Intrauterine contraception: the pendulum swings back

Prioritizing patient experience: Validation of the person-centered contraceptive counseling measure as a performance measure

OBJECTIVE

A performance measure assessing how often patients experience patient-centered contraceptive counseling can inform quality improvement in contraceptive care and enable efforts to enhance equity in the provision of this care. We sought to test the validity and reliability of the Person-Centered Contraceptive Counseling (PCCC) measure as a performance measure, in preparation for application for endorsement from the National Quality Forum.

STUDY DESIGN

We combined data from two research studies, a statewide quality improvement assessment, and a dedicated data collection effort at nine sites, all collected between 2009 and 2019 at 22 total sites in the United States, to evaluate the validity and reliability of the four-item PCCC measure aggregated at the provider and facility level. We scored the PCCC dichotomously as a "top-box" score of 20 versus less than 20. We assessed reliability using the Spearman-Brown coefficient, and validity by comparing scores on the PCCC to aggregated scores on single-item measures of patient satisfaction.

RESULTS

We included 22 facilities and 34 providers in the analyses. The average PCCC top-box score by provider and facility was 81% and 79%, respectively. We found adequate reliability with panel sizes of 20-50. PCCC scores were strongly associated with the single-item measures of satisfaction. There were notable disparities by race/ethnicity and language (Spanish vs English) in PCCC scores.

DISCUSSION

The PCCC is a valid and reliable performance measure for use at the provider and facility level. The development and use of the measures of patient experience, like the PCCC, is critical for prioritizing patient-centeredness in reproductive health care.

IMPLICATIONS

The PCCC measure can facilitate the identification of gaps and disparities in patient-centered contraceptive counseling and enable quality improvement to promote quality, equitable contraceptive care. Using this measure provides the opportunity to enhance patient experience of care and build trust between contraceptive providers and the communities they serve.

Contraception use and attitudes: women's concerns regarding hormonal contraception and copper intrauterine devices

OBJECTIVE

To estimate the prevalence of contraceptive method use among women, assess concerns about hormonal contraception (HC) and copper intrauterine device (Cu-IUD) and determine characteristics associated with concerns of HC and Cu-IUD.

METHOD

Cross-sectional study. Swedish speaking women (n = 212) aged 16-50 attending midwives at four outpatient clinics in two of Sweden's larger cities answered a waiting room questionnaire. Content analysis was used to categorise open-ended questions with free text answers.

RESULTS

Long-acting reversible contraceptives (LARC) was used by 30.4%, short acting reversible contraceptives (SARC) by 28.0%, and 16.4% did not use any contraception during most recent intercourse. Four out of ten (41.2%) had concerns about using HC and 52.3% about using Cu-IUD. The most common reason for having concerns regarding HC was unspecified side effects, fear of hormones and adverse mood symptoms; regarding Cu-IUD, concerns related to increased bleeding and menstrual pain. Among those expressing concerns, experience of induced abortion was twice as common. Women who did not have concerns about HC were using combined oral contraception (COC) to a higher extent.

CONCLUSION

Concerns about using HC and Cu-IUD are common. This needs to be considered during contraceptive counselling.

Intrauterine device use and risk of ovarian cancer: Results from the New England Case-Control study and Nurses' Health Studies

Results of studies assessing intrauterine device (IUD) use and ovarian cancer risk are inconsistent. We examined the association between IUD use, including duration, type and timing of use, and ovarian cancer risk using three population-based studies. Data from the New England Case-Control Study (NEC) and two prospective cohort studies, the Nurses' Health Studies (NHS/NHSII), were included in the analysis. Information on IUD use was collected by in-person interview in NEC and by biennial questionnaire in NHS/NHSII. We used unconditional logistic regression to calculate odds ratios (OR) and 95% confidence intervals (CI) in NEC and Cox regression to calculate hazard ratios (HR) and 95% CI in NHS/NHSII. We used meta-analysis to combine the NEC and the pooled NHS/NHSII results. Overall, IUD use was not associated with epithelial ovarian cancer risk (OR = 0.96, 95% CI: 0.81-1.14 in NEC; HR = 0.89, 95% CI: 0.69-1.15 in NHS/NHSII; combined RR = 0.94, 95% CI: 0.81-1.08). Among IUD users, older age at first use was associated with increased ovarian cancer risk (P-trend = .03). We did not observe significant associations by IUD type or duration of use. In conclusion, IUD use was not associated with ovarian cancer risk in our study.

