Retrospective review of intrauterine device in adolescent and young women

Factors Predicting Removals of the Levonorgestrel-Releasing Intrauterine System in an Adolescent Cohort

OBJECTIVE

Use of 52-mg levonorgestrel intrauterine system (LNG-IUS) in adolescents for heavy menstrual bleeding (HMB), dysmenorrhea, and contraception has increased, yet little is known about the factors predicting removal and dissatisfaction in adolescents. The aim of this study was to identify factors predicting LNG-IUS removal in adolescents.

METHODS

This was a retrospective cohort study including all adolescents (9-19 years) who underwent LNG-IUS insertion between 2012 and 2021 (n = 536). A medical record review was conducted and data were collated on medical and gynecological history, age, indications for insertion, complications, expulsions, and removals. The data were analyzed using χ2 tests.

RESULTS

Indications for LNG-IUS insertions (n = 536) among 517 individual patients (n = 517) included menstrual management (n = 142), HMB alone (n = 118), HMB and pelvic pain/dysmenorrhea (n = 105), dysmenorrhea/pelvic pain alone (n = 47), and contraception (n = 16). Associated diagnoses included intellectual disability (44.29%, 229/517), chronic pain conditions (12.77%, 66/517), and additional mental health concerns (24.37%, 126/517). Patient dissatisfaction with LNG-IUS led to removal in 61 (11.38%), mostly for pain or persistent bleeding. Higher removal rates occurred in those with associated chronic pain conditions (46.97%, χ2 = 55.9, P < .05), mental health concerns (16.67%, χ2 = 5.06, P < .05), and bleeding disorders (26.32%, χ2 = 5.09, P < .05). Among the cohort with an intellectual disability, lower rates of removal occurred (5.7%, χ2 = 11.2, P < .05). Whereas the LNG-IUS removal rate among gender-diverse youth was 23.07%, this was not statistically significant. Younger age was also not associated with a statistically significant increase in removals (13.72%, χ2 = 0.73, P > .05).

DISCUSSION

Adolescents have a low dissatisfaction and removal rate (11.38%) of LNG-IUS. Chronic pain, bleeding tendency, and mental health concerns are associated with higher removal rates and intellectual disability with lower rates. These findings are useful in counselling patients and families about LNG-IUS.

Long-acting reversible contraception in gender-diverse adolescents and young adults: Outcomes from a multisite collaborative

OBJECTIVES

This study aimed to describe the clinical experience of gender-diverse adolescents and young adults receiving long-acting reversible contraception (LARC).

STUDY DESIGN

This was a secondary analysis of prospectively collected quality improvement data among gender-diverse adolescents and young adults receiving LARC in four adolescent medicine clinics.

RESULTS

Most attempted insertions (59/63) were successful. A majority (54%) chose LARC for both contraception and menstrual management. Pelvic pain/cramping and unsatisfactory bleeding were reported side effects. One known expulsion and six known LARC removals occurred.

CONCLUSIONS

Gender-diverse adolescents and young adults had high rates of successful LARC insertion and demonstrated a side effect profile similar to a broader adolescent and young adult population seeking LARC care.

IMPLICATIONS

LARC is an important and well-tolerated method of menstrual management and contracention in gender-diverse adolescents and young adults, although more investigation is needed to understand how gender-affirming testosterone therapy may impact the LARC experience in this population.

Expulsion and continuation rates of the 52 mg levonorgestrel intrauterine system in adolescents and adult women

OBJECTIVE

To compare the continuation rates, expulsion, and other reasons for discontinuation of the hormonal intrauterine device with 52 mg of levonorgestrel (52 mg LNG-IUD) in adolescents and adult women.

METHODS

We conducted a retrospective cohort study that included 393 women in whom we placed a 52 mg LNG-IUD and followed up to 5 years. We created two retrospective cohorts, one with 131 adolescents (aged between 12 and 19 years) and the other with 262 women aged ≥20 years. Each adolescent was paired with two adult women who had the same parity and who had a 52 mg LNG-IUD inserted on the same day. We used the Mann-Whitney test to compare numerical variables in both groups, the Kaplan-Meier method, and the log-rank test to compare the continuation, expulsion and other reasons for IUD discontinuation of the two groups.

RESULTS

Age of the adolescents and adult women were mean ± SD 18.1 (±1.1) and 31 (±6.8) years, respectively (p = 0.015). Continuation rates by the fifth year of use were 55.6/100 women-years (W-Y) and 70.3/100 W-Y among adolescents and adult women (p = 0.106); and expulsion rates were 8.4/100 and 6.0/100 W-Y, respectively (p = 0.463). Adolescents had a lower continuation rate during 3 to 5 years of follow-up (p = 0.011) and a high rate of removals due to bleeding/pain (18.5 ± 5.7/100 W-Y vs 6.4/100 ± 2.1 W-Y, p = 0.039).

