FFPRHC Guidance (January 2004) The Copper Intrauterine Device as Long-term Contraception

Differential expression of microRNAs in human endometrium after implantation of an intrauterine contraceptive device containing copper

Intrauterine devices containing copper placement will release a large amount of Cu2+ into the uterine fluid, leading to local endometrial damage and inflammation, which is considered to be one of the causes of abnormal uterine bleeding. Studies have shown that the metabolism and function of metal ions are related to the regulation of microRNA. The aims of this study were to investigate changes in endometrial microRNA levels after implantation of an intrauterine device containing copper and to preliminarily explore the signalling pathways involved in abnormal uterine bleeding. The subjects were fertile women, aged 25-35, without major obstetrics and gynaecology diseases. Human endometrial tissues were collected before implantation or removal of the intrauterine device containing copper. High-throughput microRNA sequencing was performed on human endometrial tissues, and real-time quantitative PCR, western blotting and immunohistochemistry were used to detect the expression of relevant genes. MicroRNA sequencing results showed that 72 miRNAs were differentially expressed in the endometrial tissue after the insertion of the intrauterine device containing copper. Implantation of an intrauterine device containing copper implantation can up-regulate the expression of miR-144-3p in endometrial tissue, and therefore, decreases the mRNA and protein expression levels of genes related to endometrial injury and tissue repair, including the MT/NF-κB/MMP damage pathway and the THBS-1/TGF-β/SMAD3 repair pathway. In this study, the molecular mechanisms of abnormal uterine bleeding due to an intrauterine device containing copper were preliminarily investigated. The information will be beneficial for the clinical treatment of abnormal uterine bleeding caused by intrauterine device.

Compliance and user satisfaction with the intra-uterine contraceptive device in Family Planning Service: The results of a survey in Fife, Scotland, August 2004

OBJECTIVES

The study was designed to assess user satisfaction and duration of use of intrauterine contraceptive device (IUD) in Fife.

METHODS

A questionnaire was given to 254 women attending a Fife Family Planning Clinic, in whom an IUD had been fitted over 3 years ago, with a 71% response rate.

RESULTS

The majority of respondents were over age 30 years (81%) and parous (91%). The most frequently used IUD was the levonorgestrel-releasing intrauterine system (LNG-IUS: 39%), with the rest of the coils being an assortment of copper-medicated coils. Side effects were common, occurring in 92% of users and compliance was low, with 23% using for less than 1 year. Comparisons between LNG-IUS and other IUD-users showed similar side-effects, although mood disorders were higher with LNG-IUS.

CONCLUSIONS

Overall satisfaction rates with the family planning service were high. Methods to improve IUD uptake and compliance are needed, particularly in younger women and nulliparous women.

Retrospective analysis of the impact of increasing access to long acting reversible contraceptives in a commercially insured population

Background

Unintended pregnancies have been shown to be associated with high costs for the healthcare system, among other adverse impacts, but could still account for up to 51 % of pregnancies in the US. Improvements in contraception among women are needed. Long acting reversible contraceptives (LARCs), which have proved their safety and efficacy, have been found to significantly decrease the risk of unintended pregnancy. Yet they are still marginally employed. This study aims at investigating the evolution of LARC use over 15 years and at assessing the impact of the introduction of newer LARCs on LARC use relative to all contraceptive use.

Methods

This retrospective study identified women with LARC or short acting reversible contraceptive (SARC) claims from a US insurance claims database (01/1999-03/2014). Yearly proportions of LARC users relative to all contraceptive users were reported. Generalized estimating equation models were used to assess the impact of user characteristics, such as age group (15–17, 18–24, 25–34, and 35–44), and of time periods related to the introduction of new LARCs (01/2001: Mirena, 07/2006: Implanon, 01/2013: Skyla) on LARC use.

Results

A total of 1,040,978 women were selected. LARC use increased yearly from 0.6 % (1999) to 16.6 % (2013) among contraceptive users. Time periods associated with the introduction of a newer LARC were significant predictors of LARC use; women in 2006-2012 and 2013-2014 were respectively 3.7-fold (95 % CI:3.57–3.74) and 6.6-fold (95 % CI:6.43–6.80) more likely to use LARCs over SARCs relative to women in 2001-2006. The increase in LARC use was especially pronounced in young women. Compared to women aged 18–24 in 2001-2006, women aged 18–24 in 2006-2012 and 2013-2014 were respectively 6.4-fold (95 % CI:5.91–6.86) and 14.7-fold (95 % CI:13.59–15.89) more likely to use LARCs over SARCs.

