Safety of insertion of the copper IUD and LNG-IUS in nulliparous women: a systematic review

Levonorgestrel maintains goal-directed behavior in habit-trained intact female rats

Hormonal contraceptives are utilized by millions of women worldwide. However, it remains unclear if these powerful endocrine modulators may alter cognitive function. Habit formation involves the progression of instrumental learning as it goes from being a conscious goal-directed process to a cue-driven automatic habitual motor response. Dysregulated goal and/or habit is implicated in numerous psychopathologies, underscoring the relevance of examining the effect of hormonal contraceptives on goal-directed and habitual behavior. This study examined the effect of levonorgestrel (LNG), a widely used progestin-type contraceptive, on the development of habit in intact female rats. Rats were implanted with subcutaneous capsules that slowly released LNG over the course of the experiment or cholesterol-filled capsules. All female rats underwent operant training followed by reward devaluation to test for habit. One group of females was trained at a level that is sub-threshold to habit, while another group of females was trained to a level well over the habit threshold observed in intact females. The results reveal that all sub-threshold trained rats remained goal-directed irrespective of LGN treatment, suggesting LNG is not advancing habit formation in female rats at this level of reinforcement. However, in rats that were overtrained well above the threshold, cholesterol females showed habitual behavior, thus replicating a portion of our original studies. In contrast, LNG-treated habit-trained rats remained goal-directed, indicating that LNG impedes the development and/or expression of habit following this level of supra-threshold to habit training. Thus, LNG may offset habit formation by sustaining attentional or motivational processes during learning in intact female rats. These results may be clinically relevant to women using this type of hormonal contraceptive as well as in other progestin-based hormone therapies.

Concern that contraception affects future fertility: How common is this concern among young people and does it stop them from using contraception?

Objectives

This study examines the concern that contraception affects future fertility among community college students and its association with contraceptive use.

Study design

We used baseline data from a randomized controlled trial with 2060 community college students assigned female at birth. We used mixed-effects multivariate logistic regression adjusted for clustered data to assess sociodemographic factors associated with concerns about contraception affecting future fertility and to test the association between this concern and contraceptive use.

Results

Most participants (69%) worried about contraception affecting their future fertility. Multivariable results indicated that first-generation college students (adjusted odds ratio [aOR], 1.24; 95% confidence interval [CI], 1.01-1.55) and non-English speakers at home (aOR, 1.30; 95% CI, 1.04-1.64) were more concerned. Racial and ethnic differences were significant, with Black non-Hispanic (aOR, 2.83; 95% CI, 1.70-4.70), Asian/Pacific Islander non-Hispanic (aOR, 2.12; 95% CI, 1.43-3.14), and Hispanic (aOR, 1.54; 95% CI, 1.17-2.02) participants more likely to be concerned than White non-Hispanic counterparts. Participants who received contraceptive services in the past year had lower odds of this concern (aOR, 0.72; 95% CI 0.59-0.88). Furthermore, participants with this concern had lower odds of using contraception (aOR, 0.67; 95% CI, 0.49-0.91), especially hormonal contraception (aOR, 0.77; 95% CI, 0.61-0.97).

Conclusions

Most students feared contraception's impact on fertility, and this fear was associated with not using contraception. Disparities in this concern may be tied to discrimination, reproductive coercion, and limited reproductive health care access. Addressing concerns about contraception affecting future fertility is crucial to person-centered contraceptive counseling.

Implications

This study examines the concern that contraception affects future fertility among sexually active female community college students and its impact on contraceptive use. Most participants expressed concerns about contraception affecting future fertility. Addressing future fertility concerns in patient-centered contraceptive counseling is crucial for reaching young people.