Depot-Medroxyprogesterone Acetate Use Is Associated with Decreased Risk of Ovarian Cancer: The Mounting Evidence of a Protective Role of Progestins

BACKGROUND

Combined oral contraceptive use is associated with a decreased risk of invasive epithelial ovarian cancer (ovarian cancer). There is suggestive evidence of an inverse association between progestin-only contraceptive use and ovarian cancer risk, but previous studies have been underpowered.

METHODS

The current study used primary data from 7,977 women with ovarian cancer and 11,820 control women in seven case-control studies from the Ovarian Cancer Association Consortium to evaluate the association between use of depot-medroxyprogesterone acetate (DMPA), an injectable progestin-only contraceptive, and ovarian cancer risk. Logistic models were fit to determine the association between ever use of DMPA and ovarian cancer risk overall and by histotype. A systematic review of the association between DMPA use and ovarian cancer risk was conducted.

RESULTS

Ever use of DMPA was associated with a 35% decreased risk of ovarian cancer overall (OR, 0.65; 95% confidence interval, 0.50-0.85). There was a statistically significant trend of decreasing risk with increasing duration of use (P trend < 0.001). The systematic review yielded six studies, four of which showed an inverse association and two showed increased risk.

CONCLUSIONS

DMPA use appears to be associated with a decreased risk of ovarian cancer in a duration-dependent manner based on the preponderance of evidence. Further study of the mechanism through which DMPA use is associated with ovarian cancer is warranted.

IMPACT

The results of this study are of particular interest given the rise in popularity of progestin-releasing intrauterine devices that have a substantially lower progestin dose than that in DMPA, but may have a stronger local effect.

Intrauterine device use is safe among nulligravidas and adolescent girls

The use of intrauterine devices (IUDs), including the copper-bearing device and the levonorgestrel intrauterine system (LNG-IUS), is safe among nulligravidas and adolescent girls. However, several misconceptions limit their use in clinical practice; health-care providers are hesitant to prescribe IUDs, and several myths associated with their usage in nulligravidas and adolescents exist among both providers and women themselves. The high rates of unplanned pregnancies (which in many settings constitute a public health issue, primarily among adolescent females) can be attributed at least partially to lack of awareness and limited use of highly effective contraceptives such as IUDs. In this review, we discuss the role of non-hormonal and hormonal IUDs as effective contraceptives in nulligravidas and adolescent girls. We present a literature review of data that highlight contraceptive efficacy, side effects (including reasons for discontinuation), and continuation rates with the method. We searched the PubMed/MEDLINE, Cochrane Library, Embase, and Scopus databases for all articles published in English between January 1990 through September 2020. A large body of evidence confirmed the effectiveness of IUD/IUS, independent of age and parity. Studies showed a high expulsion rate among adolescents but not among nulligravidas. Additionally, bleeding patterns among adolescents and nulligravidas were similar to those observed among adults and parous women. The high early removal rates observed in adolescents were attributable to bleeding and/or pain, which indicate that compared with adults, adolescents are less likely to accept IUD-induced side effects. IUD placement is an excellent strategy to avoid the high rates of unplanned pregnancies in adolescents and nulligravidas. IUDs are more effective than short-acting reversible contraceptives with failure rates that are equivalent to those observed with permanent contraception. However, few long-term studies have investigated this category of women to definitively establish the role of IUD/IUS as effective means of contraception.

