treatment seems to be a reasonable choice. However, further studies are required to examine the different routes and modes of administration as well as optimal quantities.

Pediatricians' Knowledge and Practices Related to Long-Acting Reversible Contraceptives for Adolescent Girls

STUDY OBJECTIVE

A 2014 American Academy of Pediatrics (AAP) policy statement identified long-acting reversible contraceptives (LARCs) as first-line choices for adolescents, but pediatricians' current knowledge and practices about intrauterine devices (IUDs) and subdermal contraceptive implants (Implants) is unknown. We aimed to characterize pediatricians' knowledge and practices about LARCs for adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional online survey emailed to a convenience sample of AAP member pediatricians in New York, Utah, Illinois, and Kansas in 2015 and 2016. The study included 561 practicing pediatricians.

MAIN OUTCOME MEASURES

We measured knowledge about the suitability of IUDs and Implants for adolescents using two 7-item scales; a score of 7 indicates all correct. We dichotomized participants' scores as high and low knowledge if they scored ≥85% correct or <85%, respectively.

RESULTS

Mean age was 47.4 (±11) years; 73% were female; and 72% general pediatricians. Almost all, 88%, counsel about contraception; 64% counsel about IUDs, and Implants, but only 4.1% insert them; 72% prescribe short-acting hormonal contraceptives; 44% had read the AAP policy statement. Mean score on the knowledge scale was lower for IUDs than for Implants (4.2 vs 5.1, respectively; P < .001). Multivariable regression analysis indicated that female pediatricians, adolescent medicine subspecialists, agreeing that pregnancy is a serious problem for adolescents in their practice, and having read the AAP policy statement predicted high knowledge about IUDs as well as Implants for adolescents.

CONCLUSION

Most pediatrician respondents provided reproductive health care for adolescents and counseled about LARCs, but few inserted the devices. We identified knowledge deficits about suitability of IUDs for adolescents.

Effects of Obstetric Complications on Adolescent Postpartum Contraception and Rapid Repeat Pregnancy

STUDY OBJECTIVE

To determine whether complications during pregnancy or at delivery influence postpartum contraception choices and rapid repeat pregnancy rates in adolescent women. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: This retrospective cohort study included 321 adolescents delivering at UMASS Memorial Healthcare. Complications during pregnancy and delivery along with subsequent contraception use were investigated. Postpartum contraception choice (long-acting reversible contraception [LARC] vs non-LARC) at either delivery, hospitalization discharge, or at postpartum outpatient appointment, and rapid repeat pregnancy rate (pregnancy confirmed within 12 months of index delivery), were analyzed according to pregnancy complications. Comparisons were made with χ² and Fisher exact tests for categorical variables, and with Wilcoxon rank sum test for continuous variables.

RESULTS

Of the study population, 27.7% (n = 89/321) used LARC in the postpartum period. The LARC and non-LARC patient populations differed significantly regarding history of abortion (P = .029), with no differences in obstetric complications between the groups. Of the population, 16.6% (n = 53/320) became pregnant again within 1 year of their index delivery. Those with a rapid repeat pregnancy had significantly increased gravidity (P = .002), parity (P = .003), number of previous spontaneous or therapeutic abortions (P = .026); they were also more like to have nonlive birth as a complication (P = .028), compared with those without repeat pregnancy. No other obstetrical complications were statistically significantly different between the compared groups.

CONCLUSION

Obstetrical complications seem to have little effect on postpartum contraception choice or repeat pregnancy rate with the notable exception of nonlive birth being associated with rapid repeat pregnancy.

Access Barriers to Long-Acting Reversible Contraceptives for Adolescents

The United States continues to have the highest adolescent birth rate of any industrialized country. Recently published guidelines by the American Academy of Pediatrics create a new consensus among professional organizations around the suitability of long-acting reversible contraceptives as first-line contraception for adolescents. Through a narrative review of U.S. studies published after 2000, this study seeks to summarize existing access barriers to long-acting reversible contraceptives for adolescents and highlight areas that warrant further intervention so that the recommendations of these professional organizations can be effectively integrated into clinical practice. Existing barriers include costs for institutions providing contraceptive care and for recipients; consent and confidentiality for adolescent patients; providers' attitudes, misconceptions and limited training; and patients' lack of awareness or misconceptions. Systemic policy interventions are required to address cost and confidentiality, such as the Affordable Care Act's mandate that contraceptive coverage be a part of essential health benefits for all insurance providers. Individual-level access barriers such as providers' misconceptions and gaps in technical training as well as patients' lack of awareness can be addressed directly by professional medical organizations, health care training programs, and other interventions.