Long-Acting Reversible Contraception for Adolescents: A Review of Practices to Support Better Communication, Counseling, and Adherence

Long-acting reversible contraception (LARC) methods, including levonorgestrel and copper intrauterine devices (IUDs) and the subdermal contraceptive implant, are the most effective reversible forms of contraception and thus are an important aspect of adolescent pregnancy prevention. While LARC efficacy, safety, and appropriateness are supported by major medical organizations and usage rates are increasing, overall LARC uptake among United States (US) adolescents remains lower than uptake of short-acting contraceptive methods. A better understanding of the barriers affecting adolescent LARC uptake and reasons for discontinuation could help facilitate effective communication. For example, learning how to improve adolescent-centered communication, shared decision-making, and motivational counseling strategies may be the first step to improving utilization rates. This narrative review includes three sections. First, this review will describe the history, mechanisms of action, and epidemiology of adolescent LARC use in the US and globally. Next, this review will describe key factors influencing adolescent LARC uptake, reasons for discontinuation, and multilevel barriers specific to adolescent LARC use. Finally, this review will characterize communication techniques and LARC counseling strategies for adolescents in the context of a reproductive justice approach set in the health belief model framework. The distinction between moving away from a presumptive counseling approach towards an adolescent-centered, shared decision-making approach to encourage parent-adolescent sexual health communication to lay the foundation of empowering adolescent reproductive autonomy should be the underpinning of all effective reproductive communication strategies.

Pain and ease of insertion of three different intrauterine devices in Brazilian adolescents: A participant-blinded randomized trial

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.

Menstrual cup and risk of IUD expulsion - a systematic review

BACKGROUND

The menstrual cup is a safe, cost-effective, and environmentally friendly menstrual product which is increasing in usage, especially in younger women. The potential risk for concomitant menstrual cup use to increase IUD expulsion has been raised over the last 10 years, however, few studies assess this. This systematic review aims to identify, appraise and synthesize the current specific evidence on menstrual cup use and risk of partial or total IUD expulsion.

METHODS

PubMed, and the Cochrane Library were searched for publications available in English, until February 20th, 2021. Quantitative and qualitative studies, systematic reviews and case series reports were included. Websites of menstrual cup manufacturers LenaCup®, DivaCup®, Lunette®, AllMatters® and Saalt® were searched for warnings relevant to IUD expulsion.

RESULTS

Seven studies were included in this review, comprising 73 partial or total IUD expulsion events in patients with IUD contraception using menstrual cups. The case study reports included two individuals who each experienced two and three expulsions respectively. Of the seven publications, three reported expulsion rates of 3.7%, 17.3% and 18.6%. Time to expulsion ranged from less than one week to two and a half years. These three studies disagree on whether there is a statistically significant association between menstrual cup use and IUD expulsion.

CONCLUSION

There is a possible association between menstrual cup use and increased risk of IUD expulsion and this information should be shared with patients. However evidence is scarce and high-quality randomised controlled trials are needed to address this risk and the impact of factors such as age, menstrual cup removal technique, pelvic anatomy, IUD type, and measures such as cutting the IUD strings short or delaying menstrual cup use for a period post-insertion. This research gap is limiting patients' ability to make informed choices regarding intrauterine contraception and menstrual management and must urgently be addressed in the context of rising IUD and menstrual cup use, particularly among a younger demographic who are seeking highly effective contraception.

[Contraceptive Counseling: The Medical Toolbox Must Include the Full Range of Reversible Contraceptive Methods Also for Adolescent Women]

Contraceptive Counseling: The Medical Toolbox Must Include the Full Range of Reversible Contraceptive Methods Also for Adolescent Women Abstract. When counselling adolescents, empathy and age-appropriate information on medical confidentiality are important. Addressing individual needs and wishes enables the targeted use of the necessary information and resources and is the best guarantee for successful contraception over time. The goal is to make informed decisions and to have a positive experience of successfully protected sexual and reproductive health. The range of suitable contraceptive options is very broad. To make the most of this potential, all methods should be addressed with their advantages and disadvantages, including information on sexually transmitted infections and protection against them. Concerns and questions should be answered comprehensively and openly, and the experiences with sexuality described should be approached without prejudice. Often this is also an opportunity to talk about experienced situations of sexual assault.