Uterine dimensions and intrauterine device malposition: can ultrasound predict displacement or expulsion before it happens?

OBJECTIVE

Intrauterine devices (IUDs) are the most commonly used method of long-acting reversible contraception. IUD malpositions are described as expulsion, embedding, displacement, and perforation, which may cause contraception failure, organ injury, hemorrhage, and infection. The aim of the study was to evaluate the relationship between displacement and IUD positioning in the uterus, and uterine dimensions as measured using transvaginal ultrasonography.

MATERIALS AND METHODS

Three-hundred and eighty-four patients who had TCu380A devices inserted at a tertiary hospital were evaluated at insertion and at 1 month, 3 months, and 6 months after insertion. At the insertion visit, demographic characteristics, history of menorrhagia, dysmenorrhea, previous IUD displacement, and obstetric history were recorded. Transvaginal ultrasonographic measurement of the uterine cavity, uterine length, uterine width, cervix length, cervix width, transverse diameter of the uterine cavity, the distance between the tip of the IUD and the fundus, and endometrium were measured to evaluate IUD displacement.

RESULTS

Sixteen of 384 patients had displacement. There were significant differences in times between last pregnancy outcomes and IUD insertion and dysmenorrhea history (p = 0.004 and p = 0.028, respectively). Among TCu380A users, women with 7.5 mm IUD endometrium distances had a higher risk for displacement with a sensitivity of 81% and specificity of 37.5% (AUC: 0.607, 95% CI 0.51-0.70). Women with uterus width less than 41.5 mm were more likely to have displacement with a sensitivity of 53.8% and a specificity of 75% (AUC: 0.673, 95% CI 0.60-0.75).

CONCLUSION

IUD endometrium distance and uterus width are important parameters for displacement for TCu380A.

Long-acting reversible contraceptive (LARCs) methods

Unplanned pregnancy (UP) is a public health problem, which affects millions of women worldwide. Providing long-acting reversible contraceptive (LARC) methods is an excellent strategy to avoid or at least reduce UP, because the effectiveness of these methods is higher than other methods, and is indeed comparable to that of permanent contraception. As the initial introduction of the inert plastic intrauterine device (IUD) and of the six-rod implant, pharmaceutical companies have introduced a copper IUD (Cu-IUD), different models of levonorgestrel-releasing intrauterine system (LNG IUS), and one and two-rod implants, which certainly improved women's LARC options. The main characteristic of LARCs is that they provide high contraceptive effectiveness with a single intervention, and that they can be used for a long time. Emerging evidence from the last few years has demonstrated that it is possible to extend the use of the 52 mg LNG IUS and of the etonogestrel-implant beyond five- and three years, respectively, which adds new value to these LARCs.

Provider self-disclosure during contraceptive counseling

OBJECTIVES

Provider self-disclosure (PSD) - defined as providers making statements regarding personal information to patients - has not been well characterized in the context of contraceptive counseling. In this study, we describe the incidence, content and context of contraceptive PSD.

STUDY DESIGN

This mixed methods analysis used data from the Provider-Patient Contraceptive Counseling study, for which 349 family planning patients were recruited from 2009 to 2012 from six clinics in the San Francisco Bay Area. Audio-recordings from their visits were analyzed for the presence or absence of PSD, and those visits with evidence of PSD were analyzed using qualitative methods. The associations of patient and provider demographics and patient satisfaction measures, obtained from survey data, with PSD were analyzed using bivariable and multivariable analyses.

RESULTS

Thirty-seven percent of providers showed evidence of PSD during at least one visit, and PSD occurred in 9% of clinic visits. Fifty-four percent of PSD statements were about intrauterine devices. About half of PSD statements occurred prior to the final selection of the contraceptive method and appeared to influence the choice of method. In post-visit surveys, all patients who reported receiving PSD considered it to be appropriate, and patient-reported PSD was not statistically associated with measures of patient satisfaction.

