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Envall N, Elgemark K, Kopp Kallner H. Mepivacaine instillation for pain reduction during intrauterine device placement in nulliparous women: a double-blinded randomized trial. Am J Obstet Gynecol 2024:S0002-9378(24)00624-0. [PMID: 38796037 DOI: 10.1016/j.ajog.2024.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/01/2024] [Accepted: 05/19/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Fear of pain associated with intrauterine device (IUD) placement has been identified as a significant barrier to the adoption of long-acting reversible contraception, contributing to lower utilization of the most effective reversible contraceptive methods. OBJECTIVE To assess whether instillation of intrauterine mepivacaine before IUD placement alleviates pain more effectively than a placebo. STUDY DESIGN We conducted a multicenter, double-blind, randomized, placebo-controlled trial involving nulliparous women undergoing IUD placement. An intrauterine instillation of 10 mL of 20 mg/mL mepivacaine or 0.9 mg/mL sodium chloride was administrated through a hydrosonography catheter 2 minutes prior to IUD placement. Pain scores were assessed using a 100 mm visual analog scale (VAS) at prespecified time points. Primary outcome measured the difference in VAS pain scores between the intervention group and the placebo group during IUD placement. Secondary outcomes included VAS pain scores at instillation and 10 minutes after placement, tolerability of the placement pain, as well as acceptability of the analgesia method. RESULTS We enrolled 151 participants, with 76 assigned to the mepivacaine group and 75 to the placebo group. The mean VAS pain score during IUD placement showed a difference of 13.3 mm (95% confidence interval (CI) 5.75-20.87; P<.001): the mepivacaine group had a mean of 53.9 mm (standard deviation [SD] 22.8), while the placebo group had a mean of 67.2 mm (SD 22.4). After adjusting for each individual provider's impact, the difference in mean pain scores remained statistically significant (12.2 mm 95% CI 4.85-19.62; P<.001). A greater proportion of women in the intervention group reported tolerable pain during placement with 70/75 participants (93.3%) compared to 53/66 participants (80.3%) in the placebo group (P=.021). CONCLUSION The intrauterine instillation of mepivacaine results in statistically significant reduction in pain score among nulliparous women during IUD placement. Although the precise clinical impact of this pain reduction method remains uncertain, the observed reduction in pain score result in a higher proportion of women reporting tolerable pain. This finding and the high acceptance as a pain reduction method thereby suggests clinical relevance. Intrauterine instillation of mepivacaine is a possible strategy to increase IUD utilization, particularly among nulliparous women who are at high risk of unintended pregnancy.
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Affiliation(s)
- Niklas Envall
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; School of Health and Welfare, Dalarna University, Falun, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Karin Elgemark
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden.
| | - Helena Kopp Kallner
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden
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2
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Anjos FCQS, Marcelino AC, Espejo-Arce X, Pereira PDC, Barbosa PF, Juliato CT, Bahamondes L. Pain and ease of insertion of three different intrauterine devices in Brazilian adolescents: A participant-blinded randomized trial. Contraception 2023; 122:109997. [PMID: 36841463 DOI: 10.1016/j.contraception.2023.109997] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/07/2023] [Accepted: 02/16/2023] [Indexed: 02/27/2023]
Abstract
OBJECTIVES To compare pain and ease of insertion of the copper 380 mm2, levonorgestrel 52 mg, and levonorgestrel 19.5-mg intrauterine devices (IUDs) in Brazilian adolescents. STUDY DESIGN We conducted a participant-blinded randomized trial at two clinics in Brazil. We enrolled 318 adolescents<19 years old in a 1:1:1 ratio from November 2021 to February 2022. We informed the adolescents about the IUD type inserted after they evaluated the pain associated with the IUD insertion using a Visual Analogue Scale and immediately after that the healthcare provider who placed the IUD evaluated the ease of the procedure. RESULTS The VAS pain level was significantly higher after the levonorgestrel 52-mg IUD placement, median and [interquartile range, IQ] 8.0 [4.0] than the copper 380-mm2 IUD 7.0 [4.0], and the levonorgestrel 19.5-mg IUD 7.0 [6.0] (p = 0.001). The placement was easier after the copper 380-mm2 IUD (87/106, 82.1%) and the levonorgestrel 19.5-mg IUD (91/106, 85.8%) when compared with the levonorgestrel 52-mg IUD (75/105, 70.7%). After multiple logistic regression analyses, the higher VAS pain scores were associated with the levonorgestrel 52-mg IUD (OR = 2.90), low number of pregnancies (OR -0.48), and with a history of dysmenorrhea (OR = 2.67). CONCLUSIONS The placement of the copper 380-mm2 IUD and the levonorgestrel 19.5-mg IUD was associated with lower pain according to the adolescent and was easier according to the provider when compared with the levonorgestrel 52-mg IUD. However, the small observed differences may not be clinically relevant. IMPLICATIONS We found that the three types of IUDs were generally easy to place; however, mean pain scores were high during insertions. Our findings of high pain scores reinforce the need for interventions to reduce pain for adolescent IUD insertion.
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Affiliation(s)
- Fabiana C Q S Anjos
- Department of Obstetrics and Gynecology, University of Gurupi, Faculty of Medical Sciences, Gurupi, TO, Brazil
| | - Ana C Marcelino
- Department of Obstetrics and Gynecology, University of Campinas, Faculty of Medical Sciences, Campinas, SP, Brazil
| | - Ximena Espejo-Arce
- Department of Obstetrics and Gynecology, University of Campinas, Faculty of Medical Sciences, Campinas, SP, Brazil
| | - Paula da C Pereira
- Department of Obstetrics and Gynecology, University of Campinas, Faculty of Medical Sciences, Campinas, SP, Brazil
| | - Priscila F Barbosa
- Department of Obstetrics and Gynecology, University of Gurupi, Faculty of Medical Sciences, Gurupi, TO, Brazil
| | - Cassia T Juliato
- Department of Obstetrics and Gynecology, University of Campinas, Faculty of Medical Sciences, Campinas, SP, Brazil
| | - Luis Bahamondes
- Department of Obstetrics and Gynecology, University of Campinas, Faculty of Medical Sciences, Campinas, SP, Brazil.
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Ali MK, Ramadan AK, Abu-Elhassan AM, Sobh AMA. Ultrasound-guided versus uterine sound-sparing approach during copper intrauterine device insertion: a randomised clinical trial. EUR J CONTRACEP REPR 2022; 27:3-8. [PMID: 33855908 DOI: 10.1080/13625187.2021.1900565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/02/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To compare the outcomes of trans-abdominal ultrasound (TAS) guided approach and uterine sound-sparing approach (USSA) during copper intrauterine device (IUD) insertion. STUDY DESIGN A randomised open-label clinical trial (Clinical Trials.Gov: NCT03383432) included multiparous women requesting Copper IUD insertion for birth control were invited to participate. The eligible women were randomised into two groups (44 women in each group); group I (TAS-guided IUD insertion) and group II: USSA. The primary outcome was to measure the satisfaction score of IUD insertion in both methods. Secondary outcomes included the easiness score (ES), the difference in pain scores during IUD insertion, the duration of insertion, and the successful device placement after one week and one month evaluated by transvaginal ultrasound (TVS). RESULTS Eighty-eight women were analysed in both groups. The VAS for satisfaction was significantly higher in the USSA group than the TAS-guided group (7.80 ± 1.27 vs. 5.45 ± 1.42, p = .0001). There was significantly lower VAS of pain scores during IUD insertion in the USSA group as compared with the TAS-guided IUD (p = .001). A lower ES and a significantly shorter duration of IUD insertion were also determined among the USSA group (p = .0001). CONCLUSIONS USSA is associated with higher satisfaction and less pain during insertion than the TAS-guided IUD insertion approach. However, both techniques have optimal intra-uterine device positioning.