Systematic review of copper intrauterine contraception continuation in young nulliparous women based on intrauterine device type

OBJECTIVES

No copper intrauterine device (IUD) type is known to better suit young nulliparous women who tend to experience higher rates of IUD discontinuation compared with their older parous counterparts. A systematic review to determine which IUDs have higher continuation rates in young nulliparous women was undertaken.

DESIGN

Systematic review and meta-analyses of available evidence based on IUD type.

DATA SOURCES

AMED, BNI, CINAHL, DARE, EMBASE, EMCARE, HMIC, MEDLINE, PsycINFO, PubMed, TRIP, and the Cochrane Library electronic databases were searched from inception to 11 May 2022; as well as the Bandolier, Medicines and Healthcare products Regulatory Agency, Faculty of Sexual and Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists, Department of Health, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines, WHO and Google Scholar websites.

ELIGIBILITY CRITERIA

All studies on IUDs currently available in the UK or comparable (same design and size) to those available in the UK, involving nulliparous women of any age including those aged under 30.

DATA EXTRACTION AND SYNTHESIS

Independently extracted data were assessed as low risk of bias using the Mixed Methods Appraisal Tool. Random effects meta-analyses of proportions were performed where data, including subgroups, were amenable to quantitative synthesis. Heterogeneity was reported using tau² and I² statistics, and sensitivity analyses were also performed.

RESULTS

Nineteen studies involving 13 045 nulliparous women were included but the heterogeneity of participant ages, parity and IUD types made quantitative synthesis of outcome data in totality inappropriate. The highest continuation rate obtained was 91.02% (95% CI 88.01% to 93.64%) for the smaller TCu 380A at 12 months post insertion.

CONCLUSIONS

Evidence for IUD use in young nulliparous women based on IUD type remains limited. Smaller sized IUD types appear better suited to this group of IUD users, however, more research is needed.

PROSPERO REGISTRATION NUMBER

CRD42019120969.

Expulsion and continuation rates of the levonorgestrel 52 mg intrauterine system was similar among nulligravid and parous users

OBJECTIVE

To compare the expulsion and continuation rates of the levonorgestrel (LNG) 52 mg intrauterine system (IUS) in a cohort of nulligravid and parous users.

METHODS

We conducted a retrospective cohort study that included 996 participants in whom we placed an LNG-IUS, and the participants were monitored for up to 5 years after device placement. We identify 498 nulligravid participants in the medical record database between 2012 and 2020. Each nulligravida was paired with a parous users who had an LNG-IUS inserted on the same day, just before or after the nulligravida. The Kaplan-Meier method and the log-rank test were used to compare the survival curves of the two groups.

RESULTS

By the fifth year of use, the expulsion rates were 7.6/100 and 8.2/100 women-years (W-Ys) and the continuation rates were 641/100 W-Ys and 65.4/100 W-Ys without difference among nulligravid and parous users, respectively (P = 0.782 and P = 0.564, respectively). We observed 29 and 31 expulsions among nulligravid and parous users, respectively.

CONCLUSION

Nulligravid and parous participants who used the 52 mg LNG-IUS showed similar expulsion and continuation rates during five years of use.

Pain scores at the insertion of the 52 MG levonorgestrel-releasing intrauterine system among nulligravidas and parous women

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.

Rates of Intrauterine Device Expulsion Among Adolescents and Young Women

STUDY OBJECTIVE

The objective of our study was to determine the rate of intrauterine device (IUD) expulsion and risk factors for expulsion among adolescents and young adults.

DESIGN

Retrospective chart review.

SETTING

IUD insertions were performed at a single children's hospital.

PARTICIPANTS

Eligible adolescent and young adult patients who underwent IUD insertion between August 2009 and March 2019.

INTERVENTIONS

IUD insertion.