CONCLUSIONS

This study provides some support for the appropriateness of PSD during family planning encounters, at least as practiced during the sampled visits. Further research could explore whether this counseling strategy has an impact on patients' ability to identify the best contraceptive methods for them.

IMPLICATIONS

In this study, PSD did not have a demonstrated negative effect on the provider-patient relationship. In almost half of visits, PSD appeared to influence patients' choice of a method; whether this influence is beneficial needs further research.

Barriers and Misperceptions Limiting Widespread Use of Intrauterine Contraception Among Canadian Women

Unintended pregnancy is a major social and public health problem with adverse effects on neonatal and developmental outcomes, as well as maternal health and wellbeing. Traditionally, family planning policies have focused on increasing contraceptive uptake in non-users; however, rates of non-use are low in many developed nations. A high proportion of unintended pregnancies are attributable to contraceptive failure, particularly when using barrier and short-acting hormonal contraceptives. Intrauterine contraceptive devices (IUCDs) are highly effective and have been shown to reduce unintended pregnancy rates. Despite this, global utilization rates are low, and IUCD uptake in Canada has been particularly low. In this review we explore why IUCDs are not more widely used, and specifically focus on barriers and misperceptions that may influence IUCD uptake, particularly in Canada. We reviewed relevant articles published in English between 1990 and 2014, through searches of PubMed and Medline, including primary studies of any design containing information on the knowledge and attitudes of health care providers and women. Providing education to care providers, women, and policy makers may help overcome misperceptions about the use of IUCDs, and may facilitate greater use. Increased support from federal and provincial health programs may also encourage the use of IUCDs in Canadian women, and help to reduce unintended pregnancy rates.

Counseling about IUDs: a mixed-methods analysis

CONTEXT

IUDs are infrequently used in the United States. Assessing how counseling about this method is delivered can help identify barriers to IUD use that might be overcome by improving services.

METHODS

A sample of 342 family planning visits at six clinics in the San Francisco Bay Area in 2009-2012 were audio-recorded, and patients completed surveys both before and after their visits. Descriptive quantitative analyses of counseling were performed, and correlates of IUDs' being mentioned during counseling were investigated using logistic regression. Qualitative analyses investigated the counseling women received about IUDs generally (in a subset of 42 visits), as well as counseling for women who already had an IUD in place (13 visits) or who felt their provider inappropriately expressed a preference for IUDs (five visits).

RESULTS

IUDs were mentioned in 75% of visits. Patient-initiated mention of IUDs was more likely in visits by women aged 35 or older than in those by women younger than 20 (odds ratio, 6.4); provider-initiated discussion of this method was less common if the provider was older than 55 than if he or she was younger than 46 (0.3). Providers more often discussed potential adverse effects of IUD use than benefits; counseling often was noninteractive and did not address how patient preferences related to characteristics of IUDs. Counseling was frequently fragmented by the need for return visits or referral elsewhere for insertion.

CONCLUSIONS

IUD counseling may be improved by enhancing comprehensiveness and patient-centeredness, and by decreasing fragmentation of care.

Women's social communication about IUDs: a qualitative analysis

CONTEXT

Few U.S. women use an IUD, despite the method's efficacy and ease of use. While studies have found that misconceptions about IUDs are prevalent, few have examined the influence of women's social networks on perceptions of the method.

METHODS

Twenty-four interviews and three focus groups (comprising 14 participants) were conducted in 2013 with a diverse sample of women aged 15-45 recruited from family planning clinics and the community in San Francisco. Half of participants had used IUDs. Women were asked about their social communication concerning contraceptives, particularly IUDs, and about the content of the information they had received or given. Transcripts were analyzed using a modified grounded theory approach to identify themes of interest.

RESULTS

Women reported that communication with female friends and family members was a valued means of obtaining information about contraceptives, and that negative information (which often was incorrect) was more prevalent and memorable than positive information in such communication. Women heard about negative experiences with IUDs from social contacts and television commercials; clinicians were a major source of positive information. Women who had never used IUDs expressed interest in learning about potential side effects and how IUDs feel, while users reported emphasizing to friends and family the method's efficacy and ease of use.