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Affiliation(s)
- Mohammed K Ali
- Department of Obstetrics & Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Asmaa K Ramadan
- Department of Obstetrics & Gynecology, Assiut General Hospital, Assiut, Egypt
| | - Ahmed M Abu-Elhassan
- Department of Obstetrics & Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed M A Sobh
- Department of Obstetrics & Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
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Abern L, Krempasky C, Diego D, De Guzman G, Kiely K, Cook J, Maguire K. The Intrauterine Device Experience Among Transgender and Gender-Diverse Individuals Assigned Female at Birth. J Midwifery Womens Health 2021; 66:772-777. [PMID: 34767305 DOI: 10.1111/jmwh.13310] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 09/15/2021] [Accepted: 10/11/2021] [Indexed: 01/16/2023]
Abstract
INTRODUCTION The intrauterine device (IUD) is a long-acting and highly efficacious form of contraception that can also be used for menstrual suppression. Although IUD use is increasing, the type chosen, appeal, and satisfaction among individuals who are transgender and gender diverse and assigned female at birth (TGD-AFAB) is unknown. The purpose of this study is to evaluate IUD usage among TGD-AFAB individuals. METHODS TGD-AFAB individuals who had an IUD for a minimum of 6 months at the time of completing the survey or had one in the past completed an anonymous online survey. Descriptive statistics were used to analyze the data. RESULTS One hundred and five TGD-AFAB individuals completed the survey. Among participants who were sexually active, 88% reported they were in a relationship in which it was possible to get pregnant. There were 85 individuals who currently had an IUD: 62 (73%) chose a 52-mg levonorgestrel (LNG) IUD, 5 (6%) chose a lower-dose LNG IUD, 17 (20%) chose the copper IUD, and one chose an IUD unavailable in the United States. Menstrual suppression was the primary reason for choosing a 52-mg LNG IUD (58%). Most individuals who opted for a copper IUD did so to avoid hormonal contraception (71%). Participants reported experiencing IUD side effects; however, few desired removal. Among the 36 respondents who had an IUD in the past, the most frequent reasons for removal were expiration of the device (LNG IUDs) and undesired side effects (copper IUD). Approximately half of participants who had an IUD removed had it replaced with another IUD. DISCUSSION Pregnancy can occur among TGD-AFAB individuals even if they are on testosterone and amenorrheic. IUDs are well tolerated in this population, with few current users desiring removal for unwanted side effects. Clinicians should counsel TGD-AFAB individuals about the contraceptive and noncontraceptive benefits of IUDs and expected side effects.
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Affiliation(s)
| | | | | | | | | | - Jake Cook
- Philadelphia Fight, Philadelphia, Pennsylvania
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5
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Branger B, Priou E, David P. [Copper-containing intrauterine device (cIUD): Comparison of tolerance and efficacy in nulliparous and parous women over 6 months]. ACTA ACUST UNITED AC 2021; 49:897-906. [PMID: 34144222 DOI: 10.1016/j.gofs.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The copper-containing intra-uterine device IUD (cIUD) is a non-hormonal, effective, long-acting method of contraception, which is not widely used in nulliparous patients in France. The objectives of the study are to compare the safety of the cIUD by the rate of continuation at 6 months between nulliparous and parous patients, and to assess the complications and side effects at insertion and during follow-up. Material and method This is a multicenter prospective epidemiological study with follow-up for 6 months. The adult patients were included in Nantes from February 2019 to October 2019 during the insertion of a IUD in different centers: the student health service (SUMPPS) (Nantes), the Clotilde de Vautier center in the Clinic Jules Verne (Nantes) and in the gynecological offices of the city of Nantes. RESULTS A total of 94 patients were included during the insertion of the cIUD. At 6 months, 77 patients answered the second questionnaire, 49 patients were nulliparous and 28 were parous. The pain on insertion was greater in nulliparous patients with a VAS of 6.5±2.4 (0-10) versus 3.9±2.2 (0-8) for multiparous patients (P<10-4). The 6-month continuation rate for the cIUD was 92.8% for 83.4% for nulliparous patients, and parous patients with no significant difference (P=0.25). Expulsion was the only complication found with 12.2% in nulliparous and 3.5% in parous (P=0.40). Otherwise, 64% of the patients observed heavy bleeding than before without difference with the parity, and 72% of the nulliparous declared to have dysmenorrhea requiring the use of analgesics, against 47% of the parous (P=0.025). The nulliparous were very satisfied or satisfied for 89% in daily life and 96% of them in sex life, without difference compared to parous (97% and 100% respectively). CONCLUSION There is no difference in the rate of continuation at 6 months between nulliparous and parous. Nulliparous complained more often of dysmenorrhea in comparison to the period before the cIUD. The satisfaction rates were comparable.
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Affiliation(s)
- B Branger
- Épidémiologie, 11bis, rue Gabriel-Luneau, 44000 Nantes, France.
| | - E Priou
- Médecin généraliste, 120, rue de Bretagne, 44880 Sautron, France
| | - P David
- Gynécologue-Obstétricien, clinique Jules-Verne, 2-4, route de Paris, 44300 Nantes, France
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Chaves IA, Baêta T, Dolabella GB, Barbosa LR, Almeida NM, Oliveira FR, Oliveira EC, L Silva-Filho A, Rocha ALL. Pain scores at the insertion of the 52 MG levonorgestrel-releasing intrauterine system among nulligravidas and parous women. EUR J CONTRACEP REPR 2021; 26:399-403. [PMID: 34096433 DOI: 10.1080/13625187.2021.1925882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE This study aimed to assess the pain scores at the insertion of the 52 mg levonorgestrel-releasing intrauterine system (LNG-IUS) among nulligravidas, parous women with previous vaginal delivery and parous women with elective caesarean-delivery without any previous labour or cervix dilation. MATERIALS AND METHODS The present research is a prospective, single-cohort study that included 413 women aged 15-49 years who opted for LNG-IUS placement for contraception or treatment of heavy menstrual bleeding. Women who participated in the present study were not submitted to any pharmacological pain-relieving intervention to perform the procedure. Pain at insertion was evaluated by using a Visual Analogue Scale (VAS). Pain was classified as absent (0), mild (1-3), moderate (4-6), or severe (7-10). The women were divided as: (1) nulligravidas, (2) parous women with a previous vaginal delivery, or (3) parous women with elective caesarean-delivery without any previous labour or cervix dilation. RESULTS Nulligravidas women presented a higher mean pain score, when compared to women with elective caesarean-delivery and women with previous vaginal delivery (6.6 ± 2.0 vs 5.5 ± 2.1 and 3.9 ± 2.4, respectively; p < 0.001). Nulligravidas and women with elective caesarean-delivery were more likely to have pain classified as moderate or severe (in relation to absent or mild) than women with previous vaginal delivery (p < 0.001). Multiple Linear Regression Analysis demonstrated that 29.5% of all variability of the pain score was explained by two predictor/independent variables: nulligravidas or women with elective caesarean and difficulty at IUD insertion. CONCLUSIONS Women with previous vaginal delivery had lower pain scores at LNG-IUS insertion when compared to nulligravidas and women with elective caesarean-delivery without any previous labour.
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Affiliation(s)
- Isabella A Chaves
- Department of Obstetrics and Gynecology, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Thaís Baêta
- Department of Obstetrics and Gynecology, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Gabriella B Dolabella
- Department of Obstetrics and Gynecology, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Luma R Barbosa
- Department of Obstetrics and Gynecology, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Natália M Almeida
- Department of Obstetrics and Gynecology, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Flávia R Oliveira
- Department of Obstetrics and Gynecology, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Elaine C Oliveira
- Department of Obstetrics and Gynecology, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Agnaldo L Silva-Filho
- Department of Obstetrics and Gynecology, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Ana Luiza Lunardi Rocha
- Department of Obstetrics and Gynecology, Federal University of Minas Gerais, Belo Horizonte, Brazil
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Elkhateeb RR, Kishk E, Sanad A, Bahaa H, Hagazy AR, Shaheen K, Moustafa E, Fares H, Gomaa K, Mahran A. The acceptability of using IUDs among Egyptian nulliparous women: a cross-sectional study. BMC WOMENS HEALTH 2020; 20:117. [PMID: 32503576 PMCID: PMC7275565 DOI: 10.1186/s12905-020-00977-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 05/20/2020] [Indexed: 11/16/2022]
Abstract
Background Although intrauterine contraceptive device is highly effective, safe, long term and reversible method of contraception, the general population and physicians refuse. IUDs for nulliparous women due to persistent rumors about its side effects and complications. The aim of this study was to assess the acceptability of IUD use in nulliparous women by both women and health care providers in Egypt. Methods Five hundred thirty nulliparous women and 200 physicians were interviewed in 10 family planning clinics in Suez and Minia cities – Egypt. The knowledge and attitudes of women and health care providers towards IUD use in nulliparous women were assessed through a well designed questionnaire over 2 years. Those women who accepted using IUD were then followed up for 6 months. Results Most of nulliparous women sought for contraception reported a negative impression of IUD method (96.2%). 82.5% of physicians had the same attitude. The reasons for refusing IUD among nulliparous women are fear of side effects including infection (52.8%), and bleeding (37.7%).Also, fear of subsequent infertility 51.9% of women. Regarding the providers, increased pelvic inflammatory disease (PID) represented the highest percentage (70%) for non acceptability, followed by difficult insertion (52.5%). Ninety women who accepted use IUD were followed up 6 months later, 94.4% were still using the method and77.8% were happy with the results. Conclusion The main barriers that hinder the use of IUD in nulliparous women are the women insufficient knowledge and attitude of their physicians. Good client counseling. Good training for physician to improve their experience would help increase the use of such effective and safe method.