MAIN OUTCOME MEASURES

Primary outcome was the incidence of IUD expulsion in adolescents and young women. Secondary outcomes were risk factors for IUD expulsion including heavy menstrual bleeding, abnormal uterine bleeding (AUB), anemia, or a bleeding disorder diagnosis.

RESULTS

Six hundred forty-two eligible patients underwent IUD insertion. The incidence of first IUD expulsion in this population was 58/642 (9.03%). Among those who chose to have a second IUD placed (n = 29), 8/29 (27.6%) had a second expulsion. Patients who expelled their IUD were more likely to have a history of AUB, heavy menstrual bleeding, anemia, or a bleeding disorder. When controlled for body mass index and age at insertion, history of AUB and anemia remained significant risks for IUD expulsion.

CONCLUSION

This study similarly showed a higher risk of primary and secondary IUD expulsion in adolescents and young women. A history of AUB, anemia, bleeding disorder, and elevated body mass index are associated with higher risk for IUD expulsion. This population should be counseled that these conditions might place them at higher risk for expulsion.

Intrauterine device use is safe among nulligravidas and adolescent girls

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

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

PURPOSE

Intrauterine devices (IUDs) are highly effective at preventing pregnancy. Levonorgestrel (LNG) IUDs also have beneficial effects on menstrual bleeding and abdominal and pelvic pain. Although there are increasing data on use of IUDs for contraception in adolescents and for medical indications in adults, there are extremely limited data on LNG IUD use for medical indications in adolescents. Our objective is to describe the characteristics and experiences of LNG IUD use in nulliparous adolescents and young women using IUDs for medical indications.

METHODS

We conducted a retrospective chart review of all nulliparous patients aged 22 years and younger who underwent LNG IUD insertion at a tertiary care children's hospital between July 1, 2004 and June 30, 2014 primarily for noncontraceptive indications. Descriptive statistical analysis was performed.

RESULTS

We identified 231 LNG IUDs placed in 219 nulliparous women for medical indications during this time period. Mean patient age was 16.8 years (±2.2). Only 41% reported ever being sexually active. IUD continuation rate at 1 year was 86%. The amenorrhea rate at 1 year was 51%. Approximately 80% of women reported improvements in menstrual bleeding and abdominal and pelvic pain. Side effects and complications were low.

CONCLUSIONS

This study provides evidence that LNG IUDs are effective, well-tolerated, and safe menstrual management options in young nulliparous women, including younger adolescents and those who have never been sexually active. This method is an excellent first-line therapy option for adolescents and young women for both contraceptive and noncontraceptive indications, regardless of age, parity, or sexual activity.

From awareness to usage of long-acting reversible contraceptives: Results of a large European survey

Objective

The PULSE survey investigated contraceptive decision making, focusing on the use of long‐acting reversible contraceptives (LARCs) to determine reasons for their low adoption rates.

Methods

An online questionnaire was sent to women aged 18–49 years in 14 European countries who were considering starting or changing contraceptive method and asked questions based on four stages of contraceptive decision making: awareness, consideration, consultation, and adoption.

Results

Overall, 7221 women responded. LARC awareness was high (~73%) but current usage was low (11.3%). Only 24% of LARC‐aware women would consider switching to them. Factors associated with decision making differed depending on the stage: e.g. at the awareness phase, women were concerned with suitability, reversibility, and whether the method is hormonal; and at the consideration phase, the efficacy, convenience, and adverse‐effect profile were important. Healthcare professionals (HCPs) were the most trusted information source for women’s contraceptive decision making. LARCs were discussed less frequently during consultations than other contraceptives and HCPs may be perceived to hold negative opinions on LARCs.

Conclusion

A lack of knowledge about the features and benefits of LARCs can contribute to misconceptions and low adoption rates. HCPs play an important role in addressing this, as information conveyed during consultations influences women’s contraceptive choices.