CONCLUSIONS

Misinformation and negative information about IUDs are prevalent in social communication, and the information transmitted through social networks differs from the information never-users wish to receive. Findings support the creation of peer-led interventions to encourage IUD users to share positive personal experiences and evidence-based information.

Worldwide use of intrauterine contraception: a review

BACKGROUND

Globally, 14.3% of women of reproductive age use intrauterine contraception (IUC), but the distribution of IUC users is strikingly nonuniform. In some countries, the percentage of women using IUC is <2%, whereas in other countries, it is >40%. Reasons for this large variation are not well documented. The aims of this review are to describe the worldwide variation in IUC utilization and to explore factors that impact utilization rates among women of reproductive age in different continents and countries.

STUDY DESIGN

Published literature from 1982 to 2012 was reviewed, using Medline and Embase, to identify publications reporting diverse practices of IUC provision, including variation in the types of IUC available. Local experts who are active members of international advisory groups or congresses were also consulted to document variations in practice regulations, published guidelines and cost of IUC in different countries.

RESULTS

Multiple factors appear to contribute to global variability in IUC use, including government policy on family planning, the types of health care providers (HCPs) who are authorized to place and remove IUC, the medicolegal environment, the availability of practical training for HCPs, cost differences and the geographical spread of clinics providing IUC services.

CONCLUSIONS

Our review shows that the use of IUC is influenced more by factors such as geographic differences, government policy and the HCP's educational level than by medical eligibility criteria. These factors can be influenced through education of HCPs and greater understanding among policy makers of the effectiveness and cost-effectiveness of IUC methods.

IMPLICATIONS

Globally, 14.3% of women of reproductive age use IUC, but the percentage of women using IUC is in some countries <2%, whereas in other countries, it is >40%. This paper reviews the reasons for this diverse and highlights possible starting points to improve the inclusion of IUC in contraceptive counseling.

Disparities in abortion rates: a public health approach

Women of lower socioeconomic status and women of color in the United States have higher rates of abortion than women of higher socioeconomic status and White women. Opponents of abortion use these statistics to argue that abortion providers are exploiting women of color and low socioeconomic status, and thus, regulations are needed to protect women. This argument ignores the underlying causes of the disparities. As efforts to restrict abortion will have no effect on these underlying factors, and instead will only result in more women experiencing later abortions or having an unintended childbirth, they are likely to result in worsening health disparities. We provide a review of the causes of abortion disparities and argue for a multifaceted public health approach to address them.

Labhardt's colpoperineocleisis: subjective results of an alternative treatment for genital prolapse in patients who are not sexually active--2-year follow-up

INTRODUCTION AND HYPOTHESIS

Genital prolapse affects up to 50 % of multiparous women and has an impact on quality of life (QoL) for many. Vaginal obliterative techniques are relevant in older patients who are not sexually active. We performed Labhardt's colpoperineocleisis in such patients. The objective was the evaluation of subjective outcomes of this technique using PGI-I.

METHODS

Retrospective cohort analysis of patients. We performed a bivariate, multivariate analysis, and survival curves for subjective improvement.

RESULTS

Seventy-four cases were analyzed. Average age of the patients was 72 years, median parity 4, 95.9 % POP-Q stage III or IV, anterior leading edge defect in 61.1 %. Operating time: 54 min, estimated blood loss 70 ml, no intraoperative complications, 12 patients had protocol deviations with changes in the recommended type of suture. Median hospital stay was 2 days and average follow-up 24.9 months. There was 13.5 % anatomical recurrence, 3 of which (30 %) were in patients with protocol deviations. 1.9 % developed clinically significant de novo stress urinary incontinence (SUI).