Conclusions

This broadly representative commercial claim-based study showed that the proportion of privately insured women of childbearing age using LARCs increased over time and that the introduction of newer LARCs corresponded with significant increases in overall LARC use. Future research is needed to assess LARC use in uninsured or publicly-insured populations.

[Pelvic actinomycosis: Diagnostic and therapeutic aspects]

OBJECTIVES

Actinomycosis is a rare little known granulomatous suppurative disease, more common in women, aided by the use of contraceptive purposes intrauterine device (IUD). Pelvic location is the rarest with an extension to adjacent organs making preoperative diagnosis difficult and misleading clinical presentation. Early diagnosis of this affection determines the therapeutic strategy and avoids mutilating interventions especially in young women.

METHODS

We reviewed the record of women who consulted the department of obstetrics and gynecology at Ben Arous hospital (Tunisia) between January 2003 and December 2013 for a pelvic pain syndrome and in whom diagnosis of actinomycosis was suspected by clinical and imaging and confirmed by pathology.

RESULTS

Eight cases of gynecologic abdominopelvic actinomycosis were diagnosed during the study period. Seven patients were carriers of an intrauterine device, with an average duration of 5 years wearing. Functional signs were essentially pelvic pain and fever. Physical examination of patients mainly showed two clinical presentations: a pelvic tumor syndrome or abdominopelvic and an array of pelvic abscess or pelvic inflammatory disease. Radiological investigations were allowed to suspect the diagnosis of actinomycosis only in one patient, in whom percutaneous biopsy confirmed the histological diagnosis without resorting to a surgical procedure. Operative procedures performed were varied as appropriate. The diagnosis of actinomycosis was made by pathology without any cases of bacterial isolation. All patients received antibiotic treatment with penicillin. The subsequent evolution was favorable.

CONCLUSION

The diagnosis of actinomycosis should be considered in any invasive abdominal mass of neoplastic appearance and in case of table of genital infection especially in patients bearing IUD for 5 years or more.

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

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

Contraception for adolescents

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

Contraception for adolescents

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.

Comparison of two- and three-dimensional transvaginal ultrasound in the visualisation of intrauterine devices

The aims of the study were to evaluate whether three-dimensional transvaginal ultrasound (3D TV US) is superior to two-dimensional transvaginal ultrasound (2D TV US) at visualising intrauterine devices and determining their position. This prospective study included 52 participants with an intrauterine device fitted, who underwent 2D TV US and 3D TV US. 2D TV US and 3D-reconstructed coronal images were reviewed by two gynaecological radiologists to assess ease of visualisation and position of the intrauterine devices. Statistical analysis was performed using Wilcoxon signed-rank, McNemar and Chi-squared tests. The inter-observer agreement was measured using Cohen's Kappa. Intrauterine device visualisation scores were significantly higher with 2D TV US compared with 3D TV US (Radiologist 1 p = <0.001, Radiologist 2 p = 0.007). A significant number of T-arms appeared to perforate into the adjacent myometrium on the 3D-reconstructed coronal image, but were normal on the 2D images (Radiologist 1 p = <0.001, Radiologist 2 p = 0.008). Radiologist 1 found 19 perforated T-arms on 3D TV US compared with four on 2D TV US. Radiologist 2 found 13 perforated T-arms on 3D TV US compared with five on 2D TV US. Both radiologists agreed on the positions of the intrauterine devices substantially with 3D TV US (Kappa = 0.69) and moderately with 2D TV US (Kappa = 0.55). The 3D TV US did not visualise an intrauterine device better than 2D TV US. The 3D-reconstructed coronal image of the uterus can reliably display cases of T-arm perforation into the adjacent myometrium, which could be missed on 2D TV US images. The 3D TV US should be used in addition to 2D TV US in all cases where an intrauterine device is under evaluation.

Do intrauterine device/intrauterine system users check their threads?

BACKGROUND

Expulsion of an intrauterine device (IUD) occurs in about 1 in 20 women and expulsion may not be noticed by the user. Current guidance recommends that users are instructed to check regularly for their threads. This is the first study to explore the reality of how women feel about checking their threads and the details surrounding how frequently checks are done.