European women are usually aware of long‐acting reversible contraceptives but often do not choose these methods, perhaps through misinformation about their effectiveness, suitability, and safety profile.

Reasons Why Young Women in the United States Choose Their Contraceptive Method

Background: Understanding reasons for birth control method choice may inform interventions that help young women choose the best method for them. The purpose of this study was to examine why young women in the general population select their method of contraception. Methods: An online survey was advertised through social media in 2017. After consenting, participants were gated through questions that ensured they were female, within the age range (16-25 years old), lived in the 50 U.S. states, and using intrauterine devices (IUDs), hormonal birth control, or barrier methods specified in the survey. Surveys with incompatible responses were excluded. Satisfaction, plans to discontinue, and primary reason for using current contraceptive method were examined and compared by contraception types using chi-square analyses. Multivariable binary logistic regression was used to examine satisfaction between contraceptive methods and races/ethnicities. Results: A total of 2632 responses were included. A high frequency of women using less effective methods (48.6% of nonhormonal birth control) chose them primarily to prevent pregnancy (20.6% of Copper T IUD, 23.0% of hormonal IUD, and 30.9% of Mirena IUD users), while other more effective birth control methods were often chosen primarily for other reasons. Recommendations from family or friends (14.6%) were used by some to make their contraception decision. Black respondents were less likely and Hispanic respondents were more likely to be satisfied with their birth control compared to white women. Conclusion: Providers should consider that their young patients may want to better understand benefits and side effects of their birth control outside of pregnancy prevention. Furthermore, young women may utilize their friends and family to make their contraceptive choice, which should be taken into consideration when counseling patients.

Levonorgestrel-Releasing Intrauterine System as a Contraceptive Method in Nulliparous Women: A Systematic Review

The aim of this review was to summarize the available evidence about the use of levonorgestrel-releasing intrauterine system (LNG-IUS) as a contraceptive method in nulliparous women. For this purpose, studies evaluating the efficacy, safety, bleeding pattern, satisfaction and discontinuation of the levonorgestrel-releasing intrauterine system in nulliparous women were analyzed. Only original research articles published in English between 1990–27th March 2020 were considered eligible. Reviews, book chapters, case studies, conference papers, opinions, editorials and letters were excluded. The systematic literature search of PubMed/MEDLINE, Scopus, Embase and Cochrane Library databases identified 816 articles, 23 of which were analyzed. The available evidence indicates that LNG-IUS is an effective and safe contraceptive method for nulliparous women that achieves high levels of satisfaction among patients. Moreover, nulliparous women seem to experience fewer expulsions than parous ones. Bleeding pattern is acceptable for the majority of patients, and bleeding disorders mainly occur in the first months after the insertion. More in-depth, long-term prospective studies are needed in this patient group to determine risk factors for the occurrence of side effects and associated discontinuations, which should not, however, delay the wider use of the method in this group, given the number of advantages.

Contraception in chronic kidney disease: a best practice position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology

Even though fertility is reduced, conception and delivery are possible in all stages of CKD. While successful planned pregnancies are increasing, an unwanted pregnancy may have long-lasting deleterious effects, hence the importance of birth control, an issue often disregarded in clinical practice. The evidence summarized in this position statement is mainly derived from the overall population, or other patient categories, in the lack of guidelines specifically addressed to CKD. Oestroprogestagents can be used in early, non-proteinuric CKD, excluding SLE and immunologic disorders, at high risk of thromboembolism and hypertension. Conversely, progestin only is generally safe and its main side effect is intramestrual spotting. Non-medicated intrauterine devices are a good alternative; their use needs to be carefully evaluated in patients at a high risk of pelvic infection, even though the degree of risk remains controversial. Barrier methods, relatively efficacious when correctly used, have few risks, and condoms are the only contraceptives that protect against sexually transmitted diseases. Surgical sterilization is rarely used also because of the risks surgery involves; it is not definitely contraindicated, and may be considered in selected cases. Emergency contraception with high-dose progestins or intrauterine devices is not contraindicated but should be avoided whenever possible, even if far preferable to abortion. Surgical abortion is invasive, but experience with medical abortion in CKD is still limited, especially in the late stages of the disease. In summary, personalized contraception is feasible, safe and should be offered to all CKD women of childbearing age who do not want to get pregnant.