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Affiliation(s)
- Reham Refaat Elkhateeb
- Obstetrics and Gynecology, Faculty of medicine Minia University, Maternity Hospital Minia University, Minia, Egypt.
| | - Eman Kishk
- Obstetrics and Gynecology, Faculty of Medicine Suez Canal University, Suez, Egypt
| | - Ahmad Sanad
- Obstetrics and Gynecology Minia University, Minia, Egypt
| | - Haitham Bahaa
- Obstetrics and Gynecology, Faculty of Medicine Minia University, Minia, Egypt
| | - Abdel Rahman Hagazy
- Obstetrics and Gynecology, Faculty of Medicine Minia University, Minia, Egypt
| | - Kareem Shaheen
- Obstetrics and Gynecology Minia University, Minia, Egypt
| | - Enas Moustafa
- Obstetrics and Gynecology Minia University, Minia, Egypt
| | - Hahem Fares
- Obstetrics and Gynecology Minia University, Minia, Egypt
| | - Khalid Gomaa
- Obstetrics and Gynecology at Maternity Hospital, Minia University, Minia, Egypt
| | - Ahmad Mahran
- Obstetrics and Gynecology, Faculty of Medicine Minia University, Minia, Egypt
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Hillard PJA. Practical Tips for Intrauterine Device Counseling, Insertion, and Pain Relief in Adolescents: An Update. J Pediatr Adolesc Gynecol 2019; 32:S14-S22. [PMID: 30802602 DOI: 10.1016/j.jpag.2019.02.121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 02/15/2019] [Accepted: 02/15/2019] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Paula J Adams Hillard
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California.
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Gemzell-Danielsson K, Jensen JT, Monteiro I, Peers T, Rodriguez M, Di Spiezio Sardo A, Bahamondes L. Interventions for the prevention of pain associated with the placement of intrauterine contraceptives: An updated review. Acta Obstet Gynecol Scand 2019; 98:1500-1513. [PMID: 31112295 PMCID: PMC6900125 DOI: 10.1111/aogs.13662] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 05/11/2019] [Indexed: 01/09/2023]
Abstract
A 2013 review found no evidence to support the routine use of pain relief for intrauterine contraceptive (IUC) placement; however, fear of pain with placement continues to be a barrier to use for some women. This narrative review set out to identify (1) new evidence that may support routine use of pain management strategies for IUC placement; (2) procedure‐related approaches that may have a positive impact on the pain experience; and (3) factors that may help healthcare professionals identify women at increased risk of pain with IUC placement. A literature search of the PubMed and Cochrane library databases revealed 550 citations, from which we identified 43 new and pertinent studies for review. Thirteen randomized clinical trials, published since 2012, described reductions in placement‐related pain with administration of oral and local analgesia (oral ketorolac, local analgesia with different lidocaine formulations) and cervical priming when compared with placebo or controls. Four studies suggested that ultrasound guidance, balloon dilation, and a modified placement device may help to minimize the pain experienced with IUC placement. Eight publications suggested that previous cesarean delivery, timing of insertion relative to menstruation, dysmenorrhea, expected pain, baseline anxiety, and size of insertion tube may affect the pain experienced with IUC placement. Oral and local analgesia and cervical priming can be effective in minimizing IUC placement‐related pain when compared with placebo, but routine use remains subject for debate. Predictive factors may help healthcare professionals to identify women at risk of experiencing pain. Targeted use of effective strategies in these women may be a useful approach while research continues in this area.
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Affiliation(s)
- Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institutet, WHO-Center, Karolinska University Hospital, Stockholm, Sweden
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Ilza Monteiro
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
| | | | - Maria Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Attilio Di Spiezio Sardo
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Luis Bahamondes
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Campinas, Campinas, Brazil
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Akdemir Y, Karadeniz M. The relationship between pain at IUD insertion and negative perceptions, anxiety and previous mode of delivery. EUR J CONTRACEP REPR 2019; 24:240-245. [DOI: 10.1080/13625187.2019.1610872] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Yesim Akdemir
- Department of Obstetrics and Gynaecology, School of Medicine, Bulent Ecevit University, Zonguldak, Turkey
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11
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Foran T, Butcher BE, Kovacs G, Bateson D, O’Connor V. Safety of insertion of the copper IUD and LNG-IUS in nulliparous women: a systematic review. EUR J CONTRACEP REPR 2018; 23:379-386. [DOI: 10.1080/13625187.2018.1526898] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Therese Foran
- School of Women’s and Children’s Health, University of New South Wales, Sydney, NSW, Australia
- Royal Hospital for Women, Sydney, NSW, Australia
| | - Belinda E. Butcher
- Biostatistics and Medical Writing, WriteSource Medical Pty Ltd, Sydney, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Gab Kovacs
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
- Institute of Obstetrics and Gynaecology, Epworth HealthCare, Melbourne, VIC, Australia
| | - Deborah Bateson
- Family Planning NSW, Sydney, NSW, Australia
- Discipline of Obstetrics, Gynaecology and Neonatology, University of Sydney, Sydney, NSW, Australia
| | - Vivienne O’Connor
- Mater Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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DeBoer TH, Hensley JG. Increasing Accessibility to Long-Acting Reversible Contraception in a Public Health Setting. Nurs Womens Health 2018; 22:302-309. [PMID: 30077236 DOI: 10.1016/j.nwh.2018.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/23/2018] [Accepted: 06/01/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To increase access to long-acting reversible contraception (LARC) by developing and implementing evidence-based criteria for LARC insertions at a public health clinic. DESIGN A quality improvement pilot project aimed at improving access to LARC for women of reproductive age and decrease associated costs. SETTING/LOCAL PROBLEM Eligibility criteria for LARC at a public health clinic in rural Georgia required two clinic visits and unnecessary screening tests for women interested in these methods. These criteria limited eligibility of candidates who desired LARC, increased time between requests for and insertion of LARC, and increased costs. PARTICIPANTS Fifteen women of reproductive age who were uninsured or underinsured had a LARC inserted during project implementation. INTERVENTION/MEASUREMENTS The average number of days between visits based on the old (2007) criteria was compared with the average number of days between visits after implementation of the new (2017) criteria, with specific focus on the number of same-day LARC insertions. A secondary analysis of cost savings was calculated. RESULTS After implementation of the 2017 criteria, a statistically significant (p < .01) decrease in the mean number of days between request for and insertion of LARC was noted. Every woman who requested a LARC received it, and more than half of LARC insertions were provided the same day. Furthermore, the clinic noted savings of nearly $1,000 on LARC insertions. CONCLUSION The wait time for LARC insertion substantially decreased, and more than half of women had a LARC inserted the same day they requested it. By decreasing the wait time between request for and insertion of a LARC and implementing a policy to advocate for same-day insertion, use of the 2017 criteria decreased women's risk for unintended pregnancy.