CONCLUSION

Adolescents who used the 52 mg LNG-IUD showed a lower continuation rate 3-5 years after device placement than adult women. The expulsion rates were similar in both groups.

How Can We Address What We Do Not Measure? A Systematic Scoping Review of the Measurement and Operationalization of Social Determinants of Health Research on Long-Acting Reversible Contraceptive among Adolescents in the US

Teen pregnancy is often considered an adverse health outcome that accentuates gender inequities, diminishes opportunities, and jeopardizes the safety of adolescent and young adult birthing people. Long-Acting Reversible Contraceptives (LARC) have been hailed as a panacea for teen pregnancy. However, adolescents and emerging adults intersect with multiple assaults on their health and well-being due to gender inequity and racism. To establish equitable care, it is imperative to discern all barriers that influence their reproductive autonomy. This study evaluates the measurement, operationalization, and quality of research conducted on adolescents and emerging adults that analyzed the use of LARC within the social determinant of health framework (SDOH) in the US. SDOH were assessed using the Dahlgren and Whitehead model, and reports were analyzed using a modified version of the Joanna Briggs Institute (JBI) Critical Appraisal tools. Nineteen articles were included in this study. Researchers found the insufficient measurement of race, ethnicity, sexuality, and gender among studies on LARC and SDOH in adolescents and emerging adults. Future studies must measure a full range of identities in data collection to generate knowledge on the impact of SDOH and LARC use among diverse populations.

Intrauterine Device Outcomes in Young Women with Heavy Menstrual Bleeding: Comparing Patients with and without Inherited Bleeding Disorders

STUDY OBJECTIVE

To evaluate the use of intrauterine devices (IUDs) in two young women's hematology clinics and compare adverse events in adolescents with and without inherited bleeding disorders (BDs) DESIGN: Retrospective multicenter cohort study from February 2014 through February 2020 SETTING: Young women's hematology clinics at Nationwide Children's Hospital in Columbus, Ohio, and Children's Medical Center in Dallas, Texas PARTICIPANTS: Female patients evaluated for heavy menstrual bleeding (HMB) who underwent IUD placement INTERVENTIONS AND MAIN OUTCOME MEASURES: Rates of IUD expulsion, malposition, and ongoing HMB requiring additional medical treatment RESULTS: We identified 43 patients with BDs and 35 patients without BDs who underwent placement of an IUD for HMB. The mean age was 14.9 years (range 11.0-21.4 years) at the time of presentation and 15.8 years (range 11.0-21.4 years) at IUD placement. Those with BDs were younger at the time of IUD insertion. Most patients (90%) had previously failed other methods to control HMB. The annual rate of IUD adverse events was 0.25 per year of use, and all adverse events occurred in the first 20 months after placement. There were no significant differences in adverse IUD events in patients with and without BDs, although those without BDs requested IUD removal more frequently.

CONCLUSIONS

In this cohort of adolescent females, the presence of a BD was not associated with a higher IUD expulsion rate. IUD placement should be considered a first-line option for adolescents with BDs who experience HMB.

Post-Placental Intrauterine Device Insertion in Brazilian Adolescents: Clinical Outcomes at 12 Months

STUDY OBJECTIVE

To assess the acceptability, expulsion and continuation rates, satisfaction, and complications associated with post-placental intrauterine device insertion (PPIUDI) in Brazilian adolescents DESIGN: Prospective cohort SETTING: A single public, tertiary teaching hospital PARTICIPANTS: Adolescents (≤ 19 years) giving birth by vaginal delivery or cesarean section INTERVENTION: PPIUDI MAIN OUTCOME MEASURES: Primary outcomes were PPIUDI acceptability, expulsion, continuation, and user satisfaction. Secondary outcomes were changes in menstrual bleeding and pain, infection, uterine perforation, and repeat pregnancy up to 12 months after PPIUDI.

RESULTS

Of 1710 adolescents who delivered during the study period, 294 accepted PPIUDI (acceptability 17.2%). There were no cases of infection or uterine perforation among the 91 adolescents who completed the 12-month follow-up. Overall expulsion rate was 28.6%, and most cases (54%) occurred in the first 6 weeks after insertion. At 12 months, 85.7% of users were satisfied with the method, and continuation rate was 69.2%. At the end of 12 months, there were no repeat pregnancies among the adolescents who remained with the device in place.