International Perspectives: IUDs and Adolescents

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

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

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

Long-acting reversible contraception: A route to reproductive justice or injustice

This article presents information on unintended pregnancies and the ongoing efforts of policy makers to promote long-acting reversible contraception (LARC) to reduce the numbers of such pregnancies. Also discussed is the tension between the encouragement of LARC to promote the public's interests in achieving that goal versus the need to assure that all women can decide about their bodies and reproductive needs. Our discussion includes information, primarily from the United States, on (a) risks associated with unintended pregnancies, (b) LARC devices approved in the United States (copper intrauterine devices (IUDs), hormone IUDs, and implants), (c) public and social benefits of increasing the use of LARC, (d) disadvantages and barriers to using LARC, (e) dangers of promoting LARC in unjust ways, and (f) the meaning of reproductive justice and its connection to social justice. By sharing the information with the audience of this journal, we hope that it will be integrated into clinical work and research on mental health and development. We also hope that experts in those fields will become discussants in the conversation regarding women's reproductive health and social justice that is taking place in the United States and elsewhere.

Consensus of best practice in intrauterine contraception in France

Objective: Our aim was to provide a consensus of best practice in intrauterine contraception (IUC) for French practitioners. Methods: A meeting of 38 gynaecologists was held to establish a consensus of best practice in IUC, using the validated nominal group (NG) method to reach consensus. Seventy questions were posed covering insertion, monitoring and removal of IUC devices. Two working groups were formed and all proposals were voted on, discussed and approved by the NG. Results: Of the 70 questions asked, answers to only four failed to reach NG consensus. While, in general, the IUC practices of French gynaecologists are in line with international guidelines, some notable differences were identified: for example, when to use the levonorgestrel-releasing intrauterine system versus the copper intrauterine device; practice recommendations in the event of upper genital tract infections; and immediate postpartum insertion. Clinicians are encouraged to inform women about IUC, irrespective of their age or parity. In general, the wishes and characteristics of the woman must be the main criteria informing the choice of IUC, once all potential contraindications have been excluded and information about IUC shared. Conclusions: This consensus paper is intended to update and standardise knowledge about IUC for health care professionals, to address any reticence about use of this contraceptive method.

Real-world experience with the IUB Ballerine MIDI copper IUD: an observational study in the French-speaking region of Switzerland

Objective: The aim of the study was to assess the acceptability of the intrauterine ball IUB Ballerine MIDI copper intrauterine device (IUD), using real-world data collected from users and physicians. Methods: In this retrospective, observational study, conducted in the French-speaking region of Switzerland, healthy women (n= 207) who had had an IUB Ballerine MIDI inserted ≥12 months before enrolment, and their physicians completed questionnaires relating to device insertion, user experience and outcome. Questions relating to current menstrual patterns, physical comfort and product satisfaction were only posed to women still using the device. Results: The mean age at insertion was 30.8 ± 7.2 years, with an average 14.2 ± 2.9 month lapse from time of insertion until study commencement. At the time of the study, 140 (67.6%) women were still using the device. The expulsion rate was 5.3% (n= 11) and the pregnancy rate was 1.4% (n= 3). Most of the women still using the device reported no to moderate pain or cramps (80.7%). The majority of women reported moderate to high (65.7%) satisfaction with the device, with 81.4% claiming they would recommend it to friends and relatives. Over 84.8% of physicians reported that the device was easy to insert, with no difficulties encountered during the procedure. Conclusions: The IUB Ballerine MIDI was demonstrated to be safe and acceptable in different clinical settings and risk groups among a socioeconomically and demographically diverse study population.