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Overcoming barriers to levonorgestrel-releasing intrauterine system placement: an evaluation of placement of LNG-IUS 8 using the modified EvoInserter ® in a majority nulliparous population. Contraception 2017; 96:426-431. [DOI: 10.1016/j.contraception.2017.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 08/10/2017] [Accepted: 08/16/2017] [Indexed: 11/22/2022]
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14
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Abbas AM. Comments on manuscript: Lidocaine for pain control during intrauterine device insertion. J Obstet Gynaecol Res 2017; 44:588. [PMID: 29171102 DOI: 10.1111/jog.13536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/27/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Ahmed M Abbas
- Faculty of Medicine, Department of Obstetrics and Gynecology, Assiut University, Assiut, Egypt
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Dakhly DMR, Bassiouny YA. Ultrasound-guided intrauterine device insertion: a step closer to painless insertion: a randomized control trial. EUR J CONTRACEP REPR 2017; 22:349-353. [PMID: 28978240 DOI: 10.1080/13625187.2017.1381234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIM OF STUDY To reduce the pain and duration of the intrauterine device (IUD) insertion procedure through minimizing instrumentation and using trans-abdominal sonography (TAS). METHODS This randomized control trial was conducted in a university hospital and included 102 eligible females, fulfilling the inclusion criteria. They were randomly assigned into two groups via 1:1 computer-based randomization program; the trans-abdominal guided IUD insertion group (n = 51), and the traditional IUD insertion group (n = 51). The main outcomes were the pain experienced during the procedure as scored by the visual analogue score and the duration of the procedure. RESULTS The trans-abdominal guided IUD insertion was found to be statistically superior to the traditional technique for IUD insertion regarding the pain scores (according to the Visual Analogue Scale, from 0 to 10) recorded by the candidates (2.4 ± 2.1 vs. 5.0 ± 1.7, p < .001) as well as the time (in seconds) taken for IUD insertion procedure (32.2 ± 14.8 vs. 77.7 ± 30.6, p < .001). CONCLUSIONS Due to the decrease in pain and time taken for IUD insertion, the trans-abdominal guided technique can be used as a modified technique for IUD insertion. ClinicalTrials.gov Identifier: NCT02582268.
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Lohr PA, Lyus R, Prager S. Use of intrauterine devices in nulliparous women. Contraception 2017; 95:529-537. [DOI: 10.1016/j.contraception.2016.08.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 08/23/2017] [Indexed: 02/07/2023]
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Abstract
Contraception services should be part of routine health care maintenance in reproductive-aged women, especially in light of the fact that approximately 50% of pregnancies in the United States remain unplanned. Barrier methods, especially condoms, may play a role in sexually transmitted disease prevention but are less efficacious for pregnancy avoidance. There are several available hormonal contraceptive options, including the combination hormonal pill, progestin-only pill, combination hormonal patches and rings, injectable progestins, implantable progestins, intrauterine devices (copper or progestin), and permanent sterilization. These methods have varying efficacy, often related to patient compliance or tolerance of side effects.
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Affiliation(s)
- Erin E Tracy
- Vincent Obstetrics and Gynecology, Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Harvard Medical School, Founders 406, 55 Fruit Street, Boston, MA 02114, USA.
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Usinger KM, Gola SB, Weis M, Smaldone A. Intrauterine Contraception Continuation in Adolescents and Young Women: A Systematic Review. J Pediatr Adolesc Gynecol 2016; 29:659-667. [PMID: 27386754 DOI: 10.1016/j.jpag.2016.06.007] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/07/2016] [Accepted: 06/21/2016] [Indexed: 10/21/2022]
Abstract
STUDY OBJECTIVE Adolescents are at high risk for unintended pregnancies. Although intrauterine devices (IUDs), long-acting reversible contraceptives (LARCs), are known to be highly effective in preventing pregnancy, little is known about IUD adherence in adolescents. In this systematic review (SR) we examined IUD continuation rates compared with other forms of contraception in young women aged 25 years and younger. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A systematic search of Ovid Medline, Cochrane Library, and Embase was conducted for the years 1946-2015. Included studies examined IUD use in women 25 years of age and younger, compared IUD use with another form of contraception, and measured continuation rates at 12 months. The quality of each study was appraised using the Downs and Black criteria, and 12-month continuation rates among studies were pooled and analyzed according to contraceptive type. RESULTS Of 3597 articles retrieved, 9 studies met criteria for SR. Synthesized across studies, 12-month continuation was significantly higher for IUD users (86.5%, 12,761/14,747) compared with oral contraceptives (39.6%, 1931/4873), Depo-Provera (Pfizer Inc, New York, NY) hormonal injection (39.8%, 510/1282), vaginal ring (48.9%, 196/401), and transdermal patch (39.8%, 37/93; all P values < .001). There was no statistically significant difference in 12-month continuation between the IUD and another LARC method, the subdermal etonogestrel implant (85.3%, 4671/5474). CONCLUSION Findings of this SR suggest that continuation rates for IUDs are generally higher compared with other contraceptive methods for women aged 25 years and younger. In a population with high rates of unintended pregnancies, generally low adherence, and imperfect use with other non-LARCs, IUD use should be encouraged.
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Affiliation(s)
- K M Usinger
- Columbia University School of Nursing, New York, New York
| | - S B Gola
- Columbia University School of Nursing, New York, New York
| | - M Weis
- Columbia University School of Nursing, New York, New York
| | - A Smaldone
- Columbia University School of Nursing, New York, New York.
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A multicenter study assessing uterine cavity width in over 400 nulliparous women seeking IUD insertion using 2D and 3D sonography. Eur J Obstet Gynecol Reprod Biol 2016; 206:232-238. [DOI: 10.1016/j.ejogrb.2016.09.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 08/28/2016] [Accepted: 09/13/2016] [Indexed: 11/22/2022]
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Speedie JMM, Mansour D, Landy R, Clement KM. A randomised trial comparing pain and ease of use of two different stabilising forceps for insertion of intrauterine contraception. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2016; 42:241-246. [DOI: 10.1136/jfprhc-2016-101446] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 06/27/2016] [Accepted: 07/05/2016] [Indexed: 11/04/2022]
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Clark TC, Lucassen MF, Fleming T, Peiris-John R, Ikihele A, Teevale T, Robinson E, Crengle S. Changes in the sexual health behaviours of New Zealand secondary school students, 2001-2012: findings from a national survey series. Aust N Z J Public Health 2016; 40:329-36. [DOI: 10.1111/1753-6405.12543] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 02/01/2016] [Accepted: 02/01/2016] [Indexed: 11/29/2022] Open
Affiliation(s)
| | | | - Theresa Fleming
- Department of Psychological Medicine; The University of Auckland; New Zealand
- Department of Paediatrics: Child and Youth Health; The University of Auckland; New Zealand
| | - Roshini Peiris-John
- Section of Epidemiology and Biostatistics, School of Population Health; The University of Auckland; New Zealand
| | - Amio Ikihele
- Department of Psychological Medicine; The University of Auckland; New Zealand
| | | | - Elizabeth Robinson
- Section of Epidemiology and Biostatistics, School of Population Health; The University of Auckland; New Zealand
| | - Sue Crengle
- Department of Psychological Medicine; The University of Auckland; New Zealand
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Evaluation of an intervention designed to improve the management of difficult IUD insertions by advanced practice clinicians. Contraception 2016; 93:533-8. [PMID: 26820912 DOI: 10.1016/j.contraception.2016.01.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 01/20/2016] [Accepted: 01/22/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To assess whether clinical skills training in cervical dilation and paracervical anesthesia, as well as the introduction of a clinical protocol for difficult insertions, increased intrauterine device (IUD) insertion success rates among advanced practice clinicians (APCs) including women's health and family practice nurse practitioners, physician assistants and certified nurse midwives. STUDY DESIGN This prospective study assessed an intervention to improve IUD insertions among APCs at six family planning clinics in Utah. We collected data on IUD insertions performed by participating clinicians during two observation phases: preintervention (Phase 1) and postintervention (Phase 2). Using electronic medical records, we tracked patient characteristics, IUD insertion success, difficulties and failures. We constructed a mixed-effects logistic regression model to control for provider and patient demographics influencing insertion success rates. RESULTS Nine clinicians participated in both preintervention and postintervention phases. The analysis included 428 IUD insertion procedures (242 preintervention and 186 postintervention). During Phase 1, 31/242 (12.8%) insertions failed. Insertion rates in Phase 2 improved with only 8/186 (4.3%) failures. Using mixed-effects logistic regression, the odds of a successful insertion postintervention was 4.8 times greater than preintervention (aOR=4.8.95% CI 1.8-12.7) when controlling for provider and patient characteristics. Increased risk of insertion failure was associated with nulliparity and younger age during Phase 1, but not during Phase 2. CONCLUSIONS A brief training for APCs and the use of a clinical protocol for difficult insertions may be able to improve IUD insertion rates. IMPLICATIONS Clinics with high rates of IUD insertion failure can improve care with a simple intervention, which may yield significant benefits in IUD service delivery.