Let's talk about sex (again): advancing the conversation around long-acting reversible contraception for teenagers

Long-acting reversible contraception (LARC) has incredible potential for decreasing teenage pregnancy rates in the USA, but use among adolescents remains low. LARC methods, including intrauterine devices and implants, are recommended as first-line choices for teenagers by multiple medical professional associations. Barriers at the system, provider and patient level persist, but new demonstration projects, in addition to provisions of the Affordable Care Act, show great promise in facilitating LARC use. A renewed national discourse should acknowledge the reality that many US teenagers have sex, that LARC is safe and effective and that LARC offers an opportunity to prevent teenage pregnancy. By encouraging widespread access and use, a large, positive impact across multiple health and economic sectors can be achieved.

Integrating reproductive health services into HIV care: strategies for successful implementation in a low-resource HIV clinic in Lilongwe, Malawi

BACKGROUND

Lighthouse Trust operates two public HIV testing, treatment and care clinics in Lilongwe, Malawi, caring for over 26 000 people living with HIV, 23 000 of whom are on antiretroviral treatment (ART). In August 2010, Lighthouse Trust piloted a step-wise integration of sexual and reproductive health (SRH) services into routine HIV care at its Lighthouse clinic site. The objectives were to increase uptake of family planning (FP), promote long-term reversible contraceptive methods, and increase access, screening and treatment for cervical cancer using visual inspection with acetic acid.

METHODS AND RESULTS

Patients found integrated SRH/ART services acceptable; service availability appeared to increase uptake. Between August 2010 and May 2014, over 6000 women at Lighthouse received FP education messages. Of 859 women who initiated FP, 55% chose depot medroxyprogesterone acetate, 19% chose an intrauterine contraceptive device, 14% chose oral contraceptive pills, and 12% chose an implant. By May 2014, 21% of eligible female patients received cervical cancer screening: 11% (166 women) had abnormal cervical findings during screening for cervical cancer and underwent further treatment.

CONCLUSIONS

Several lessons were learned in overcoming initial concerns about integration. First, our integrated services required minimal additional resources over those needed for provision of HIV care alone. Second, patient flow improved during implementation, reducing a barrier for clients seeking multiple services. Lastly, analysis of routine data showed that the proportion of women using some form of modern contraception was 45% higher at Lighthouse than at Lighthouse's sister clinic where services were not integrated (42% vs 29%), providing further evidence for promotion of SRH/ART integration.

Evidence-based pain management for endometrial biopsies and IUD insertions

Intrauterine device (IUD) insertions and endometrial biopsies (EMB) are common outpatient office procedures performed by advanced practice nurses. There are currently no guidelines for pain management with either IUD insertions or EMB procedures. Combination modalities are the most likely to impact pain perception, but more research is required in this area.

Practices and perceptions among pediatricians regarding adolescent contraception with emphasis on intrauterine contraception

STUDY OBJECTIVE

This study was conducted to characterize pediatricians' current practice patterns and perceived barriers related to adolescent contraception counseling with an emphasis on intrauterine contraception (IUC).

DESIGN

We performed a mailed survey study to 400 general pediatricians.

SETTING

Surveys were mailed to pediatricians at their individual office locations.

PARTICIPANTS

General pediatricians belonging to the Massachusetts Pediatric Society were included in the study.

INTERVENTIONS

The survey instrument assessed current practice patterns and perspectives as related to contraception counseling for adolescents.

MAIN OUTCOME MEASURES

Use of contraception among adolescent patients, policy to recommend IUC to adolescents in various clinical scenarios, and barriers to adolescent contraceptive counseling.

RESULTS

Over 50% of pediatricians considered abstinence their favored method of contraception for adolescents, while fewer than 20% reported discussing IUC as an option. Female pediatricians were more likely to discuss IUC (25% vs 8%, P = .01), as were younger pediatricians (28% vs 14%, P = .13). Given 8 clinical scenarios suitable for IUC use, less than 25% of pediatricians would offer IUC to a teen unless she had a history of a vaginal delivery or abortion. Seventy percent of pediatricians reported lack of training with IUC, and more than 30% reported legal, fertility and parental concerns as barriers to discussing IUC with adolescents.

CONCLUSIONS

Efforts are warranted to improve the education of pediatricians regarding the most current guidelines for proper IUC use in adolescents with the goal to increase the frequency with which this effective contraceptive method is discussed with this vulnerable population.

Practical tips for intrauterine devices use in adolescents

The American Congress of Obstetricians and Gynecologists (ACOG) has endorsed intrauterine devices (IUDs) as first-line contraceptive choices for both nulliparous and parous adolescents. The committee opinion did address some of the practical elements of IUD use in adolescents, but because these practical concerns may be barriers to use for both teens and clinicians, this review is devoted to "practical tips," based on the available literature as well as the author's clinical experience. Counseling, informed consent, techniques of pain management, and preventive guidance about possible side effects are addressed in an effort to promote successful use of this long-acting reversible contraception (LARC) option.

