A Renaissance for Long-Acting Reversible Contraception

The intrauterine device (IUD) has come a long way since the 1970s when many were pulled off the market after being linked to pelvic inflammation, infections, and even death. The modern redesigned IUDs, plus recommended testing for sexually transmitted diseases (STDs) prior to insertion, have all but eradicated such complications, allowing a new generation of women to revive the IUD.

Studies show that IUDs and the subdermal implant prevent unintended pregnancies far more effectively than other reversible options on the market, with a maximum of 1 contraceptive failure per 100 women in a year. The Depo-Provera shot came in second with an incidence of 3 per 100, followed by the pill at 8 per 100 and condoms at 15 per 100.

The IUD’s convenience, which requires replacement every five years for the Mirena, a device that releases the synthetic hormone levonorgestrel, and 10 years for the copper-only ParaGard, has won over many providers and patients, but these devices still comprise a small share of the contraceptive market. According to Jeffrey F. Peipert, M.D., M.P.H., M.H.A., Robert J. Terry Professor of Obstetrics & Gynecology and vice chair of clinical research at Washington University School of Medicine, and author of the “Effectiveness of Long-term Reversible Contraception” recently published in The New England Journal of Medicine, there are three barriers slowing the spread of IUDs: education, access, and affordability.

The U.S. Food and Drug Administration did not approve IUDs for women who had not given birth until 2005. Jesuit hospitals often will not prescribe IUDs because they prevent fertilization and implantation rather than ovulation. Insurers frequently deny coverage for IUDs over other types of birth control, making the up-front costs of about $400-$1,000 a barrier.

Despite these obstacles, Catherine M. Gordon, M.D., M.Sc., director of the Bone Health Program in the Divisions of Adolescent Medicine and Endocrinology at Boston Children’s Hospital and lead author of the recent article “Approach to the Adolescent Requesting Contraception” in The Journal of Clinical Endocrinology & Metabolism, has noticed a distinct rise in Mirena IUD requests among her patients. “Generally older adolescents have an interest in this method.” The initial discomfort of IUD insertion into the cervix can be difficult for younger teens. She noted that Children’s Hospital does not have physicians trained to insert IUDs, meaning that patients must go to the neighboring adult hospitals. Special training is required, which has also slowed the popularity of the IUD.

Complications during and after insertion may occur if not done correctly. Alexandra Glorioso, 25, a financial systems specialist in New York City, had an unfortunate experience at her university’s student health services: “It took like 45 minutes, and they gave me Vicodin afterward, which is atypical.” Despite the initial pain, she says the Mirena IUD was worth it in the long run. “In general I don’t even remember that I have it,” said Glorioso. She explained that the IUD provides security and simplicity that other forms of birth control cannot. She has tried everything from the pill to Depo Provera shots to NuvaRing. She said she is considering switching to the Implanon arm implant when her Mirena turns five next year, but she still highly recommends the IUD.

Many other women are also singing the praises of the Mirena IUD. The Contraceptive Choice Project, conducted by Peipert, educated women on their birth control options and allowed them to choose their preference free of charge. The researchers found that the Mirena IUD had the highest overall satisfaction rate, with 88 percent sticking with it after one year. The ParaGard and Implanon implants were not far behind, at 84 percent and 83 percent, but all other forms were under 60 percent in the same time period. After removing the three barriers, 75 percent of the 9,256 participants chose long-acting reversible contraception with almost 50 percent deciding upon the Mirena IUD.

Long-term satisfaction with Mirena is often driven by reduced menstrual flow and dysmenorrhea. About 20 percent stop having periods altogether after one year, and even more in the following two to three years. Gordon sometimes prescribes it to patients with mild endometriosis. But, when asked if the discontinued menstruation could affect bone density, both doctors agreed that it requires further investigation. Currently, evidence is insufficient to know if Mirena has such risks, but Peipert hypothesizes that the localized nature of the device should not affect bone health.

Studies also show that most women return to fertility quickly after IUD removal. Gordon explained that the World Health Organization endorses the use of IUDs, even in teens. She says that an increased incidence of STDs in women with IUDs is a myth, and it is an accepted form of “safe and effective contraception.” Only women at very high risk for STDs may not be candidates for an IUD.

The future of long-term reversible contraception is bright. Peipert is currently seeking grants for studies that could extend the accepted lifespan of Mirena from five to eight years. “I believe IUDs are probably good for a lot longer than they’re approved for,” he said. “So I don’t think it’s a major concern if people leave it in longer. They just have to be aware that it’s not approved for that long.” Insurance coverage remains a primary hurdle, but once cost-reducing benefits are recognized, such as reduced incidents of unintended pregnancy, dysmenorrhea, endometriosis, and patient attrition, birth control pills may become a thing of the past.

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