Holy healthcare, women!!! I’m thrilled for everyone that our preventive services are now free. What is happening, particularly in contraception provision in the United States, will be an entirely different post – but first and foremost regarding free preventive service provision for women – hoorah! Now on to a clinical experience from this week: IUD counseling for women with any level of track record of STIs or multiple partners. Also known as, why the risk of “multiple partners” is a ridiculous term, and is irrelevant to contraceptive care provision. This, after a patient was told she couldn’t consider the IUD an option because she has a history of Chlamydia x 2 in the past.
First, I bring you an incredible Mad Men clip: Peggy and the Gynecologist
Historically, providers believed that women needed a physical exam to be prescribed any form of birth control. This was at a time when the pill was, essentially, the only option. Mad Men-style, Peggy and Joan, as reference points for women seeking a method, were subjected to a pelvic exam (to determine who knows what) to obtain a contraceptive method. Given the dominance of men providers during that time, Mad Men writers may not be far off in their assumption of provider’s guidance on how to use the methods. Including, in some cases, those men’s/provider’s opinions on how those women should comport themselves. Also known as, how to not be promiscuous. Strumpets. Pumps. Sluts. “I will warn you now, I will take you off this medicine if you abuse it. It’s for your own good, really.” Corroborating with recent and current political beliefs that Plan B will create a wild world of loose women, anyone? “The promiscuity part we don’t regulate.”
Current screening procedures for most birth control methods involve personal and familial medical history to rule out concerns of adverse effects of the hormones. Any complaints about something going on down there will involve more conversation. Undiagnosed vaginal bleeding, aside from regular menses, should be looked into further. And women age 21 and older should have regular preventive screening and well-woman visits. But generally speaking, one’s pelvis does not need invaded for a birth control prescription. That’s healthcare. And now, it’s free for women.
In the age of a more abundant list of methods, including the Mirena and Paragard intrauterine devices (IUDs), perhaps things have become more complicated. IUDs are an incredibly popular method currently for women, at risk for pregnancy (nod to Lola Mc., at risk for baby infection), with and without children. For a woman unsure of what method she would like, it can be difficult to decide. Hormonal method or not? How long would you like to use the method (month to month; every three months; every three, five, or ten years)? Do you want to use something every day? Do you want to experience a period (withdrawal bleed if using a hormonal method), or are you okay with and/or would you prefer to not have a monthly menses? Do you want to see a provider to stop the method, or do you want to be able to control if and when you stop the method? Would you like for your partner(s) to know about your using the method, or do you want something discreet? IUDs rival sterilization (tubal ligation) in their effectiveness – huzzah, enter an awesome, reversible, long-term method for women.
I’m currently in a four-week orientation period, mandated for all new midwives, with a bit of extra time added on because I’m a recent grad. Thus, I have more time to work with other midwives before working da sola, as is the set-up in this practice. I’m enjoying the time to still be with other midwives, observe their style, and listen to their counseling, management, and plans for patients. A number of patients over the past two days were seeking either a new method, or to change their current method, and had long lists of questions about the IUDs. Want to know about IUDs – this is the place for you, especially if your provider shoo’d away your concerns or if the internet frightened you entirely.
So, there are medical eligibility criteria for using contraception.
For both IUDs, in Category three, or “risks outweigh benefits,” specifically listed is a woman’s increased risk of gonorrhea and chlamydia infection. And this is my point of contention, so let’s take this step-by-step. Risks outweigh benefits: what does that mean exactly to a provider? It means that when you have a known medical history to be on a list of “risks,” for that specific method, that method is possibly not for you. There’s also a list of “absolutely not to be used in the case of this risk,” or Category 4. For contraceptive methods, there’s a mix of both public health and medical research on whether it’s riskier for that woman to become pregnant, or to experience the complications of that “risk” + using the method. Perhaps more tangibly, an example is the standard “pill,” which is a combination of forms of estrogen and progesterone. For the pill: using estrogen if you have a history of migraines with aura: huge ‘absolutely not’ in the world of medicine. If you have a history of migraines without aura, probably okay, but let’s talk about all your options. (Full lists of medical eligibility criteria are available through the CDC MMWR).
In the case of IUDs, there is concern in the literature about upper genital tract (cervix, uterus, fallopian tube) infection, largely with a possible vaginal infection being pushed into the uterus during the IUD insertion process. However, there is concern that, theoretically, the strings create a conduit from the non-sterile vaginal flora to the sterile uterine environment. Say wha? The IUD strings hanging in your vag can make it easier for an infection (gonorrhea or chlamydia (GC/CT), specifically) to travel upwards and cause serious infections. This is a concern because GC/CT can cause pelvic inflammatory disease (PID/salpingitis) and possibly affect the woman’s ability to conceive in the future, among other issues.
