Last week, I was asked to comment on recently published research (Green Journal, May 2013) regarding the appropriateness of intrauterine devices (IUDs) for adolescents. What’s that you say? Weren’t IUDs released with specific criteria, uterine size and existing health conditions to be the deciding factor as to whether or not this method was appropriate? Why yes, they were, but the paternalistic research continues.
I can only assume the concerns that are minimally discussed are 1) possible increased risk for STIs due to a potentially sexually promiscuous population, as evidenced by documented higher STI rates in this age group, and 2) provider concern with small uterine size for nulligravidous women, thus increased risk for perforation or expulsion upon insertion. However, nulligravidous women interested in IUDs could be in any age group, not just adolescents, so I defer back to topic 1. Topic 2 also is more of a discussion for provider comfort with IUD insertion (i.e. the provider’s responsibility to not perforate the uterus), since expulsion is (should be) discussed with all women, and the slightly increased risk of expulsion for nulligravidous women should be among those discussions. I digress, but a provider concerned about perforation in nulligravidous women sounds like they should have increased training for all women, since every woman’s uterus is a different place. The fundus is the fundus, y’all, short or tall. You find it and you measure it. Moving on.
Just so you can rest assured I have back-up here, even ACOG is on board with IUDs for teens. And that’s saying a lot, I suppose.
I have already covered most of this topic, regarding the inappropriateness of witholding IUDs from women whom you think (you, provider, with your judgments and assumptions), will be at higher risk for STIs, or for pregnancy. I’ll quote myself here, since that post took a lot of work way back in the day:
“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…”
Let’s re-watch the Mad Men video to drive home the point, making it seem equally ridiculous to withhold oral contraceptive pills for concerns of promiscuity:
You may respond that witholding IUDs from “risky women” comes from a place of concern for your patient’s well-being, but unfortunately, that concern is complete non-evidence-based and unfounded. The greatest risk of infection is on time of insertion, which puts the onus to rule out infection on you. No research has shown that the IUD itself increases infection with STIs, or that the strings-as-a-pathway into the uterus increase risk of progression to pelvic inflammatory disease (PID). I again quote myself:
“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.”
Perhaps this is a good point to discuss that if there is documented repeat infection with gonorrhea, chlamydia, or trichomoniasis (the tricky, newer STI that people are still unsure of), a serious convo should happen with the woman about her chronic risk of PID, because that’s what happens with repeat, long-term infection with an STI. That isn’t a time to insert a conversation around: “Shame on you, now I can’t give you one of the best chances to prevent pregnancy because you keep messing it up.” Her health is on the line here, and she should know it. Additionally, if she becomes pregnant with salpingitis, she is at increased risk for ectopic pregnancy or for the pregnancy/baby to have serious problems. So give her the most effective form of contraception possible if that is what she seeks. Women are smart, which we may forgot in all of this conversation, which focuses on assumptions and judgment rather than evidence.
I tell you this as words of love for you and for your patients. Adolescents, and anyone interested in long acting reversible contraceptives (LARCs), should be provided them regardless of sexual activity. It’s a contraceptive. Discusion around STI prevention is a separate conversation. Perhaps they happen in the same visit, but do not confuse the two and, importantly, do not let women confuse the two.
I will close with a reference to the newest IUD, Skyla. A Bayer representative, an older white gentleman, interrupted my charting time the other day with Skyla materials, all bright pink as they were (hope you all are catching my subtle references here). He was surprised to hear that I had read that Skyla would be marketed to adolescents and nulligravidous women due to its smaller size compared to the Mirena and Paragard, and told me that was not part of their marketing at all (though I do not understand why it wouldn’t be, as to me it makes anatomical sense). Skyla also releases a smaller amount of progesterone on average over the daily lifetime of the IUD, so women may experience less side effects than with Mirena. The strings are softer than Mirena, another plus for those irritated by the tougher metallic string. The insertion device is slightly different, with the strings encased in the inserter so the provider isn’t fiddling with them tangling as they hang down on the outside.
Three years of an IUD is another LARC to add to the list, and I’m thrilled. Skyla will be hitting the clinical shelves soon, y’all. Bring on the adolescents, errr, nulligravidas, errr, ANYONE who is interested in the method, since as a contraceptive it’s marketed to anyone who would like it. Oh and those condoms? Still the only way to prevent STIs, errr increased risk of PID, errr, ectopic pregnancy and chronic pelvic pain caused by PID, errr, STIs in sexually active women! So keep talking about those!