PGI-I

64 (86 %) reported subjective improvement and 10 did not. In the subjective improvement group, 98.4 % reported being very much or much better. In the non-subjective improvement group 80 % reported that they were the same as before surgery and 20 % were worse. In bivariate analysis anatomical recurrence showed significance and persisted after multivariate analysis with an OR of 8322 for subjective failure.

CONCLUSION

Labhardt's colpoperineocleisis is a safe technique with good subjective results. It has few complications, an acceptable recurrence rate, and a low rate of de novo SUI. It may be important to use the #0 or #1 polydioxanone sutures, as these are associated with better outcomes in this series. Comparative studies with other obliterative techniques are needed.

Multimodality imaging of intrauterine devices with an emphasis on the emerging role of 3-dimensional ultrasound

The intrauterine contraceptive device (IUD) is one of the most widely used reversible contraception methods throughout the world. With advancing technology, it has rapidly gained acceptance through its increased effectiveness and practicality compared with more invasive means such as laparoscopic tubal ligation. This pictorial essay will present the IUDs most commonly used today. It will illustrate both normal and abnormal positions of IUDs across all cross-sectional imaging modalities including 2-dimensional ultrasound, computed tomography, and magnetic resonance imaging, with a focus on the emerging role of 3-dimensional ultrasound as the modality of choice.

A review of barriers and myths preventing the more widespread use of intrauterine contraception in nulliparous women

Objectives Intrauterine contracepives (IUCs) are highly effective and safe for use in all women, including those who are nulliparous. However, many myths and barriers prevent more widespread utilisation. The objective of this article was to explore the health care provider (HCP), health system and user issues that prevent more widespread use of IUCs, particularly among nulliparous women, and to present the evidence that supports achieving greater utilisation of these devices.

Methods MEDLINE, PubMed and Embase were used to identify studies reporting attitudes and beliefs around IUCs, and clinical studies providing evidence of their risks and benefits.

Results HCP, health system and user factors limiting use of IUCs were identified. The most widely explored barriers in published studies are those at the HCP level. User barriers are less well documented and health system barriers are mostly assessed through indirect evidence. Many, but not all, of the barriers can be reduced through greater understanding of the evidence.

Conclusions Efforts need to be made to disseminate the evidence, which shows that few contraindications exist to IUC use. Addressing HCP lack of knowledge, training and confidence with IUC insertions, particularly in nulliparous women, could make a substantial positive impact on IUC utilisation.

A study of physician recommendations for reversible contraceptive methods using standardized patients

CONTEXT

Health care providers may influence patients' choice of contraceptive method, yet little is known about the recommendations they make to their patients.

METHODS

In 2007-2008, a total of 468 physicians at four family medicine and obstetrics and gynecology meetings were randomly assigned to view one of 18 videos of a patient seeking contraceptive advice; the patients were standardized for most relevant behaviors and characteristics, but differed by race and ethnicity, socioeconomic status and gynecologic history. Participants provided their demographic and practice characteristics and completed a survey about their contraceptive recommendations for the patient. Multivariate logistic regression analyses were conducted to identify associations between physician characteristics and recommendations for specific contraceptive methods.

RESULTS

The most frequently recommended methods were the pill (89%) and ring (80%), followed by the levonor-gestrel IUD (64%), patch (56%), injectable (49%) and copper IUD (45%). Oral contraceptives were more likely to be recommended by private practice physicians than by academic physicians (odds ratio, 2.9). Recommendations for the ring were less common among family physicians and those 56 or older than among obstetrician-gynecologists and those 35 or younger (0.6 and 0.3, respectively), and more common among physicians in private practice than among those in academia (2.4). The patch and injectable were more commonly recommended by family physicians than by obstetrician-gynecologists (2.6 and 2.5, respectively). Both IUD types were recommended less often by physicians 36 or older than by younger ones (0.2-0.5).

DISCUSSION

The advice women receive about contraception may vary according to the characteristics of their provider. Research on the reasons for these differences is needed.