Identifying counseling needs of nulliparous adolescent intrauterine contraceptive users: a qualitative approach

PURPOSE

To describe the intrauterine contraception (IUC) adoption process among nulliparous adolescents and to identify the role of the medical provider in this trajectory.

METHODS

We conducted semistructured interviews with a clinic-based sample of 20 nulliparous adolescents (aged 15-24 years) with a history of IUC use. Interviews were analyzed using modified grounded theory and cross-case analysis to reveal a process model for IUC adoption, with a focus on the role of the medical provider.

RESULTS

The model includes the following stages: first awareness, initial reaction, information gathering, adoption, and adjustment and reassessment. It is influenced by personal preferences and experiences, friends, family, sexual partner(s), and medical providers. Interactions with medical providers that study participants found helpful in navigating the adoption process included the use of visuals; tailored counseling to address specific contraceptive needs; assurance that IUC discontinuation was an option; information on a wide range of side effects; medical provider self-disclosure regarding use of IUC; and addressing and validating concerns, both before and after IUC insertion.

CONCLUSIONS

Nulliparous adolescents in this study described a complex IUC adoption process in which the medical provider plays a substantial supportive role. Findings from this study may be used to counsel and support future nulliparous adolescents regarding IUC use.

Factors associated with provision of long-acting reversible contraception among adolescent health care providers

PURPOSE

To identify provider and practice characteristics associated with long-acting reversible contraception (LARC, either progesterone contraceptive implants or intrauterine devices [IUDs]) provision among adolescent health care providers.

METHODS

We used data from a previously conducted survey of US providers on reproductive health to predict provision of any form of LARC as well as progesterone contraceptive implants or IUDs specifically using Chi-square and multivariate logistic regressions.

RESULTS

One third of providers reported any LARC provision. In logistic regressions, residency training in obstetrics/gynecology or family medicine (rather than internal medicine/pediatrics) was the strongest predictor of LARC provision, particularly for IUDs.

CONCLUSIONS

A minority of providers reported offering IUDs or contraceptive implants, most of whom had received procedural women's health training. Increasing the number of providers offering this type of contraception may help to prevent adolescent pregnancies and may be most easily accomplished via training in contraceptive implant provision.

Contraception for adolescents

CME EDUCATIONAL OBJECTIVES: 1.Identify and explain the four currently available methods of emergency contraception.2.Discuss the risk and benefits of intrauterine devices as a first-line option for contraception in adolescents.3.Review strategies for explaining the most common contraceptive methods to an adolescent. The US has the highest pregnancy rate of any industrialized nation, approximately twice that of Canada, four times that of France, and eight times that of Japan or Italy.1 In recent years, the rate has declined, partially due to delayed coitarche (age of onset of vaginal sexual intercourse) but mainly due to greater use of contraception.2 Per the 2011 Youth Risk Behavior Survey (a national survey of about 15,000 youth in schools), 33% of high school freshmen, 44% of sophomores, 53% of juniors, and 63% of seniors have had vaginal sexual intercourse. To prevent unplanned and unwanted teenage pregnancies, which have negative consequences on a teenager's health and future, pediatricians must be able to provide birth control or at least know where to refer their patients in need.

Menstrual suppression with the levonorgestrel intrauterine system in girls with developmental delay

STUDY OBJECTIVE

To describe the experiences of 21 girls with developmental delay accompanied by multiple other medical problems, seen over a 3-year interval, who underwent insertion of the levonorgestrel intrauterine system (LNG-IUS) for menstrual suppression.

STUDY DESIGN

Retrospective chart review.

SETTING

A referral pediatric and adolescent gynecology clinic within a tertiary care medical center with referrals from community pediatricians, pediatric subspecialists including developmental and behavioral pediatricians, community gynecologists, and adolescent medicine specialists.

PARTICIPANTS

Adolescents and young women with developmental delay and multiple comorbid conditions who were seen for consultation with their families requesting menstrual suppression.

INTERVENTIONS

Participants were offered hormonal options, for menstrual suppression including the LNG-IUS.

MAIN OUTCOME MEASURES

Satisfaction with menstrual suppression among families electing the LNG-IUS.

RESULTS

Adolescents and young women seen at CCHMC with developmental delay and multiple comorbid conditions with requests for menstrual suppression were offered hormonal options, including the LNG-IUS. Twenty-one families chose this option. Fifteen of 21 girls had previously used hormonal menstrual suppression. General anesthesia was required for 20 of 21 insertions, and 9 of 20 of these insertions were combined with other surgical procedures. There were no unsuccessful insertions or major complications. Mean duration of follow-up was 11 months, and families were satisfied with this option for menstrual suppression. There was 1 request for removal.