CONCLUSION

PPIUDI can be an effective and safe method to reduce repeat unplanned pregnancies in adolescents who have just given birth.

Current evidence of contraceptive uptake, pregnancy and continuation rates in young women: a systematic review and Meta-analysis

OBJECTIVE

Half of all pregnancies worldwide are unintended, and the rate is even higher in women aged ≤25 years. We sought to identify which method of contraception was the most effective option to prevent unintended pregnancy in young women and adolescents.

METHODS

Systematic searches, without language restrictions, were carried out of the PubMed, Embase, Lilacs and Cochrane databases from inception to July 2020. Abstracts and full-text articles of observational studies and randomised controlled trials comparing the use of multiple methods of long-acting reversible contraception (LARC) and short-acting reversible contraception (SARC) in young women and adolescents were screened and reviewed. Risk ratios (RRs) and mean differences with their 95% confidence interval (CI) were derived using a random-effects meta-analytical model. Meta-analyses provided pooled estimates for adverse events, continuation rates and efficacy of LARC methods in young women and adolescents. Nine of the 25 included studies compared LARC with SARC, and 16 compared LARC methods only.

RESULTS

At 12 months, young women had better adherence with LARC compared with SARC (n = 1606; RR 1.60; 95% CI 1.21, 2.12; I ² = 88%), which suggests a better unintended pregnancy prevention outcome for young women. However, more young women chose SARC (n = 2835; RR 0.37; 95% CI 0.17, 0.80; I ² = 99%). Pregnancy during LARC use was rare.

CONCLUSION

LARC methods are the most efficacious in preventing pregnancy, and women should be informed of this if pregnancy prevention is their priority. The evidence, however, is of low quality.

PROSPERO REGISTRATION NUMBER

CRD42017055452.

Copper IUD continuation, unwanted effects and cost consequences at 1 year in users aged under 30 - a secondary analysis of the EURAS-IUD study

OBJECTIVE

To conduct a secondary analysis of continuation, unwanted effects and cost consequences at 1 year in copper intrauterine device (IUD) users aged under 30 in the European Active Surveillance Study for Intrauterine Devices (EURAS-IUD study) based on IUD type.

METHODS

Descriptive and comparative analyses of copper IUD continuation, unwanted effects and estimated cost consequences at 1 year were performed in users aged under 30 based on IUD copper surface area, shape or design, width and arms' flexibility.

RESULTS

5796 copper IUD users were identified to have been aged under 30 at EURAS-IUD study recruitment and data for 5762 users (99.4%) was analysed. Higher IUD continuation, fewer unwanted effects and lower costs were observed with IUDs of the lowest copper content (<300mm²), horse-shoe frame design, widths 18 mm to <30mm and flexible IUD arms. Discontinuation, unwanted effects and costs were greater with frameless IUDs and framed, ≥30mm width IUDs with 380mm² of copper and copper bands on their rigid transverse IUD arms.

CONCLUSIONS

Significant differences in continuation, reported unwanted effects and estimated costs at 1 year between IUD types were observed in users aged under 30. Although further research is needed, clinicians should consider these findings when counselling and choosing IUD types for younger women.

Levonorgestrel Intrauterine Device Use for Medical Indications in Nulliparous Adolescents and Young Adults

PURPOSE

Intrauterine 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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Knowledge and attitudes towards contraceptives among adolescents and young adults

Background

Despite endorsements supporting the use of intrauterine devices (IUDs) for adolescents and young adult women (AYA), they have limited knowledge about them Male partners can influence contraceptive decisions, however their perceived knowledge about IUDs is lower than their objective knowledge. We aim to establish current AYA baseline contraceptive knowledge and attitudes so providers can better target their sexual health educational interventions.

Methods

Females and males, aged 13 to 23 years old, from our suburban adolescent clinic, completed an anonymous survey that assessed their knowledge and attitudes towards methods of contraception, with an emphasis on the IUD.

Results

Completed surveys totaled 130 (99 females/31 males). Demographic results revealed 31.3% Black/African-American, 30.5% Latino/Hispanic, 17.6% White, 3.0% Asian, and 14.5% Other. The majority of participants (80%) were sexually active. The majority (69.5%) stated they/their partner were currently using a contraceptive method; only 2.6% used IUDs. Half of females (56.6%) and 10.1% of males had heard of IUDs. Despite this, male and female participants lacked knowledge regarding specific IUD facts. Of the participants who had used emergency contraception (EC), only 6.4% knew the copper IUD could be used for EC.