METHODS

One hundred consecutive IUD users were interviewed regarding their type of device, duration of use, frequency of thread checking, prompts for checking and reasons for not checking.

RESULTS

Only 23% checked their threads regularly and 51% had never done so. The most common reason for not checking was forgetting about it.

CONCLUSIONS

Despite being advised to do so, the majority of users do not check their threads at all and fewer than one-quarter of them check regularly. We propose that advice offered about thread checking should be given less emphasis and suggested more for user reassurance.

Provision of long-acting reversible contraception in HIV-prevalent countries: results from nationally representative surveys in southern Africa

OBJECTIVE

To analyse the current provision of long-acting reversible contraception (LARC) and clinician training needs in HIV-prevalent settings.

DESIGN

Nationally representative survey of clinicians.

SETTING

HIV-prevalent settings in South Africa and Zimbabwe.

POPULATION

Clinicians in South Africa and Zimbabwe.

METHODS

Nationally representative surveys of clinicians were conducted in South Africa and Zimbabwe (n = 1444) to assess current clinical practice in the provision of LARC in HIV-prevalent settings. Multivariable logistic regression was used to analyse contraceptive provision and clinician training needs.

MAIN OUTCOME MEASURE

Multivariable logistic regression of contraceptive provision and clinician training needs.

RESULTS

Provision of the most effective reversible contraceptives is limited: only 14% of clinicians provide copper intrauterine devices (IUDs), 4% levonorgestrel-releasing IUDs and 16% contraceptive implants. Clinicians' perceptions of patient eligibility for IUD use were overly restrictive, especially related to HIV risks. Less than 5% reported that IUDs were appropriate for women at high risk of HIV or for HIV-positive women, contrary to evidence-based guidelines. Only 15% viewed implants as appropriate for women at risk of HIV. Most clinicians (82%), however, felt that IUDs were underused by patients, and over half desired additional training on LARC methods. Logistic regression analysis showed that LARC provision was largely restricted to physicians, hospital settings and urban areas. Results also showed that clinicians in rural areas and clinics, including nurses, were especially interested in training.

CONCLUSIONS

Clinician competency in LARC provision is important in southern Africa, given the low use of methods and high rates of unintended pregnancy among HIV-positive and at-risk women. Despite low provision, clinician interest is high, suggesting the need for increased evidence-based training in LARC to reduce unintended pregnancy and associated morbidities.

Prevalence of unwanted pregnancy in Iran: a systematic review and meta-analysis

INTRODUCTION

Different studies show that a considerable number of pregnancies are unwanted and can have side effects on mothers'' children's and finally society's health. Accordingly, this meta-analysis study has been carried out to estimate a relatively accurate level of unwanted pregnancies in Iran.

METHODS

Present studies and published documents were retrieved from Persian and English electronic databases. To increase sensitivity and to select more studies, the reference list of the published studies was checked. After studying the titles and texts of documents, repeated and irrelevant ones were excluded. Data was analyzed using STATA V.11.

RESULTS

Forty-nine qualified papers were selected with a 43,061 sample size. The meta-analysis of unwanted pregnancy prevalence in Iran equals 30.6% (CI = 28.1-33.1). Also' according to the present meta-analysis' the most common contraceptive methods used by couples prior to unwanted pregnancies are as follows: pills 27.1%' withdrawal 38.6%' IUD 11.4%' injection contraceptives 2.8%' vasectomy 0.28% and no method 24.5%.

DISCUSSION AND CONCLUSION

The results of meta-analysis showed that about one-third of pregnancies in Iran are unwanted and a high percent of them are among women who had used contraceptives. Therefore' it is necessary to adopt more appropriate policies on the following: education, proper pregnancy age, using contraceptive methods, men's role in family planning programs and quality promotion in family planning services.

Efficacy and safety of long-acting reversible contraception

Long-acting reversible contraception (LARC) includes intrauterine devices (IUDs) and the subdermal implant. These methods are the most effective reversible methods of contraception, and have the additional advantages of being long-lasting, convenient, well liked by users and cost effective. Compared with other user-dependent methods that increase the risk of noncompliance-related method failure, LARC methods can bring 'typical use' failure rates more in line with 'perfect use' failure rates. LARC methods are 'forgettable'; they are not dependent on compliance with a pill-taking regimen, remembering to change a patch or ring, or coming back to the clinician for an injection. LARC method failure rates rival that of tubal sterilization at <1% for IUDs and the subdermal implant. For these reasons, we believe that IUDs and implants should be offered as first-line contraception for most women. This article provides a review of the LARC methods that are currently available in the US, including their effectiveness, advantages, disadvantages and contraindications. Additionally, we dispel myths and misconceptions regarding IUDs, and address the barriers to LARC use.