Contraception methods, beyond oral contraceptives and tubal ligation, and risk of ovarian cancer

PURPOSE

Few studies have examined methods of contraception, beyond oral contraceptives (OCs) and tubal ligation, in relation to ovarian cancer risk.

METHODS

Nine hundred two cases with incident ovarian/peritoneal/tubal cancer were compared with 1800 population-based control subjects. Women self-reported all methods of contraception by using life calendars.

RESULTS

Each of the contraceptive methods examined reduced the risk of ovarian cancer as compared with use of no artificial contraception. Comparing ever versus never use, after adjustment for potentially confounding factors and all other methods of contraception, the methods of contraception that emerged as protective were OCs (adjusted odds ratio [adj OR] 0.75, 95% confidence interval [CI] 0.61-0.93); tubal ligation (adj OR 0.63, 95% CI 0.51-0.77); intrauterine devices (IUDs) (adj OR 0.75, 95% CI 0.59-0.95); and vasectomy (adj OR 0.77, 95% CI 0.61-0.99). Although for OCs and tubal ligation we found that the longer the duration of use, the greater the effect, for IUDs the pattern was reversed: significant protection occurred with short duration and progressively greater risk (albeit nonsignificant) was seen with longer duration of use.

CONCLUSIONS

In the largest case-control study to date, a range of effective methods of contraception reduced the risk for ovarian cancer. OCs and tubal ligation reduced ovarian cancer risk with lower odds ratios with longer duration of use, whereas IUDs reduced risk overall, having the greatest impact with short duration of use.

Recommendations for intrauterine contraception: a randomized trial of the effects of patients' race/ethnicity and socioeconomic status

OBJECTIVE

Recommendations by health care providers have been found to vary by patient race/ethnicity and socioeconomic status and may contribute to health disparities. This study investigated the effect of these factors on recommendations for contraception.

STUDY DESIGN

One of 18 videos depicting patients of varying sociodemographic characteristics was shown to each of 524 health care providers. Providers indicated whether they would recommend levonorgestrel intrauterine contraception to the patient shown in the video.

RESULTS

Low socioeconomic status whites were less likely to have intrauterine contraception recommended than high socioeconomic status whites (odds ratio [OR], 0.20; 95% confidence interval [CI], 0.06-0.69); whereas, socioeconomic status had no significant effect among Latinas and blacks. By race/ethnicity, low socioeconomic status Latinas and blacks were more likely to have intrauterine contraception recommended than low socioeconomic status whites (OR, 3.4; and 95% CI, 1.1-10.2 and OR, 3.1; 95% CI, 1.0-9.6, respectively), with no effect of race/ethnicity for high socioeconomic status patients.

CONCLUSION

Providers may have biases about intrauterine contraception or make assumptions about its use based on patient race/ethnicity and socioeconomic status.

Safety, efficacy and patient acceptability of the contraceptive and non-contraceptive uses of the LNG-IUS

Intrauterine devices (IUDs) provide highly effective, long-term, safe, reversible contraception, and are the most widely used reversible contraceptive method worldwide. The levonorgestrel-releasing intrauterine system (LNG-IUS) is a T-shaped IUD with a steroid reservoir containing 52 mg of levonorgestrel that is released at an initial rate of 20 μg daily. It is highly effective, with a typical-use first year pregnancy rate of 0.1% - similar to surgical tubal occlusion. It is approved for 5 years of contraceptive use, and there is evidence that it can be effective for up to 7 years of continuous use. After removal, there is rapid return to fertility, with 1-year life-table pregnancy rates of 89 per 100 for women less than 30 years of age. Most users experience a dramatic reduction in menstrual bleeding, and about 15% to 20% of women become amenorrheic 1 year after insertion. The device's strong local effects on the endometrium benefit women with various benign gynecological conditions such as menorrhagia, dysmenorrhea, leiomyomata, adenomyosis, and endometriosis. There is also evidence to support its role in endometrial protection during postmenopausal estrogen replacement therapy, and in the treatment of endometrial hyperplasia.