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Kemeny F, Digiusto E, Bateson D. Insertion of intrauterine contraceptive devices by registered nurses in Australia. Aust N Z J Obstet Gynaecol 2015; 56:92-6. [DOI: 10.1111/ajo.12427] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 10/29/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Fiona Kemeny
- Family Planning NSW; Ashfield New South Wales Australia
| | - Erol Digiusto
- Family Planning NSW; Ashfield New South Wales Australia
| | - Deborah Bateson
- Family Planning NSW; Ashfield New South Wales Australia
- Department of Obstetrics; Gynaecology and Neonatology; University of Sydney; Australia
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Barriers and Misperceptions Limiting Widespread Use of Intrauterine Contraception Among Canadian Women. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2015; 37:606-616. [PMID: 26366817 DOI: 10.1016/s1701-2163(15)30198-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Akintomide H, Brima N, Sewell RDE, Stephenson JM. Patients’ experiences and providers’ observations on pain during intrauterine device insertion. EUR J CONTRACEP REPR 2015; 20:319-26. [DOI: 10.3109/13625187.2015.1031885] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Hall AM, Kutler BA. Intrauterine contraception in nulliparous women: a prospective survey. ACTA ACUST UNITED AC 2015; 42:36-42. [PMID: 25854550 PMCID: PMC4717389 DOI: 10.1136/jfprhc-2014-101046] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 02/15/2015] [Indexed: 11/13/2022]
Abstract
Background Intrauterine contraception is a first-line option for young women, yet relatively few prospective studies have been performed in nulliparous women using currently available devices, and many providers are still reluctant to provide this option. Methods Between January 2012 and June 2014, 109 nulliparous women, aged 18–30 years, who had an intrauterine device (IUD) placed at a student health clinic [88 levonorgestrel-intrauterine system (LNG-IUS) users and 21 Cu T 380A (IUD) users] were surveyed at 1, 6, 12 and 18 months after insertion. Results Overall satisfaction was high; at follow-up survey 83% of 100 women (mean use 13.4 months) were ‘happy’ or ‘very happy’ with their IUD, and there were no differences in satisfaction between the two IUD types. Some 75% of participants stated that the insertion procedure went ‘very well’, despite 78% rating insertion pain as moderate to severe, and 46% experiencing vasovagal symptoms. The 12-month continuation rate was 89%, with discontinuations for expulsion (3%), side effects (6%), lack of anticipated benefit (1%) and pregnancy (1%). Users of the Cu T 380A were more likely to have heavy menses (74% vs 2%; p<0.0001) or moderate to severe cramping (68% vs 20%; p=0.0002) compared with LNG-IUS users. There were no uterine perforations or diagnoses of pelvic inflammatory disease. The rate of failed insertions during the study period was 6.2%. Conclusions Despite significant symptoms with insertion, intrauterine contraception is safe, effective and ultimately well tolerated in nulliparous women and should be provided to this population in both university and community health settings.
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Affiliation(s)
- Alexandra M Hall
- Physician, University of Wisconsin - Stout Student Health Services, Menomonie, WI, USA Physician, Gannett Health Services, Cornell University, Ithaca, NY, USA (until June 2012)
| | - Beth A Kutler
- Nurse Practitioner, Gannett Health Services, Cornell University, Ithaca, NY, USA
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Brima N, Akintomide H, Iguyovwe V, Mann S. A comparison of the expected and actual pain experienced by women during insertion of an intrauterine contraceptive device. Open Access J Contracept 2015; 6:21-26. [PMID: 29386921 PMCID: PMC5683140 DOI: 10.2147/oajc.s74624] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To compare the expected and actual pain experienced with the insertion of intrauterine contraception in women, and to determine whether either of these are related to their personal circumstances, or affected their satisfaction with the procedure. DESIGN A convenience sample of 89 women aged 15-50 years attending a sexual health clinic for same day intrauterine contraception insertion were given a questionnaire that they completed following the procedure. The women were asked to rate their expectation of pain prior to insertion and to rate the actual pain they experienced immediately after insertion, on a scale of 1-10, with 10 being severe pain. Information on the women's circumstances and their level of satisfaction with the procedure was also obtained. RESULTS Overall, the median actual pain experienced by women during insertion (4) was significantly lower than the expected pain median (6) (P<0.001). For those women who had not had a previous vaginal delivery, actual pain was significantly higher compared with women who had had a previous vaginal delivery (median [interquartile range]: 6 [3.5-7.5] and 3 [1-5], P<0.001, respectively), but there was no significant difference between expected and actual pain experiences. In women who had a previous vaginal delivery, actual pain was much lower than expected (P<0.001). Neither actual nor expected pain experiences were linked to any other sociodemographic reproductive health or service use factors. CONCLUSION All women had a high expectation of pain prior to IUD insertion, but for those who had had a previous vaginal delivery, this was significantly greater than that actually experienced. Satisfaction levels overall were high. Counseling of women should take into account their expected pain prior to IUD insertion and consideration should be given to alternative and additional methods of pain relief in women who have not had a previous vaginal delivery.
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Affiliation(s)
- Nataliya Brima
- Medical Statistics, Centre for Sexual Health and HIV Research, Research Department of Infection and Population Health, University College London, London, UK
| | - Hannat Akintomide
- Sexual and Reproductive Health, CNWL Camden Provider Services, Margaret Pyke Centre, London, UK
| | - Vivian Iguyovwe
- Department of Sexual and Reproductive Health, Camberwell Sexual Health Centre, Denmark Hill, London, UK
| | - Susan Mann
- Sexual and Reproductive Health, Kings College Hospital, London, UK
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Friedman JO. Factors associated with contraceptive satisfaction in adolescent women using the IUD. J Pediatr Adolesc Gynecol 2015; 28:38-42. [PMID: 25555299 DOI: 10.1016/j.jpag.2014.02.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 02/20/2014] [Accepted: 02/20/2014] [Indexed: 10/24/2022]
Abstract
STUDY OBJECTIVE To estimate satisfaction and to identify factors contributing to an adolescent woman's satisfaction with the levonorgestrel-containing or copper intrauterine device (IUD). DESIGN Adolescent women presenting to an urban clinic within 1 month of IUD insertion completed survey questionnaires about prior use of contraception, gynecologic/obstetric history, and a pain scale. Participants were contacted at 3 and 6 months post-insertion to complete surveys regarding satisfaction with the IUD, their menstrual bleeding patterns, and pain and cramping due to the IUD. Chi-square test, Fisher exact test, and logistic regression were used for analysis. SETTING Mount Sinai Adolescent Health Center in New York City. PARTICIPANTS Seventy-nine adolescent women aged 15-24 y. INTERVENTIONS None. MAIN OUTCOME MEASURE Satisfaction was measured at 3 and 6 months post-IUD insertion as a 10-point Likert item. RESULTS 82% and 76% percent of participants were available for follow-up at 3 and 6 months, respectively. Satisfaction with the IUD was high overall with 75.4% (49/65) of participants choosing a satisfaction rating of eight or higher on the 10-point scale at 3 months and 76.7 % (46/60) at 6 months. Prior history of pregnancy and selecting the levonorgestrel containing IUD were predictive of higher satisfaction at 3 months, but not at 6 months. Parity and prior use of contraceptive methods were not predictive of satisfaction. CONCLUSION The finding of high satisfaction across participants supports the current recommendation for the IUD as a first-line contraceptive for adolescents. Nulliparous young women and those who are naïve to contraception should be considered as candidates for the IUD.
