Intrauterine Devices: Separating Fact From Fallacy

, Magee-Womens Hospital, University of Pittsburgh School of Medicine

Disclosures
In This Article

Patient Selection

A woman who opts for an IUD not only needs to understand the risks and benefits of using an IUD but also those of the other methods available to her. The ParaGard is the most cost-effective method of contraception over a 5-year period.[30] If no contraindications to IUD use exist, a thoroughly counseled patient who understands all her other contraceptive options but strongly feels that an IUD is the best method for her is an ideal candidate for an IUD.

The most important determinant in selection of patients is not age or parity, but risk factors for STDs. Women who are in long-standing, mutually monogamous relationships and who desire highly effective contraception without personal inconvenience are ideal candidates for the IUD. Absolute contraindications to the use of IUDs include a known or suspected pregnancy, undiagnosed vaginal bleeding, active cervicitis or PID, allergy to copper or Wilson's disease (for copper-containing IUDs), malignancy of the uterus or cervix, history of pelvic actinomycosis, valve replacement,and active conditions that would increase susceptibility to infection (ie, immunosuppression or HIV disease).

Other factors are important to discuss individually, because they are not absolute contraindications but do require the clinician and patient to consider strongly whether another method may be preferable.

Parity. Nulliparous or nulligravid women are often told that an IUD is contraindicated, even though there is no medical reason for this recommendation. IUD manufacturers often recommend this limitation for liability reasons. By definition, approximately 85% of couples in the US will be infertile--defined as no conception with regular intercourse over a 1-year period. The IUD does not raise the risk of infertility unless the patient had PID during the time she was using the IUD.

However, if a nulliparous women uses an IUD and then has trouble conceiving, she is likely to blame the IUD and may file a lawsuit. Women who have proven their fertility are less likely to file a lawsuit charging infertility secondary to IUD use. Thus, nulliparity is not a valid reason to withhold this highly effective form of long-term contraception from a woman. The nulliparous or nulligravid patient who wants an IUD should have this information explained to her so she will understand how an IUD affects future fertility.

Dysmenorrhea/pelvic pain/menorrhagia. Because a copper-containing IUD can increase dysmenorrhea and can cause intermenstrual bleeding and menorrhagia, women already experiencing any of these problems may not tolerate their worsening. For these women, a progesterone-releasing IUD will not only minimize the chance of these problems but also decrease the incidence of their already existing complaints.

Distorted or abnormal uterine cavity. Because the IUD acts to prevent sperm migration into the fallopian tubes, it must be properly sited at the fundus of the uterus (Fig. 3). An enlarged or distorted cavity may not permit ideal placement of a copper-containing IUD and may decrease its effectiveness. However, because a progesterone-releasing IUD acts mainly as a hormonal contraceptive, distortion of the cavity would not prevent its desired action. Nonetheless, the clinician must consider that a cavity distorted by submucosal myomas may make insertion of the IUD difficult and may theoretically increase the risk of expulsion or perforation.

Figure 3. To prevent sperm migration into fallopian tubes, IUD must be properly sited within uterus.

History of pelvic infection. A recent history of PID (unless postabortal or postpartum) is a marker of high-risk sexual behavior and should alert the clinician that another method of contraception is probably indicated. However, "history of PID" as an absolute entity is not a contraindication. The clinician must take into account when the PID occurred in relation to the patient's current lifestyle and social situation. For example, if a 35-year-old woman had PID when she was in her early twenties, then married in her late twenties, had 3 children, and has experienced a mutually monogamous relationship with her husband, her "history of PID" is irrelevant.

History of Actinomyces on a Pap smear.Actinomyces can be found as part of the normal vaginal flora.[31,32] Although such patients may be at risk for pelvic actinomycosis with an IUD in situ, the lack of active findings consistent with Actinomyces should not contraindicate IUD use. Cervical culture for gonorrhea and Chlamydia should be obtained for women who are considering an IUD. A positive culture in an otherwise asymptomatic woman should receive routine treatment and prompt questioning as to whether or not an IUD is a good choice. If the patient has not had a recent Pap smear, one should be obtained during the examination.

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