CONCLUSIONS

LNG-IUS for menstrual suppression, in girls with developmental delay and multiple comorbid medical conditions for which amenorrhea is desirable and therapeutic, appears promising.

Teen pregnancy prevention on a LARC: an update on long-acting reversible contraception for the primary care provider

PURPOSE OF REVIEW

This update will highlight recent research and recommendations on long-acting reversible contraception (LARC) in the teen population, in order to make primary care providers more comfortable counseling on these methods in the medical home. LARC methods, which include intrauterine devices (IUDs) and subdermal hormonal implants, are used by only a small minority of sexually active teens, despite their endorsement by professional organizations as effective and well tolerated birth control options in this population.

RECENT FINDINGS

Recent studies show a lack of knowledge about LARC methods among young women, as well as persistent misconceptions among providers regarding who is eligible for LARC use. Existing trials of small numbers of adolescents generally show enthusiasm for its use among teens who are educated about LARC, high satisfaction rates among users of subdermal implants and IUDs, as well as varying pregnancy and continuation rates.

SUMMARY

The existing research on LARC shows promise for these methods in the teen population. However, larger trials are needed to establish accurate data on satisfaction, continuation, and failure rates, as well as to explore other barriers to use. Medical home providers should stay informed of research on LARC in order to improve contraceptive counseling to young women.

A clinical guideline for intrauterine device use in adolescents

PURPOSE

To present an evidence-based review of the data for and against the use of the intrauterine device (IUD) in adolescent females and to provide guidelines for selection of appropriate candidates.

DATA SOURCES

Clinical research, expert opinions, and systematic reviews of IUD use in adolescents.

CONCLUSIONS

The use of the IUD in adolescents has been questioned in the past as a result of concerns surrounding increased risks for pelvic inflammatory disease and infertility in adolescents. Current research reveals no contraindications to IUD use based solely on age or parity and illuminates many benefits to use, including a decrease in menorrhagia and dysmenorrhea.

IMPLICATIONS FOR PRACTICE

The U.S. adolescent pregnancy rates rose from 2005 to 2007, reversing a decade-long downward trend. Adolescents need safe, effective, user-friendly contraceptive methods. IUDs are a safe and effective option for adolescents and provide an additional contraceptive option for nurse practitioners to offer their patients to prevent unintended pregnancy and enhance adolescent sexual health and well-being. Proper selection of candidates for IUD use can mitigate clinical and legal risks associated with IUD use.

Duration of use of a levonorgestrel IUS amongst nulliparous and adolescent women

BACKGROUND

Intrauterine devices are cost-effective if used for 2 or more years. Early discontinuation may lead to reduced cost-effectiveness of this method and unintended pregnancy if other contraceptives are not used. This study sought to examine rates and reasons for discontinuation of IUS use in adolescents versus older women and nulliparous versus parous women, as these groups may be more likely to discontinue use.

STUDY DESIGN

Retrospective cohort study of women receiving a levonorgestrel IUS between June 2005 and April 2008 was conducted. Medical records were reviewed for all visits following placement of the IUS; rates and reasons for IUS discontinuation were calculated and categorized. Data were examined under two scenarios: (1) assuming that all women not seen for follow-up continued IUS use and (2) only including women with follow-up visits. Cox regression was used to control for age, parity, race and marital status in comparing rates of IUS discontinuation and expulsion in nulliparous versus parous women and adolescents versus older women.

RESULTS

Of the 828 women included in this analysis, 104 (12.6%) were nulliparous, and 131 (15.8%) were ≤20 years of age. Nulliparous women were not more likely than parous women to have expelled their IUS [hazard ratio (95% confidence interval), 1.40 (0.57, 3.43)]. Adolescent women were more likely to experience expulsion than older women, although this did not reach statistical significance [hazard ratio, 1.49 (0.76, 2.92)]. When we looked at reasons for IUS removal, we found that nulliparous women were not more likely than parous women to have their IUS removed because of dissatisfaction with the contraceptive method (6.7% vs. 11.5%, p=.15) or desire to become pregnant (1.9% vs. 2.6%, p=.50). Similarly, adolescents were not more likely than older women to have their IUS removed because of dissatisfaction with the contraceptive method (10.7% vs. 10.9%, p=.94) or desire to become pregnant (3.1% vs. 2.4%, p=.43).

CONCLUSIONS

Adolescents and nulliparous women are not more likely to prematurely discontinue use of their IUS than adult or parous women.