Conclusion

Contraceptive knowledge deficits, especially regarding the IUD, continue to exist for AYA patients. Many participants stated they required EC despite “satisfaction” with their birth control method(s) and most were unaware that the copper IUD could be used as EC. These discrepancies highlight the importance of comprehensive contraceptive education for AYA patients. Enhanced and consistent contraceptive options counseling can help providers ensure that their AYA patients make well-informed decisions about family planning, thus improving their quality of life.

Determinants of Long-acting Reversible Contraception (LARC) Initial and Continued Use among Adolescents in the United States

Long-acting reversible contraception (LARC) has gained attention as a promising strategy for preventing unintended adolescent pregnancies in the United States. However, LARC use among adolescents at risk for pregnancy remains low compared to women in their 20s. The purpose of the current study was to synthesize the empirical literature published between 2010 and 2018 identifying the facilitators of and barriers to adolescents' (< age 20) LARC use in the United States. Thirty quantitative and qualitative studies were included in the current systematic review. The facilitators of and barriers to adolescent LARC use fell within five themes: LARC method characteristics, individual characteristics, social networks, healthcare systems, and historical time and geographical region. Barriers to adolescent LARC use largely echoed those identified in previous research noting the barriers to LARC use among young adult women (e.g., provider concerns with placing IUDs for nulliparous women, common adverse side effects associated with some LARC methods). However, qualitative studies identified adolescents' mothers as central figures in helping adolescents successfully obtain the LARC methods they desired. Conversely, adolescents' partners seemed to only play a minor role in adolescents' contraceptive decisions. Findings within the reviewed studies also suggested some subpopulations of adolescents may be experiencing pressure to initiate LARC use or have less ability to have their LARC device removed if they wish to discontinue use. Adolescent health practitioners and clinicians should consider the unique social-environmental influences of adolescents' contraceptive access and behaviors to best meet adolescents' contraceptive needs and desires.

Intrauterine Device Use in Adolescents With Disabilities

BACKGROUND AND OBJECTIVES

Intrauterine devices (IUDs) are increasingly being used in adolescents and nulliparous women for contraception. Levonorgestrel IUDs also have beneficial effects on bleeding and pain. Although they are recommended for menstrual suppression in adolescents with disabilities, there are limited data on their use in this population. Our objective is to describe the characteristics and experiences of levonorgestrel IUD use in nulliparous children, adolescents, and young adults with physical, intellectual, and developmental disabilities.

METHODS

A retrospective chart review was conducted for all nulliparous patients ages ≤22 with physical, intellectual, or developmental disabilities who had levonorgestrel IUDs placed between July 1, 2004, and June 30, 2014, at a tertiary-care children's hospital. Descriptive statistical analysis and survival analysis were performed.

RESULTS

In total, 185 levonorgestrel IUDs were placed in 159 patients with disabilities. The mean age was 16.3 (3.3; range of 9-22) years. Only 4% had ever been sexually active; 96% of IUDs were inserted in the operating room. IUD continuation rate at 1 year was 95% (95% confidence interval: 93%-100%) and at 5 years was 73% (95% confidence interval: 66%-83%). The amenorrhea rate was ∼60% throughout the duration of IUD use among those with available follow-up data. Side effects and complications were ≤3%.

CONCLUSIONS

In this study, we provide evidence for the therapeutic benefit and safety of levonorgestrel IUD use in adolescents and young adults with physical, intellectual, and developmental disabilities. It should be considered as a menstrual management and contraceptive option for this population.

International Perspectives: IUDs and Adolescents

Unplanned or unwanted pregnancy among adolescents is a worldwide public health issue. In many countries unmarried young women are denied contraceptive services. Long-acting reversible contraceptive methods such as the intrauterine devices (IUDs) have been shown to be more effective than short-acting such as the pill, and safe also for adolescents. The popularity has varied a lot with time and between populations. Health care providers, health system, and user factors all influence IUD use. A good sexuality education through school provides a foundation, and health care providers give specific individual counseling. International and country-specific guidelines have been published during the past decade indicating the advantage of IUDs. New smaller size devices make placement easier for nulliparous adolescents. Still the uptake has remained rather low in most regions, cost being one barrier. Several municipalities have started to provide long-acting reversible contraceptive methods for adolescents free of charge, and this has led to a significant increase in IUD use, accompanied by a reduction in abortion rates. Adolescent-friendly services should offer low-cost or free contraception, including male and female condoms, emergency contraception, and a full range of modern methods, including long-acting reversible methods, according to adolescents' preferences and needs.