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Affiliation(s)
- Joy O Friedman
- Oakland University William Beaumont School of Medicine, Hough Center for Adolescent Health, Beverly Hills, MI.
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Wildemeersch D, Goldstuck N, Hasskamp T, Jandi S, Pett A. Intrauterine device quo vadis? Why intrauterine device use should be revisited particularly in nulliparous women? Open Access J Contracept 2015; 6:1-12. [PMID: 29386919 PMCID: PMC5683133 DOI: 10.2147/oajc.s72687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Long-acting reversible contraceptive (LARC) methods, including intrauterine devices (IUDs) and the contraceptive implant, are considered the best methods for preventing unintended pregnancies, rapid repeat pregnancy, and abortion in young women. An opinion paper of 2012 by the American College of Obstetricians and Gynecologists recommends Mirena and Paragard for use in nulliparous and adolescent women. However, these IUDs are not designed for young women and are not optimal as they often lead to early discontinuation. Objective This article was written with the objective to respond to the urgent need to improve intrauterine contraception as it is likely that the objectives of LARC will not be met without significant improvement of IUD design. Anatomical variations in size and shape of the uterus are not sufficiently considered, producing harm and suffering, which often lead to early removal of the IUD. Proposed problem solving The article describes why IUDs should be revisited to meet the challenge of LARC and proposes how to solve these problems. The opinion statement presented here may be considered provocative but is based on hundreds of women with IUD problems who consult or are referred to the practices of the authors of this article due to the disproportion between the IUD and their small uterine cavity. The solution is simple but requires a revision of the current design of IUDs. One-dimensional (longitudinal) IUDs are likely to be the first option. Framed devices with shortened transverse arm and IUDs which adapt to the width of the given uterus are viewed as second best. Conclusion One of the reasons of the high unintended pregnancy rate in the USA may be the paucity of suitable IUDs. Also, the legal climate in the USA seems to be a problem for developers as many lawsuits have recently been reported. Clinical studies conducted in young nulliparous and adolescent women suggest that IUDs that fit well in the uterine cavity, like a shoe, result in better tolerance, less side effects, and last but not least, higher use continuation rates.
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Affiliation(s)
- Dirk Wildemeersch
- Gynecological Outpatient Clinic and IUD Training Center, Ghent, Belgium
| | - Norman Goldstuck
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Western Cape, South Africa
| | | | - Sohela Jandi
- Gynecological Outpatient Clinic, Berlin, Germany
| | - Ansgar Pett
- Gynecological Outpatient Clinic, Berlin, Germany
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Buhling KJ, Hauck B, Dermout S, Ardaens K, Marions L. Understanding the barriers and myths limiting the use of intrauterine contraception in nulliparous women: results of a survey of European/Canadian healthcare providers. Eur J Obstet Gynecol Reprod Biol 2014; 183:146-54. [DOI: 10.1016/j.ejogrb.2014.10.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 08/16/2014] [Accepted: 10/22/2014] [Indexed: 10/24/2022]
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Abstract
OBJECTIVE To assess the relationship of preinsertion vaginal ultrasound assessment and menstrual and gynecologic history as predictors of difficult or painful intrauterine device insertion in nulligravid women. METHODS Nulligravid women seeking contraception were invited to participate in this nonrandomized study and given the choice between the levonorgestrel-releasing intrauterine system or a copper-releasing intrauterine device. All 165 enrolled women were interviewed and a pelvic examination, including vaginal ultrasonography, was performed before insertion. Insertion difficulties and pain intensity were recorded and assessed against uterine measurements and background characteristics. RESULTS Most insertions were assessed as easy (n=144 [89.4%]) and only two (1.2%) failed. Most women had uterine measurements smaller than the studied devices. Odds for difficulties at insertion decreased with every increasing millimeter in total uterine length (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.78-0.96, P=.006) and cervical length (OR 0.85, 95% CI 0.74-0.97, P=.02) and similarly with every decreasing degree of (straighter) flexion angle (OR 0.96, 95% CI 0.94-0.99, P=.005). No absolute threshold measurements could be determined. Still, the majority of insertions in small and flexed uteri were uneventful. Severe insertion pain was common (n=94 [58.4%]). Severe dysmenorrhea was the only predictor of insertion pain (OR 8.16 95% CI 2.56-26.02, P<.001). CONCLUSION Ultrasonographic evaluation does not give additional information compared with clinical pelvic examination and sound measure. Although smaller uterine length measurements and steeper flexion angle more often predicted difficulties, the majority of insertions were uneventful in women with small measures. Dysmenorrhea was the only predictor of pain. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT01685164. LEVEL OF EVIDENCE II.
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Abstract
A working knowledge of contraception will assist the pediatrician in both sexual health promotion as well as treatment of common adolescent gynecologic problems. Best practices in adolescent anticipatory guidance and screening include a sexual health history, screening for pregnancy and sexually transmitted infections, counseling, and if indicated, providing access to contraceptives. Pediatricians' long-term relationships with adolescents and families allow them to help promote healthy sexual decision-making, including abstinence and contraceptive use. Additionally, medical indications for contraception, such as acne, dysmenorrhea, and heavy menstrual bleeding, are frequently uncovered during adolescent visits. This technical report provides an evidence base for the accompanying policy statement and addresses key aspects of adolescent contraceptive use, including the following: (1) sexual history taking, confidentiality, and counseling; (2) adolescent data on the use and side effects of newer contraceptive methods; (3) new data on older contraceptive methods; and (4) evidence supporting the use of contraceptives in adolescent patients with complex medical conditions.
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Cea Soriano L, Wallander MA, Andersson S, Filonenko A, García Rodríguez LA. The continuation rates of long-acting reversible contraceptives in UK general practice using data from The Health Improvement Network. Pharmacoepidemiol Drug Saf 2014; 24:52-8. [DOI: 10.1002/pds.3710] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 07/22/2014] [Accepted: 08/12/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Lucía Cea Soriano
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE); Madrid Spain
| | - Mari-Ann Wallander
- Department of Public Health and Caring Science; Uppsala University; Uppsala Sweden
| | | | - Anna Filonenko
- Global Health Economics and Outcomes Research; Bayer Pharma AG; Berlin Germany
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Wildemeersch D, Jandi S, Pett A, Nolte K, Hasskamp T, Vrijens M. Use of frameless intrauterine devices and systems in young nulliparous and adolescent women: results of a multicenter study. Int J Womens Health 2014; 6:727-34. [PMID: 25125987 PMCID: PMC4130709 DOI: 10.2147/ijwh.s65462] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The purpose of this study was to provide additional data on the experience with frameless copper and levonorgestrel (LNG) intrauterine devices (IUDs) in nulliparous and adolescent women. METHODS Nulliparous and adolescent women, 25 years of age or younger, using the frameless copper IUD or the frameless LNG-releasing intrauterine system (IUS), were selected from previous studies and a current multicenter post-marketing study with the frameless copper IUD. The small copper-releasing GyneFix(®) 200 IUD consists of four copper cylinders, each 5 mm long and only 2.2 mm wide. The frameless FibroPlant(®) LNG-IUS consists of a fibrous delivery system releasing the hormone levonorgestrel (LNG-IUS). The main features of these intrauterine contraceptives are that they are frameless, flexible, and anchored to the fundus of the uterus. RESULTS One hundred and fifty-four nulliparous and adolescent women participated in the combined study. One pregnancy occurred with the GyneFix 200 IUD after unnoticed early expulsion of the device (cumulative pregnancy rate 1.1 at one year). Two further expulsions were reported, one with the GyneFix 200 IUD and the other with the FibroPlant LNG-IUS. The cumulative expulsion rate at one year was 1.1 with the copper IUD and 2.2 with the LNG-IUS. The total discontinuation rate at one year was low (3.3 and 4.3 with the copper IUD and LNG-IUS, respectively) and resulted in a high rate of continuation of use at one year (96.7 with the copper IUD and 95.7 with the LNG-IUS, respectively). Continuation rates for both frameless copper IUD and frameless LNG-IUS remained high at 3 years (>90%). There were no cases of perforations or pelvic inflammatory disease reported during or following insertion. CONCLUSION This report confirms earlier studies with frameless devices and suggests that the high user continuation rate is attributable to the optimal relationship between the IUD and the uterine cavity. IUD studies have shown that an IUD that does not fit well will often lead to side effects (ie, pain, bleeding, embedment, expulsion) and subsequent removal of the IUD. Early discontinuation is not the aim of long-acting reversible contraception.