What do the all-knowing texts say? According to Contraceptive Technology (contraception learning text of champions), “Both epidemiological and bacteriological evidence indicates that the insertion process, and not the device or its string, poses the transient risk of infection.” This evidence was proved again in international studies, where the risk of infection “was limited to the first 20 days after insertion.” The highest risk of causing an upper genital tract infection, or the whole issue of this hullabaloo, is during insertion. Important summaries: “the monofilament string does not increase the risk of upper genital tract infection… Again, this underscores the point that sexually transmitted diseases, not contraception, cause salpingitis.” (p. 126)* CONCLUSION: the IUD itself does not cause an increase in upper genital tract infection. For some providers, either a negative STI screen is required prior to insertion, or prophylactic antibiotic treatment is provided for same-appointment counseling and insertion. Again, avoidable hullabaloo. Gonorrhea and chlamydia are the main concern here.
What do the important organizations say? The United States Medical Eligibility Criteria typically has reigning rule here. Increased risk of chlamydia and gonorrhea infections is still on the “risks outweigh benefits” list for IUDs. The World Health Organization says the same thing: “If a woman has a very high individual likelihood of exposure to gonorrhoea or chlamydial infection, the condition is Category 3.”
Now, let’s talk. This is what I’m really pondering. Increased risk for gonorrhea and chlamydia – to whom does this apply? Let’s examine just chlamydia, since the risk profiles are essentially the same, and the infections occur so often at the same time that it’s almost one term at this point. According to the CDC, those at risk for chlamydia include someone who is an adolescent, has new or multiple sexual partners, a history of STIs, presence of another STI, or is an oral contraceptive user (lack of barrier contraception is on the bottom of the list, despite that being the only way to possibly prevent chlamydia infection unless one is abstinent). Let’s break down this list.
So, adolescents. A ridiculous, over-arching term to somehow reference those who are young and presumably unaware. Well, now we’re just on a slippery slope of ass-umptions. Given the state of sexual and reproductive health education in this country (another discussion altogether), adolescents are possibly not receiving any information, let alone accurate or thorough health education, in this regard. Enter the increased risk of STIs.
New or multiple sexual partners? Anyone having sex for the first time has a new sexual partner. If you choose to not stick with that person for the long haul, you now have multiple sexual partners. That’s just about everyone. If the term “multiple sexual partners” is really referring to people with numbers greater than one, more specifics should be included here. However, risk is increased with more exposure, so perhaps the concern is coverage from exposure, or condom use.
So, condoms. There is an incredible differential between success/failure of condom use and the condoms themselves. Condoms prevent some STIs, but not all, and if they break then there’s a risk of exposure. Condoms also do not protect against genital warts, including herpes, which hangs out for the rest of your life. In that case, one sexual encounter might give someone warts, which means what? Well, you answer, the concurrent presence of another STI!! What a conundrum.
So, possibly, even with condoms, one’s new and only sexual partner might have given them warts. Perhaps multiple might have as well, but it only takes one. Multiple, in this situation, is irrelevant, but somehow it’s there. I repeat, multiple is irrelevant: it doesn’t take five sexual partners to get an STI, it is not cumulative, and the STI itself should have no stigma attached to it in relation to one’s assumption of your sexual history. So by multiple, we really mean even one, but your chance of coming across that one infected person is higher if your “how many people have you slept with” number is higher.
History of STIs, again might have been from one sexual encounter, and the STI might have been treatable or not, but now it’s on that history and not going away, and now you’re in another category of what contraceptive method you might receive. Not to mention the fact that these risk-benefit criteria (multiple sexual partners) are largely coming from vaginal-penile intercourse, and we all know that’s not the only way that people can have fun with their bodies. But that is the way by which many people become pregnant, so it’s relevant to the category of whether or not you get a certain type of birth control.