Management of contraceptives and menstrual complaints in patients with Down syndrome

Enhanced health care for patients with Down syndrome (DS) results in improved overall quality of life and longer life expectancy. The main gynecologic complaints of patients with DS and their caregivers relate to menstrual cycles, hygiene and reproductive issues. Certain aspects, such as age of menarche, menstrual cycles, internal genitalia, and hormone profile are similar to those observed in the general population. However, individuals with DS may have a higher incidence of other disorders related to menstruation, such as hypothyroidism, epilepsy and use of anticonvulsants. Contraceptive measures for individuals with DS can be used for both contraception and control of menstrual symptoms. The physician must be to make an individualized recommendation aimed at offering the most efficient and least invasive method with the fewest side effects. Among medical options are oral contraceptives, quarterly injectable medroxyprogesterone acetate, oral progesterone, a levonorgestrel-releasing intrauterine system, transdermal patch and vaginal rings. Surgical methods, including hysterectomy, endometrial ablation, or tubal ligation, are rarely considered because they raise ethical and legal questions. This article reviews the literature and basic guidelines to assist physicians who attend adolescent girls and women with DS to provide guidance on the appropriate management of the main gynecologic complaints of this population.

Levonorgestrel-Releasing Intrauterine Device Use in Female Adolescents with Heavy Menstrual Bleeding and Bleeding Disorders: Single Institution Review

STUDY OBJECTIVE

To identify complications and efficacy of the levonorgestrel-releasing intrauterine device (LNgIUD) in adolescents with heavy menstrual bleeding (HMB) and bleeding disorders (BD).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective chart review of 13 postmenarchal adolescent girls with HMB/BD who underwent placement of an LNgIUD.

INTERVENTIONS

Placement of an LNgIUD.

MAIN OUTCOME MEASURES

Primary outcome was to identify complications from placement of an LNgIUD. Secondary outcome was to evaluate the efficacy of the LNgIUD in adolescents with BD.

RESULTS

Thirteen patients met study criteria. The mean age of diagnosis of HMB was 14.08 ± 1.75 years. BD or bleeding risk factor diagnoses included low von Willebrand (VW) activity in 5, type I VW disease in 5, type IIM VW disease in 1, low VW activity and factor 7 deficiency in 1, and acquired VW disease and factor 7 deficiency in 1. Before LNgIUD placement, other hormonal therapy (n = 13) and hemostatic therapy (antifibrinolytic agents, desmopressin acetate; n = 8) yielded poor control of HMB. The LNgIUD was placed using anesthesia with periprocedure hemostatic therapy with no complications. All patients reported significant improvement in HMB after LNgIUD placement and 60% achieved amenorrhea, with mean time to improvement of 94 ± 69 days. Mean hemoglobin and ferritin levels increased after LNgIUD placement compared with before LNgIUD placement values (P = .02, P = .0085, respectively). Use of supplemental hormonal and hemostatic agents decreased (n = 4) after LNgIUD placement. None required LNgIUD removal; 1 spontaneously expelled the LNgIUD with subsequent replacement.

CONCLUSION

Study results indicated the LNgIUD is an effective therapeutic option in postmenarchal adolescents with HMB due to BD/bleeding risk factor with minimal complications, high compliance rate, improvement in HMB and anemia, and no periprocedural bleeding with hemostatic management.

Long-acting reversible contraception in adolescents: a systematic review and meta-analysis

BACKGROUND

Among adolescent pregnancies, 75% are unintended. Greater use of highly-effective contraception can reduce unintended pregnancy. Although multiple studies discuss adolescent contraceptive use, there is no consensus regarding the use of long-acting reversible contraception as a first-line contraception option.

OBJECTIVE

We performed a systematic review of the medical literature to assess the continuation of long-acting reversible contraceptives among adolescents.

STUDY DESIGN

Ovid-MEDLINE, Cochrane databases, and Embase databases were searched using key words relevant to the provision of long-acting contraception to adolescents. Articles published from January 2002 through August 2016 were selected for inclusion based on specific key word searches and detailed review of bibliographies. For inclusion, articles must have provided data on method continuation, effectiveness, or satisfaction of at least 1 long-acting reversible contraceptive method in participants <25 years of age. Duration of follow-up had to be ≥6 months. Long-acting reversible contraceptive methods included intrauterine devices and the etonogestrel implant. Only studies in the English language were included. Guidelines, systematic reviews, and clinical reviews were examined for additional citations and relevant points for discussion. Of 1677 articles initially identified, 90 were selected for full review. Of these, 12 articles met criteria for inclusion. All studies selected for full review were extracted by multiple reviewers; inclusion was determined by consensus among authors. For studies with similar outcomes, forest plots of combined effect estimates were created using the random effects model. The meta-analysis of observational studies in epidemiology guidelines were followed. Primary outcomes measured were continuation of method at 12 months, and expulsion rates for intrauterine devices.