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Affiliation(s)
- Dirk Wildemeersch
- Gynecological Outpatient Clinic and IUD Training Center, Ghent, Belgium
| | - Sohela Jandi
- Gynecological Outpatient Clinic, Berlin, Belgium
| | - Ansgar Pett
- Gynecological Outpatient Clinic, Berlin, Belgium
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Allen RH, Carey MS, Raker C, Goyal V, Matteson K. A prospective cohort study of pain with intrauterine device insertion among women with and without vaginal deliveries. J OBSTET GYNAECOL 2014; 34:263-7. [DOI: 10.3109/01443615.2013.868424] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Yoost J. Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United States. Patient Prefer Adherence 2014; 8:947-57. [PMID: 25050062 PMCID: PMC4090129 DOI: 10.2147/ppa.s45710] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Three intrauterine devices (IUDs), one copper and two containing the progestin levonorgestrel, are available for use in the United States. IUDs offer higher rates of contraceptive efficacy than nonlong-acting methods, and several studies have demonstrated higher satisfaction rates and continuation rates of any birth control method. This efficacy is not affected by age or parity. The safety of IUDs is well studied, and the risks of pelvic inflammatory disease, perforation, expulsion, and ectopic pregnancy are all of very low incidence. Noncontraceptive benefits include decreased menstrual blood loss, improved dysmenorrhea, improved pelvic pain associated with endometriosis, and protection of the endometrium from hyperplasia. The use of IUDs is accepted in patients with multiple medical problems who may have contraindications to other birth control methods. Yet despite well-published data, concerns and misperceptions still persist, especially among younger populations and nulliparous women. Medical governing bodies advocate for use of IUDs in these populations, as safety and efficacy is unchanged, and IUDs have been shown to decrease unintended pregnancies. Dispersion of accurate information among patients and practitioners is needed to further increase the acceptability and use of IUDs.
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Affiliation(s)
- Jennie Yoost
- Marshall University Department of Obstetrics and Gynecology, Huntington, WV, USA
- Correspondence: Jennie Yoost, Marshall University Department of Obstetrics and Gynecology, 1600 Medical Center Drive Suite 4500, Huntington, WV 25701, USA, Tel +1 304 691 1460, Fax +1 304 691 1453, Email
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Higher dose cervical 2% lidocaine gel for IUD insertion: a randomized controlled trial. Contraception 2013; 88:730-6. [DOI: 10.1016/j.contraception.2013.07.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 07/15/2013] [Accepted: 07/26/2013] [Indexed: 11/19/2022]
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Practices and perceptions among pediatricians regarding adolescent contraception with emphasis on intrauterine contraception. J Pediatr Adolesc Gynecol 2013; 26:281-4. [PMID: 24012129 DOI: 10.1016/j.jpag.2013.05.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/05/2013] [Accepted: 05/11/2013] [Indexed: 11/21/2022]
Abstract
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.
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Bahamondes L, Mansour D, Fiala C, Kaunitz AM, Gemzell-Danielsson K. Practical advice for avoidance of pain associated with insertion of intrauterine contraceptives. ACTA ACUST UNITED AC 2013; 40:54-60. [PMID: 24076534 PMCID: PMC3888629 DOI: 10.1136/jfprhc-2013-100636] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Few studies in the scientific literature provide clear direction on the prevention or management of pain associated with intrauterine contraceptive (IUC) placement. Those that have been published have studied small numbers of women and fail to provide definitive conclusions. There are also no guidelines available detailing recognised standard approaches to this problem. The consensus recommendations in this review focus primarily on non-pharmacological and often non-evidence-based interventions. This review includes general considerations, practical recommendations for both routine and more difficult cases and guidance on the optimal choice of instruments. General considerations, including pre-insertion counselling, the setting for the procedure, the confidence and technique of the provider and the interplay between the provider and assistant, can influence women's level of anxiety and, in turn, influence their perception of pain and their overall experience. Further studies are required to refine the optimal strategy for managing pain associated with IUC insertion.
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Affiliation(s)
- Luis Bahamondes
- Professor of Gynaecology, Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil
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Dermish AI, Turok DK. The copper intrauterine device for emergency contraception: an opportunity to provide the optimal emergency contraception method and transition to highly effective contraception. Expert Rev Med Devices 2013; 10:477-88. [PMID: 23895075 DOI: 10.1586/17434440.2013.811865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Worldwide, 40% of all pregnancies are unintended. Widespread, over-the-counter availability of oral emergency contraception (EC) has not reduced unintended pregnancy rates. The EC visit presents an opportunity to initiate a highly effective method of contraception in a population at high risk of unintended pregnancy who are actively seeking to avoid pregnancy. The copper intrauterine device (IUD), the most effective method of EC, continues to provide contraception as effective as sterilization for up to 12 years, and it should be offered as the first-line method of EC wherever possible. Increased demand for and supply of the copper IUD for EC may have an important role in reducing rates of unintended pregnancy. The EC visit should include access to the copper IUD as optimal care but should ideally include access to all highly effective methods of contraception.
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Affiliation(s)
- Amna I Dermish
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
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Brown WM, Trouton K. Intrauterine device insertions: which variables matter? JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2013; 40:117-21. [DOI: 10.1136/jfprhc-2012-100383] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Gemzell-Danielsson K, Mansour D, Fiala C, Kaunitz AM, Bahamondes L. Management of pain associated with the insertion of intrauterine contraceptives. Hum Reprod Update 2013; 19:419-27. [PMID: 23670222 PMCID: PMC3682672 DOI: 10.1093/humupd/dmt022] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Most intrauterine contraception (IUC) placements do not require pain relief. However, small proportions of nulliparous (∼17%) and parous (∼11%) women experience substantial pain that needs to be proactively managed. This review critically evaluates the evidence for pain management strategies, formulates evidence-based recommendations and identifies data gaps and areas for further research. METHODS A PubMed literature search was undertaken. Relevant articles on management of pain associated with IUC insertion, published in English between 1980 and November 2012, were identified using the following search terms: ‘intrauterine contraception’, ‘insertion’ and ‘pain’. RCTs were included; further relevant articles were also identified and included as appropriate. RESULTS Seventeen studies were identified and included: 12 RCTs and one non-randomized study of pre-insertion oral analgesia, cervical priming and local anaesthesia; one systematic review and one RCT on post-insertion analgesia and two non-randomized studies on non-pharmacological interventions. There was no conclusive evidence that any prophylactic pharmacological intervention reduces pain associated with IUC insertion. However, most of the regimens studied were adopted from hysteroscopy or abortion and effectiveness in specific subsets of women has not been studied adequately. A systematic review found non-steroidal anti-inflammatory agents (NSAID) to be effective in reactively treating post-insertion pain, but no benefit was found with prophylactic use. CONCLUSIONS No prophylactic pharmacological intervention has been adequately evaluated to support routine use for pain reduction during or after IUC insertion. Women's anxiety about the procedure may contribute to higher levels of perceived pain, which highlights the importance of counselling, and creating a trustworthy, unhurried and professional atmosphere in which the experience of the provider also has a major role; a situation frequently referred to as ‘verbal anaesthesia’.
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Affiliation(s)
- K Gemzell-Danielsson
- Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, SE-17176 Stockholm, Sweden.