Safety, Efficacy, and Patient Acceptability of the Copper T-380A Intrauterine Contraceptive Device

The ParaGard Copper T 380A intrauterine device (CuT380A) provides reversible contraception that is as effective as sterilization for up to 20 years. The CuT380A is a mainstream, first-line contraceptive option for most healthy women, including nulligravid women, as well as many women who have serious medical problems. Because it is the most cost-effective method of birth control, the CuT380A is the preferred IUD, except for women who desire lighter or no menstrual blood loss. Surveys reveal that 95% of US CuT380A users are “very” or “somewhat” satisfied with their method. This article describes current candidates for IUD use, discusses the mechanisms of action of the CuT380A, provides guidance to reduce barriers to IUD access, suggests counseling points for patients, and outlines techniques to reduce the risks and side effects that can be associated with use of the CuT380A.

Intrauterine contraceptives that do not fit well contribute to early discontinuation

BACKGROUND

To shed additional light on various aspects of intrauterine contraception discussed recently in a comprehensive review article and on the continued development of frameless copper intrauterine devices (IUDs).

CONTENT

An essential feature of intrauterine contraceptives is their long duration of action. However, this only applies in the absence of side effects. The importance of dimensional compatibility of the IUD or intrauterine system (IUS) with the uterine cavity should be stressed: IUD/IUS designs that fit will lead to high acceptability, a prerequisite with regard to continuation of use. Dimensional incompatibility, on the other hand, is a cause of cramping pain, erratic bleeding or menorrhagia, dislocation or expulsion and, as a result thereof, pregnancy. The size of the intrauterine foreign body, in relation to that of the uterine cavity, determines its acceptability and influences menstrual bleeding. Abnormal and heavy menstrual bleeding is an issue which has not been fully resolved. It is the most common cause of discontinuation of this contraceptive modality. The size of the IUD can be reduced without jeopardizing its effectiveness provided the effective copper surface is sufficiently large.

CONCLUSION

Properly designed and fitting IUDs and IUSs are associated with fewer side effects and greater user satisfaction. This, in turn, could increase usage of intrauterine contraception and thus reduce further the number of unintented pregnancies and induced abortions.

Why do women experience untimed pregnancies? A review of contraceptive failure rates

Contraceptive failure contributes to a substantial proportion of unintended pregnancy, particularly in the developed world. A number of socio-demographic factors seem to impact on the risk of a woman experiencing contraceptive failure. Many of the issues exist across cultural boundaries and are complex to address. In discussing the failure rates for individual contraceptive methods, this article will highlight the advantage of improving uptake of long-acting reversible methods of contraception which have a high efficacy and are less user-dependent than many of the other available methods.

Contraception for the older woman: an update

Although fertility declines with advancing age as the woman approaches the menopause, some risk of pregnancy persists, and effective contraception needs to be offered to avoid an unintended pregnancy. An older woman may have menstrual dysfunction or climacteric symptoms and these factors would need consideration when making the choice of contraception. Low-estrogen dose combined oral contraceptives may be prescribed to healthy non-smoking women up to about 50 years of age. The progestogen-only pill may be an appropriate option in an older woman with declining fertility. The copper intrauterine device is an optimal method for parous women free of pre-existing menstrual problems. The levonorgestrel-releasing intrauterine system is considered the contraceptive method of choice for perimenopausal women with menstrual dysfunction. The woman should be provided with individualized advice so that she has a choice between the newer, effective, largely safe, reversible methods and sterilization.