RESULTS

This review included 12 studies, including 6 retrospective cohort studies, 5 prospective observational studies, and 1 randomized controlled trial. The 12 studies included 4886 women age <25 years: 4131 intrauterine device users and 755 implant users. The 12-month continuation of any long-acting reversible contraceptive device was 84.0% (95% confidence interval, 79.0-89.0%). Intrauterine device continuation was 74.0% (95% confidence interval, 61.0-87.0%) and implant continuation was 84% (95% confidence interval, 77.0-91.0%). Among postpartum adolescents, the 12-month long-acting reversible contraceptive continuation rate was 84.0% (95% confidence interval, 71.0-97.0%). The pooled intrauterine device expulsion rate was 8.0% (95% confidence interval, 4.0-11.0%).

CONCLUSION

Adolescents and young women have high 12-month continuation of long-acting reversible contraceptive methods. Intrauterine devices and implants should be offered to all adolescents as first-line contraceptive options.

The safety of intrauterine devices among young women: a systematic review

OBJECTIVE

The objective was to determine the association between use of intrauterine devices (IUDs) by young women and risk of adverse outcomes.

METHODS

We searched Pubmed, CINAHL, Embase, Popline and the Cochrane Library for articles from inception of database through December 2015. For outcomes specific to IUD use (IUD expulsion and perforation), we examined effect measures for IUD users generally aged 25 years or younger compared with older IUD users. For outcomes of pregnancy, infection, pelvic inflammatory disease (PID), and heavy bleeding or anemia, we examined young IUD users compared with young users of other contraceptive methods or no method.

RESULTS

We identified 3169 articles of which 16 articles from 14 studies met our inclusion criteria. Six studies (Level II-2, good to poor) reported increased risk of expulsion among younger age groups compared with older age groups using copper-bearing (Cu-) IUDs. Two studies (Level II-2, fair) examined risks of expulsion among younger compared with older women using levonorgestrel-releasing (LNG-) IUDs; one reported no difference in expulsion, while the other reported increased odds for younger women. Four studies (Level II-2, good to poor) examined risk of expulsion among Cu- and LNG-IUD users combined and reported no significant differences between younger and older women. For perforation, four studies (Level II-2, fair to poor) found very low perforation rates (range, 0%-0.1%), with no significant differences between younger and older women. Pregnancies were generally rare among young IUD users in nine studies (Level I to II-2, fair to poor), and no differences were reported for young IUD users compared with young combined oral contraceptive (COC) or etonogestrel (ENG) implant users. PID was rare among young IUD users; one study reported no cases among COC or IUD users, and one reported no difference in PID among LNG-IUD users compared with ENG implant users from nationwide insurance claims data (Level I to II-2, fair). One study reported decreased odds of bleeding with LNG-IUD compared with COC use among young women, while one study of young women reported decreased odds of removal for bleeding with LNG-IUD compared with ENG implant (Level I to II-2, fair).

CONCLUSION

Overall evidence suggests that the risk of adverse outcomes related to pregnancy, perforation, infection, heavy bleeding or removals for bleeding among young IUD users is low and may not be clinically meaningful. However, the risk of expulsion, especially for Cu-IUDs, is higher for younger women compared with older women. If IUD expulsion occurs, a young woman is exposed to an increased risk of unintended pregnancy if replacement contraception is not initiated. IUDs are safe for young women and provide highly effective reversible contraception.

Menstrual Management for Adolescents With Disabilities

The onset of menses for adolescents with physical or intellectual disabilities can affect their independence and add additional concerns for families at home, in schools, and in other settings. The pediatrician is the primary health care provider to explore and assist with the pubertal transition and menstrual management. Menstrual management of both normal and abnormal cycles may be requested to minimize hygiene issues, premenstrual symptoms, dysmenorrhea, heavy or irregular bleeding, contraception, and conditions exacerbated by the menstrual cycle. Several options are available for menstrual management, depending on the outcome that is desired, ranging from cycle regulation to complete amenorrhea. The use of medications or the request for surgeries to help with the menstrual cycles in teenagers with disabilities has medical, social, legal, and ethical implications. This clinical report is designed to help guide pediatricians in assisting adolescent females with intellectual and/or physical disabilities and their families in making decisions related to successfully navigating menarche and subsequent menstrual cycles.

Young Age, Nulliparity, and Continuation of Long-Acting Reversible Contraceptive Methods

OBJECTIVE

To assess the relationship among young age, nulliparity, and continuation of long-acting reversible contraceptive (LARC) methods.