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Russo JA, Miller E, Gold MA. Myths and misconceptions about long-acting reversible contraception (LARC). J Adolesc Health 2013; 52:S14-21. [PMID: 23535052 DOI: 10.1016/j.jadohealth.2013.02.003] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 02/03/2013] [Accepted: 02/04/2013] [Indexed: 01/09/2023]
Abstract
PURPOSE To discuss common myths and misconceptions about long-acting reversible contraception (LARC) among patients and health care providers. METHODS We address some of these common myths in an effort to provide clinicians with accurate information to discuss options with patients, parents, and referring providers. The list of myths was created through an informal survey of an online listserv of 200 family planning experts and from the experiences of the authors. RESULTS When presented with information about LARC, adolescents are more likely to request LARC and are satisfied with LARC. Clinicians have an important role in counseling about and providing LARC to their adolescent patients as well as supporting them in managing associated side effects. CONCLUSIONS This review article can be used as a resource for contraceptive counseling visits and for the continuing education of health professionals providing adolescent reproductive health care.
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Affiliation(s)
- Jennefer A Russo
- Planned Parenthood of Orange and San Bernardino Counties, Orange, California 92866, USA.
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Practical tips for intrauterine devices use in adolescents. J Adolesc Health 2013; 52:S40-6. [PMID: 23535056 DOI: 10.1016/j.jadohealth.2012.09.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 09/16/2012] [Accepted: 09/19/2012] [Indexed: 11/22/2022]
Abstract
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.
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Santos ARG, Bahamondes MV, Hidalgo MM, Atti A, Bahamondes L, Monteiro I. Pain at insertion of the levonorgestrel-releasing intrauterine system in nulligravida and parous women with and without cesarean section. Contraception 2013; 88:164-8. [PMID: 23507169 DOI: 10.1016/j.contraception.2012.10.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Revised: 10/11/2012] [Accepted: 10/12/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Despite the high contraceptive effectiveness and noncontraceptive benefits of the levonorgestrel-releasing intrauterine system (LNG-IUS) in nulligravidas, there are still concerns related to the use of this device. Pain at insertion is one of the limitations to the increased use of intrauterine contraceptives. The aim of the study was to evaluate the ease of insertion and occurrence of pain at insertion of the LNG-IUS in nulligravidas (women who never became pregnant) compared to parous women with and without cesarean section (c-section). We also assessed the difficulty at insertion in each group. METHODS Three groups of new acceptors of the LNG-IUS were studied: one with 23 nulligravida women, one with 28 parous women who had undergone at least one c-section and one with 23 parous women who had no previous c-section. Pain at insertion was evaluated by using a pain visual analogue score (VAS). The ease of insertion was defined as easy or difficult by health care providers (HCPs) and classified according to the cause of difficulty: tight cervix, anatomically distorted uterus or pain. RESULTS Almost all women reported pain at insertion, regardless of parity and form of delivery. The mean VAS was 6.6 for nulligravida women, 5.2 for parous women with c-section and 5.9 for parous women with no c-section. Although 93% of the women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS again if needed. The most common difficulties were a tight cervix in nulligravidas, an anatomically distorted uterus in parous women with c-section and pain in parous women without c-section. There was no failure of insertion in any group. HCPs reported that it was easier to perform insertion in parous women who had undergone only vaginal deliveries than nulligravid women or parous women with a prior c-section. CONCLUSIONS Although almost all women reported pain at insertion, they also reported a willingness to insert a new LNG-IUS if needed. This attitude reflects high satisfaction with the LNG-IUS. The type of difficulty at insertion was related to parity and type of delivery. The LNG-IUS was able to be inserted in all women; however, it was easier to do in parous women without c-section than nulligravid women or those with a prior C-section.
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Affiliation(s)
- Ana Raquel Gouvea Santos
- Human Reproduction Unit, Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
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Dermish AI, Turok DK, Jacobson JC, Flores MES, McFadden M, Burke K. Failed IUD insertions in community practice: an under-recognized problem? Contraception 2013; 87:182-6. [PMID: 22979954 PMCID: PMC4082821 DOI: 10.1016/j.contraception.2012.06.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 06/06/2012] [Accepted: 06/22/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND The data analysis was conducted to describe the rate of unsuccessful copper T380A intrauterine device (IUD) insertions among women using the IUD for emergency contraception (EC) at community family planning clinics in Utah. METHODS These data were obtained from a prospective observational trial of women choosing the copper T380A IUD for EC. Insertions were performed by nurse practitioners at two family planning clinics in order to generalize findings to the type of service setting most likely to employ this intervention. Adjuvant measures to facilitate difficult IUD insertions (cervical anesthesia, dilation, pain medication, and use of ultrasound guidance) were not utilized. The effect of parity on IUD insertion success was determined using exact logistic regression models adjusted for individual practitioner failure rates. RESULTS Six providers performed 197 IUD insertion attempts. These providers had a mean of 14.1 years of experience (range 1-27, S.D. ±12.5). Among nulliparous women, 27 of 138 (19.6%) IUD insertions were unsuccessful. In parous women, 8 of 59 IUD insertions were unsuccessful (13.6%). The adjusted odds ratio (aOR) showed that IUD insertion failure was more likely in nulliparous women compared to parous women (aOR=2.31, 95% CI 0.90-6.52, p=.09). CONCLUSION The high rate of unsuccessful IUD insertions reported here, particularly for nulliparous women, suggests that the true insertion failure rate of providers who are not employing additional tools for difficult insertions may be much higher than reported in clinical trials. Further investigation is necessary to determine if this is a common problem and, if so, to assess if the use of adjuvant measures will reduce the number of unsuccessful IUD insertions.
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Affiliation(s)
- Amna I Dermish
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA.
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Blumenthal PD, Shah NM, Jain K, Saunders A, Clemente C, Lucas B, Jafa K, Eber M. Revitalizing long-acting reversible contraceptives in settings with high unmet need: a multicountry experience matching demand creation and service delivery. Contraception 2012; 87:170-5. [PMID: 23153895 DOI: 10.1016/j.contraception.2012.10.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 09/20/2012] [Accepted: 10/01/2012] [Indexed: 01/24/2023]
Abstract
BACKGROUND Contraception in many developing countries is characterized by high unmet need, irregular access, low utilization and presumed demand for long-acting reversible contraceptives (LARCs). STUDY DESIGN A 13-country initiative focused on increasing consumer demand and high quality services for intrauterine devices (IUDs) began in 2009. Services were provided through (a) private sector-franchised or affiliated clinics; (b) providers seconded to the public sector and (c) special "event" days. Client intake data are used to compare the profile of IUD acceptors with IUD users from representative national datasets of select countries, as well as examine trends in IUD uptake. RESULTS During 2009-2010, 575,601 IUDs were inserted across the 13 countries. Compared to national IUD users, users in this project were slightly younger and less educated. Among IUD acceptors, 24% used no modern method at the time of IUD initiation, and 28% reported injectable use in the three previous months. CONCLUSIONS Convenient, quality, affordable services with demand creation can result in significant uptake of LARCs in settings with low use.
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Abstract
PURPOSE OF REVIEW Teen pregnancy continues to plague the United States. This review will discuss long-acting reversible contraceptive (LARC) method use in teens, comprising intrauterine devices and subdermal implants. RECENT FINDINGS The American College of Obstetricians and Gynecologists along with the American Academy of Pediatrics, the Centers for Disease Control, and the World Health Organization have recognized the potential impact of LARC (comprising intrauterine contraception and subdermal implants) to reduce unintended pregnancies. They have affirmed the safety of such devices, and no effects on long-term fertility have been identified. Teen users of these methods have been shown to have high continuation and satisfaction rates. On the contrary, oral contraceptive pills, the patch, and the contraceptive vaginal ring have significantly higher contraceptive failure rates, and these rates are magnified in young women. SUMMARY LARC methods should be considered first-line options for teens seeking contraception.
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Affiliation(s)
- Colleen McNicholas
- Division of Clinical Research, Department of Obstetrics and Gynecology, Washington University in St Louis School of Medicine, Saint Louis, Missouri, USA
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Black K, Lotke P, Buhling KJ, Zite NB. A review of barriers and myths preventing the more widespread use of intrauterine contraception in nulliparous women. EUR J CONTRACEP REPR 2012; 17:340-50. [PMID: 22834648 PMCID: PMC4950459 DOI: 10.3109/13625187.2012.700744] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Kirsten Black
- Queen Elizabeth II Research Institute for Mothers and Infants, University of Sydney, Sydney, Australia
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