Advances in contraception: IUDs from a managed care perspective

Contraceptive use in the United States is virtually universal among women of reproductive age. However, unplanned pregnancies continue to occur and can be largely attributed to the nonuse and misuse of contraception. Reducing unintended pregnancies constitutes a critical goal for managed care and the public. This can be achieved in part with intrauterine devices (IUDs), which are an effective method of contraception that require a one-time insertion and stay in place for 5-10 years. Therefore, compliance issues are largely mitigated, and actual use efficacy is the same as perfect use efficacy. The IUD is also reversible, unlike tubal ligation, and could potentially be the contraceptive of choice in today's environment. Unfortunately, safety concerns surrounding the use of older IUDs have precluded many women from recognizing the benefits of their use. Currently, the only approved IUDs in the United States are ParaGard, the copper IUD, and Mirena, the levonorgestrel-releasing intrauterine system (LNG-IUS). These devices offer superior safety profiles compared with those products that were withdrawn from the market in the 1970s. In addition to a favorable safety and tolerability profile, the LNG-IUS offers an advantage over copper IUDs, demonstrating improved efficacy in preventing intrauterine and ectopic pregnancies. Successful communication between patients and providers regarding the improved safety and efficacy of newer IUDs will ensure an appropriate place in therapy. Thus, greater numbers of women will recognize the IUD as a safe, cost-effective means to contraception, thereby reducing the economic and social burdens associated with unplanned pregnancies.

Copper IUD and LNG IUS compared with tubal occlusion

This article will cover current contraceptive use around the world, then examine the advantages and disadvantages of female sterilization, the hormonal intrauterine system and the copper intrauterine device. Finally, the need for contraceptive choice will be discussed along with a discussion on the cost-effectiveness of these methods.

Use of intrauterine devices and systems by HIV-infected women

Human immunodeficiency virus (HIV)-infected women have unique contraceptive needs. HIV infection is now considered a chronic disease and contraceptive options have widened for HIV-infected women. However, there are safety concerns regarding the use of intrauterine devices and systems in HIV-infected women. Although studies are limited, intrauterine devices appear to be safe for use by most HIV-infected women. This is a review of the available data and international recommendations.

Cochrane systematic reviews of IUD trials: lessons learned

BACKGROUND

Intrauterine devices (IUDs) are the most widely used reversible contraceptives in the world today, and decisions about their use should reflect the best available evidence.

STUDY DESIGN

We performed a computer search of the Cochrane Library for all IUD-related reviews.

RESULTS

Eleven reviews related to IUDs have been registered in The Cochrane Library; 10 have been completed, and one is in progress. Topics include type of IUD, timing of insertion, clinical management, emergency contraception and use as gynecological treatment. The copper T380A is the most effective copper IUD; the levonorgestrel intrauterine system has efficacy comparable to that of IUDs with >250 mm(2) of copper. The frameless device may be comparable in efficacy to the copper T380A, although whether problems with the initial inserter are resolved is unclear. Immediate postpartum and postabortal insertion appears safe and effective, although trials comparing immediate to delayed insertions are scarce. Prophylactic antibiotics at the time of insertion appear unwarranted except in populations with a high prevalence of sexually transmitted diseases. Many nonsteroidal anti-inflammatory drugs reduce pain and bleeding associated with IUDs, although prophylactic use of ibuprofen does not improve continuation rates. The levonorgestrel system is superior to oral progestins in treating heavy uterine bleeding. This IUD compares favorably with endometrial ablation techniques and presents an alternative to hysterectomy for many women.

DISCUSSION

Trials are needed to evaluate immediate vs. delayed insertion after delivery or abortion and to explore emerging therapeutic uses of the levonorgestrel system, such as treatment of endometrial hyperplasia.

Pain from copper intrauterine device insertion: randomized trial of prophylactic ibuprofen

OBJECTIVES

This study was undertaken to determine whether 400 mg of prophylactic ibuprofen can alleviate pain from insertion of an intrauterine device (IUD) and to measure level of pain with improved techniques.

STUDY DESIGN

We conducted a randomized, double-blind, placebo-controlled trial of 2019 first-time IUD users: 1008 women received placebo and 1011 women received 400 mg of ibuprofen. Participants took the single tablet at least 45 minutes before IUD insertion. Immediately after insertion, participants recorded level of pain by using a 10-cm visual analog scale, with the value of 10 meaning "worst imaginable pain."

RESULTS

Median level of pain was 1.0 for both ibuprofen and placebo participants; rank test statistics confirmed no difference. Some subgroups of women experienced higher pain (eg, nulliparous women), but ibuprofen still had no important impact on level of pain.

CONCLUSION

Even among first-time users, pain from IUD insertion is generally low. Prophylactic ibuprofen as used in this protocol does not reduce IUD insertion pain.