METHODS

We performed a secondary analysis of the Contraceptive CHOICE Project database, an observational cohort study of 9,256 sexually active reproductive-aged females. This analysis focused on continuation of the intrauterine device and implant in nulliparous adolescent participants compared with parous, older women. We analyzed our data by age-parity groups and individual characteristics and used multivariable analysis to assess the association of age and parity on continuation.

RESULTS

There were 6,106 participants in our analytic set, including 863 aged 14-19 years. Long-acting reversible contraceptive continuation rates at 12 months were high and similar between all age-parity groups ranging from 82-86%. In the Cox proportional hazards model, nulliparous participants using the copper intrauterine device and implant were more likely to discontinue their LARC method (copper intrauterine device: adjusted hazard ratio [HR] 1.76, 95% CI 1.13-2.73, implant: adjusted HR 1.89, 95% CI 1.35-2.64) than parous participants. This effect was not observed among levonorgestrel intrauterine system users (adjusted HR 1.16, 95% CI 0.92-1.46). Age younger than 20 years was not associated with discontinuation at 12 months (adjusted HR 0.95, 95% CI 0.74-1.22).

CONCLUSION

We found that LARC continuation rates were high and similar across age and parity. Clinicians should not hesitate to recommend LARC methods to young nulliparous females owing to fear of early discontinuation.

LEVEL OF EVIDENCE

II.

Long-acting reversible contraception in the pediatric emergency department: clinical implications and common challenges

Long-acting reversible contraception (LARC) is recommended as first-line contraception for adolescents and young adults. As the use of LARC increases, pediatric emergency medicine clinicians should be able to recognize different types of LARC and address their common adverse effects, adverse reactions, and complications. This continuing medical education activity provides an overview of LARC and will assist clinicians in the evaluation and management of patients with LARC-associated complaints.

Intrauterine devices at six months: does patient age matter? Results from an urban family medicine federally qualified health center (FQHC) network

BACKGROUND

Federally qualified health centers (FQHCs) can address high rates of unintended pregnancy among adolescents in the United States by increasing access to intrauterine devices (IUDs) in underserved settings. Despite national guidelines endorsing adolescent use of IUDs, some physicians remain concerned about IUD tolerance and safety in adolescents. Therefore we compared adolescents and adults in a family physician staffed FQHC network with regard to (1) IUD postinsertion experience, (2) device discontinuation, and (3) sexually transmitted infection (STI) rates.

METHODS

We conducted a retrospective cohort study among women <36 years old who had an IUD inserted in 2011 at a New York City FQHC staffed by family physicians.

RESULTS

We included 684 women (27% adolescents, 73% adults). During the 6-month postinsertion period, 59% of adolescents and 43% of adults initiated IUD-related clinical contact after insertion, most commonly for bleeding changes and pelvic or abdominal pain. There were no significant differences between groups in IUD expulsion or removal or STI rates.

CONCLUSIONS

Urban FQHC providers may anticipate that, compared with their adult IUD users, adolescents will initiate more clinical follow-up visits after insertion. Both groups will, however, have similar clinical concerns about, reasons for, and rate of device discontinuation and low STI rates.

Contraception for adolescents

Contraception is a pillar in reducing adolescent pregnancy rates. The American Academy of Pediatrics recommends that pediatricians develop a working knowledge of contraception to help adolescents reduce risks of and negative health consequences related to unintended pregnancy. Over the past 10 years, a number of new contraceptive methods have become available to adolescents, newer guidance has been issued on existing contraceptive methods, and the evidence base for contraception for special populations (adolescents who have disabilities, are obese, are recipients of solid organ transplants, or are HIV infected) has expanded. The Academy has addressed contraception since 1980, and this policy statement updates the 2007 statement on contraception and adolescents. It provides the pediatrician with a description and rationale for best practices in counseling and prescribing contraception for adolescents. It is supported by an accompanying technical report.

IUDs as EC? Limited awareness and high reported acceptability: evidence from Argentina

BACKGROUND

We explored knowledge and attitudes regarding the copper intrauterine device (IUD) as emergency contraception (EC) among women in Buenos Aires, Argentina.

STUDY DESIGN

We interviewed a convenience sample of women attending a family planning center at a public hospital. Participants were asked about knowledge and use of contraceptives, including EC (pre-script). Then they were given information about the IUD as EC and subsequently asked about acceptability of using the copper IUD as EC (post-script), the primary outcome in this analysis.