There are complicating factors here. Gonorrhea and chlamydia may not have obvious symptoms – for many women, their knowledge of their infection may only occur after a routine exam, a urine culture sent during a birth control consult, or if the partner is reporting something. These infections can hang out for a while and cause some serious damage if they’re not treated. Often a urine test can screen for these issues, but if not, then a quick pelvic swab, possibly self-administered, might do the trick. So there’s not a big complaint list from the provider standpoint on things we would have to do to rule out a woman’s current infection – easy-peasy. Again, there are precautionary procedures in place, of securing a negative STI screen pre-insertion or treating prophylactically, so infection during insertion is no longer up for debate here. I repeat, from the provider standpoint, easy-peasy. What we’re talking about is whether your current sexual activities will preclude our conversation about what methods I will or will not provide to you.
There is also the benefit-of-the-doubt argument for all those awesome providers out there. For patient populations where one is diagnosing STIs on the regular, the concern of possible PID for one’s patients can cause genuine concern. And published literature about how the ‘infection doesn’t travel up the strings and cause upper genital tract infection’ is not that interesting when you have someone in the room about whom you’re concerned for their long-term safety. Evidence-based care or not, that provider may be coming from a place of genuine concern. But perhaps that visit should be spent really talking about risk of STIs in that community. That patient should be screened for those infections if the thought pops into your head that the IUD may not be great for them, because what you’re really thinking is, she’s at increased risk for things. The first thought shouldn’t be, nope, the IUD isn’t for you. If someone tests positive for gonorrhea or chlamydia, standard of care is to screen three months later for reinfection after a successful test of cure. Why? Well, because maybe your partner wasn’t treated, the medicine was effective, or because you had sex with someone else. And I want to keep you healthy. Though midwives cannot prescribe for male partners, there is the handy method of putting one refill on the prescription, and encouraging the woman to use that effectively to make sure both she and her partner are treated. There are ways to handle these things well, and I think that largely providers are doing the right thing here.
What do I think is really at the core of this argument? Education. People should know their risk of STI infections, know that some don’t have symptoms, and get checked out about every three months if they’re sexually active with someone, non-monogamous, or just because it’s good for you. If we’re concerned about someone’s risk for an infection, we talk about prevention methods, educate to empower, and treat when necessary. Fullstop.
But, hold. the. phone. What was all of this ranting for? MULTIPLE SEXUAL PARTNERS. Written into the literature as a risk factor, as a potential anti-benefit to women seeking IUD contraception. Put that Mad Men clip on repeat, and listen to the number of times that provider references potentially floozy-ish, strumpet, town-pump, slut activity and the restriction of a method based on that approach to one’s sexual life. And what is important is that providers are still considering women’s sexual activity and withholding contraception based on that risk, despite evidence to the contrary. And terms like “multiple sexual partners” is only precipitating this action. Pregnancy and STI prevention are TWO CONVERSATIONS that need to happen, not wrapped up in one package and leading to confusion on what method someone should receive. So, is the term ‘multiple sexual partners’ null and void, since most people in their lifetime will have more than one? Or is this term used specifically in reference to woman-provided care, as a continued way to point only to women’s potential for rampant sex-having. It’s more subtle than the ridiculous political arguments against Plan B, but it’s there, and confusing, and concerning in its reference to women’s activity.
If a woman, adolescent, mother, fellow midwife, is seeking contraception, what would it mean to them to say “I’m not comfortable giving you this method because you’ve had multiple sexual partners.” Decoded: you sleep, or have slept, around. I realize that this would likely not be any provider’s only determination of whether or not to prescribe something, but it’s on the list of possibilities. Multiple sexual partners, if it really means concern for risk of STI infection, should say just that: increased risk of STIs. And then, whatever non-judgmental language should be listed for all birth control methods that don’t prevent STIs, which is all of them excluding condoms. There shouldn’t be this subtle “history of slutty behavior” in the literature. Language like this, when read by women seeking contraception, may then alter what medical history they reveal to providers, knowing that there is judgement in those words. If a woman does in fact have multiple concurrent sexual partners, that’s all the more argument for a super-effective contraceptive method, and then the important conversation about STI protection. I’m proud of my bias that any woman’s argument for contraception is good enough for me, and it’s important to talk about all the risks and benefits that go along with that method. If any woman is seeking contraception, it means she’s thinking about or is having sex, and thus a conversation about STIs should happen. But continuing to provide contraception based on the provider’s judgment of the amount of “fun” they’re going to have with it, when looking to just the terms “multiple sexual partners,” is appalling. It was appalling in the Mad Men video, and it’s abhorrent now. I hope everyone is having a lot of fun, actually, preventing contraception when they want to, and knowing how to prevent STIs when it’s a possible risk.
*Please note: These quotes and page numbers are from the 19th edition of Hatcher, so if the 20th includes different information, I’d love to know.