Risk factors for IUD failure: results of a large multicentre case-control study

BACKGROUND

This study was conducted to identify the risk factors for intrauterine device (IUD) failure.

METHODS

A retrospective case-control study was carried out between 1999 and 2002. Cases (women with an IUD and a confirmed pregnancy) and controls (women with an IUD and who were not pregnant) were recruited by gynaecologists. An anonymous questionnaire was filled in during the consultation, with specific items regarding any type of drugs used before the predicted fertile period for cases and within the cycle that ended in menses for controls.

RESULTS

Two hundred and sixteen cases were compared with 657 controls. Age was associated with IUD failure, with a significantly lower failure risk in women>35 years. A significant relationship was observed between a history of IUD expulsion and IUD failure risk (age-adjusted odds ratio 3.31, 95% CI 1.40-7.81). No relationship was observed between the risk of IUD failure and gynaecological background (fibroma, polyps and miscarriage), nor with any type of medicine taken by the woman.

CONCLUSION

This study is clearly reassuring, as we found that anti-inflammatory drugs and any other medicines taken by the woman were not implicated in IUD failure. Only a history of previous IUD expulsion was found to be a risk factor for failure, indicating that these women should have regular medical and echographical follow-up. Comparing the efficacy rate of various types of IUDs, we found a clear advantage for levonorgestrel-releasing devices.

Evidence based contraceptive choices

People who attend for contraceptive advice have usually formulated an idea of the type of contraceptive that will suit them best. They may wish to use a method that is long, short or medium acting. These are defined as follows: Long-acting method requires renewal no more frequently than every 3 months (e.g. injectable or intrauterine). Short-acting method used daily or with every act of intercourse (e.g. pills, condoms) Medium-acting method requires renewal weekly or monthly (e.g. ring, patch). For men the choice is limited to condoms or vasectomy. Some women do not wish to use hormonal preparations or have an intrauterine device (IUD) or implant inserted. There may also be cultural influences making certain methods of contraception unacceptable. Each of these factors influences the final decision of which method of contraception is decided upon. In addition to taking a full medical and sexual history to identify any risks to the individual's health, which might be increased by a particular contraceptive, time must be spent discussing the options available. It is important to ensure that there is a full understanding of the advantages and disadvantages of each method. The most successful contraceptive method is likely to be the one that the woman (or man) chooses, rather than the one the clinician chooses for them. Access for women to contraception can be improved by having convenient clinic times and service developments such as nurse prescribing and Patient Group Directions.

‘Older’ age is a risk factor for pelvic inflammatory disease in intrauterine device users

BACKGROUND

To asses the role of a copper intrauterine device (IUD) per se in the development of pelvic inflammatory disease (PID) and complicated PID in women considered at low risk of PID.

METHODS

Cases were 51 women admitted to hospital with a diagnosis of acute PID, and controls were 50 healthy women attending an outpatient clinic for routine gynecological check-up. The women were 25-45 years old. Data were analyzed and compared between groups using the statistical program package sas.

RESULTS

IUD use was not associated with an increased risk of PID in general, but in women > or =35 years, IUD use was associated with a risk of PID [odds ratio (OR) = 4.2, confidence interval (CI) 1.1-16.3]. When adjusting for smoking, educational level, employment, and microbial findings in women with PID, IUD use was associated with complicated PID in women > or =35 years (OR = 33.9, CI 1.2-959.6), but not in younger women. When adjusting age and IUD use duration for each other in IUD users, age > or =35 years was a significant risk factor for PID (OR = 4.9, CI 1.3-19.2), but not long (> or =5 years) duration. In IUD users with PID, age > or =35 years was a risk factor for a PID to be complicated in both the unadjusted and adjusted analysis (OR = 12.7, CI 1.6-102.3; OR = 12.1, CI 1.4-104.7), whereas long duration of IUD use was not. When adjusting for significant endocervical microbial findings, long duration of IUD use and age, only age > or =35 years, remained significantly associated with both PID and complicated PID (OR = 5, CI 1.1-21.9; OR = 36, CI - 1.9-670).

CONCLUSIONS

IUD use was not associated with PID in low-risk younger women, but in women > or =35 years, IUD use was associated with an increased risk of PID. The study also demonstrates an association between IUD use and complicated PID in women > or =35 years.