RESULTS

We analyzed data on 273 women. While only 1.83% of participants knew the IUD served as EC at baseline, 79.85% said they would be willing to use the device as such if the need arose after given relevant information. Multivariate results from a pre-script revealed that women with low levels of education and those born outside of Argentina were less knowledgeable about EC pills. Only previous use of the IUD was associated with high levels of IUD knowledge. Post-script, results indicated that being Argentine [odds ratio (OR)=2.15, 95% confidence interval (CI) 1.21, 3.81] and previous IUD use (OR=2.12, 95% CI=1.07, 4.19) were positively associated with considering the IUD as EC. Nulliparity was negatively associated with willingness to use the IUD as EC (OR=0.44, 95% CI 0.22, 0.86).

CONCLUSION

We examined acceptability of the copper IUD as EC in a Latin American setting and found that, while prior levels of knowledg'e were low, acceptability of the IUD as EC was high. Implications for programming and policy include outreach and education regarding this highly effective method and advocacy to change existing regulations in Argentina prohibiting the use of IUD as EC.

IMPLICATIONS

After given information about the IUD as a method of EC, women interviewed said they would be willing to use the IUD EC despite their limited prior knowledge of this method. With more widespread information and availability of the IUD as EC, more women may opt for this highly effective method, which can provide additional protection against unwanted pregnancy for up to 10 years.

Twenty-four-month continuation of reversible contraception

OBJECTIVE

To estimate 24-month continuation rates of all reversible contraceptive methods for women enrolled in the Contraceptive CHOICE Project.

METHODS

We analyzed 24-month data from the 9,256 participants enrolled in the Contraceptive CHOICE Project, a prospective observational cohort study that provides no-cost contraception to women in the St. Louis region. The project promoted the use of long-acting reversible contraception (LARC) (intrauterine devices [IUDs] and implants) in an effort to reduce the rates of unintended pregnancy. This analysis includes participants who received their baseline contraceptive method within 3 months of enrollment and who completed a 24-month follow-up survey (N=6,153).

RESULTS

Twenty-four month continuation rates for long-acting reversible contraception and non-LARC methods were 77% and 41%, respectively. Continuation rates for the levonorgestrel and the copper IUDs were similar (79% compared with 77%), whereas the implant continuation rate was significantly lower (69%, P<.001) compared with IUDs at 24 months. There was no statistically significant difference in 24-month continuation rates among the four non-LARC methods (oral contraceptive pill [OCP] 43%, patch 40%, ring 41%, depot medroxyprogesterone acetate [DMPA] 38%; P=.72). Participants who chose a LARC method at enrollment were at significantly lower risk of contraceptive method discontinuation (adjusted hazard ratio 0.29, 95% confidence interval 0.26-0.32) compared with women who selected a non-LARC method.

CONCLUSION

Intrauterine devices and the implant have the highest rates of continuation at 24 months. Given their effectiveness and high continuation rates, IUDs and implants should be first-line contraceptive options and shorter-acting methods such as OCPs, patch, ring, and DMPA should be second tier.

LEVEL OF EVIDENCE

II.

Trends in menstrual concerns and suppression in adolescents with developmental disabilities

PURPOSE

Demonstrate changes in methods of menstrual suppression in adolescents with developmental disabilities in a recent 5-year cohort compared with an historical cohort at the same hospital.

METHODS

Retrospective cohort study of patients with physical and cognitive challenges presenting for menstrual concerns at an Adolescent Gynecology Clinic between 2006 and 2011 compared with a previous published cohort (1998 to 2003).

RESULTS

Three hundred patients with developmental disabilities aged 7.3 to 18.5 years (mean 12.1 ± 1.6) were analyzed. Caregiver concerns included menstrual suppression, hygiene, caregiver burden, and menstrual symptoms. Ninety-five percent of patients had cognitive disabilities, 4.4% had only physical impairments. Thirty-two (31.7) percent of patients presented premenarchally. The most commonly selected initial method of suppression was extended or continuous oral contraceptive pill (OCP) (42.3%) followed by patch (20%), expectant management (14.9%), depot medroxyprogesterone acetate (DMPA) (11.6%), and levonorgestrel intrauterine system (LNG-IUS) (2.8%). Published data from 1998 to 2003 indicated a preference for DMPA in 59% and OCP in 17% of patients. The average number of methods to reach caregiver satisfaction was 1.5. Sixty-five percent of initial methods were continued. The most common reasons for discontinuation were breakthrough bleeding, decreased bone mineral density, or difficulties with patch adherence. Second-choice selections included OCP (42.5%), LNG-IUS inserted under general anesthesia (19.2%), DMPA (17.8%), and patch (13.7%).

CONCLUSIONS

Since identification of decreased bone mineral density with DMPA and emergence of new contraceptive options, use of extended OCP or patch has surpassed DMPA for menstrual suppression in our patient population. LNG-IUS is an accepted, successful second-line option in adolescents with developmental disabilities.