Contraception, IUD & Barrier Methods

General Considerations

• Contraception should be available to all women and men of reproductive ages

• Education about and access to contraception are especially important for sexually active teenagers and for women following childbirth or abortion

• Intrauterine devices (IUDs) are not abortifacients

Intrauterine devices

• Available IUDs include Skyla, Liletta, and Mirena (which release levonorgestrel) and TCu380A (which is copper-bearing)

• Duration of effectiveness

  • Skyla: 3 years

  • Mirena, Liletta, and Kyleena: 5 years

  • TCu380A: 10 years

• The hormone-containing IUDs have the advantage of reducing cramping and menstrual flow

• Nulliparity is not a contraindication to IUD use

• Adolescents are candidates for IUD use

• The hormone-containing IUDs may have a protective effect against upper tract infection similar to that of oral contraceptives

• Contraindications to use of IUDs are outlined in Table 18–4

• A copper-containing IUD can be inserted within 5 days following a single episode of unprotected mid-cycle coitus as a postcoital contraceptive

• Evidence is mounting that suggests IUDs can be safely inserted in the immediate postabortal and postpartum periods

• An IUD should not be inserted into a pregnant uterus

• If pregnancy occurs as an IUD failure, there is a greater chance of spontaneous abortion if the IUD is left in situ (50%) than if it is removed (25%)

• Spontaneous abortion with an IUD in place is associated with a high risk of severe sepsis, and death can occur rapidly

• Women using an IUD who become pregnant should have the IUD removed if the string is visible

• An IUD can be removed at the time of abortion if this is desired

• If the string is not visible and the patient wants to continue the pregnancy, she should be informed of the serious risk of sepsis and, occasionally, death with such pregnancies

• Such women should be informed that any symptoms of fever, myalgia, headache, or nausea warrant immediate medical attention for possible septic abortion

• Since the ratio of ectopic to intrauterine pregnancies is increased among IUD users, clinicians should search for adnexal masses in early pregnancy and should always check the products of conception for placental tissue following abortion

Diaphragm

• The diaphragm (with contraceptive jelly) is safe and effective; the diaphragm stretches from behind the cervix to behind the pubic symphysis

• Its features make it acceptable to some women and not others

• Advantages

  • Has no systemic side effects

  • Gives significant protection against pelvic infection and cervical dysplasia as well as pregnancy

• Disadvantages

  • Must be inserted before and near the time of coitus

  • Pressure from the rim predisposes some women to cystitis after intercourse

• Failure rates range from 6% to 16%, depending on the motivation of the woman and the care with which it is used

Cervical cap

• The cervical cap (with contraceptive jelly) is similar to the diaphragm but fits snugly over the cervix only

• Advantages

  • Can be used by women who cannot be fitted for a diaphragm because of a relaxed anterior vaginal wall

  • Can be used by women who have discomfort or develop repeated bladder infections with the diaphragm

• Disadvantages

  • More difficult to insert and remove than diaphragm

  • Because of the small risk of toxic shock syndrome, a cervical cap or diaphragm should not be left in the vagina for over 12–18 h, nor should these devices be used during the menstrual period (see above)

• Failure rates are 16% (typical use) and 9% (perfect use) in nulliparous women and 32% and 26%, respectively, in parous women

Contraceptive foam, cream, film, sponge, jelly, and suppository

• All contain the spermicide nonoxynol-9, which also has some virucidal and bactericidal activity

  • Nonoxynol-9 does not appear to adversely affect the vaginal colonization of hydrogen peroxide-producing lactobacilli

  • The Food and Drug Administration requires a warning on these products explaining that they do not protect against HIV or other STDs and their use can irritate the vagina and rectum and may increase the risk of getting the AIDS virus from an infected partner

• Advantages

  • Simple to use

  • Easily available without prescription

• Typical failure rate ranges between 10% and 22%

Condom

• The latex, polyurethane, or animal membrane male condom affords protection against pregnancy

  • Efficacy is comparable to that of a diaphragm used with spermicidal jelly

  • Latex and polyurethane (but not animal membrane) condoms also offer protection against sexually transmitted disease (STD) and cervical dysplasia

  • For protection against HIV transmission, a latex condom along with spermicide during vaginal or rectal intercourse is advised

  • The failure rate of a condom used with a spermicide, such as vaginal foam, approaches that of oral contraceptives

  • Condoms coated with spermicide are available in the United States

  • Disadvantages of condoms are dulling of sensation and potential for spillage of semen due to tearing, slipping, or leakage with detumescence of the penis

• The polyurethane and synthetic nitrile female condoms have failure rates of 5% to 21%

  • Efficacy is comparable to that of the diaphragm

  • These are the only female-controlled method that offers significant protection from both pregnancy and STDs

Therapeutic Procedures

Intrauterine devices

• Insertion can be performed during or after the menses, at midcycle to prevent implantation, or later in the cycle if the patient is not pregnant

• Both types of IUDs may be may be inserted up to 48 hours after vaginal delivery, or prior to closure of the uterus at the time of cesarean section

• Insertion immediately following abortion is acceptable if there is no sepsis and if follow-up insertion a month later will not be possible; otherwise, it is wise to wait until 4 weeks postabortion

• Misoprostol (200 mcg the night before) and nonsteroidal anti-inflammatory drugs given as premedications may help insertions in nulliparous patients or when insertion is not performed during menses

Complications

Intrauterine devices

• Pelvic infection

  • Women with a history of recent or recurrent pelvic infection are not good candidates for IUD use

  • At the time of insertion, women with an increased risk of STDs should be screened for gonorrhea and chlamydia

  • There is an increased risk of pelvic infection during the first month following IUD insertion

  • The subsequent risk of pelvic infection appears to be primarily related to the risk of acquiring STDs

• Infertility rates do not appear to be increased among women who have previously used the currently available IUDs

• Menorrhagia or severe dysmenorrhea

  • The copper IUD can cause heavier menstrual periods, bleeding between periods, and more cramping, so it is generally not suitable for women who already suffer from these problems

  • However, the hormone-releasing IUD Mirena has been approved by the FDA to treat heavy menstrual bleeding

  • Nonsteroidal anti-inflammatory drugs are also helpful in decreasing bleeding and pain

• Complete or partial expulsion

  • Spontaneous expulsion of the IUD occurs in 10–20% of cases during the first year of use

  • Any IUD should be removed if the body of the device can be seen or felt in the cervical os

• Missing IUD strings

  • If the transcervical tail cannot be seen, this may signify unnoticed expulsion, perforation of the uterus with abdominal migration of the IUD, or simply retraction of the string into the cervical canal or uterus owing to movement of the IUD or uterine growth with pregnancy

  • Once pregnancy is ruled out, a cervical speculum may be used to visualize the IUD string in the cervical canal. If not visualized, probe for the IUD with a sterile sound or forceps designed for IUD removal, after administering a paracervical block

  • If the IUD cannot be detected, pelvic ultrasound will demonstrate the IUD if it is in the uterus, or anteroposterior and lateral radiographs of the pelvis with another IUD or a sound in the uterus as a marker can confirm an extrauterine IUD

  • If the IUD is in the abdominal cavity, remove by laparoscopy or laparotomy

Prognosis

• The IUD is highly effective, with failure rates similar to those achieved with surgical sterilization

• Women who are not in mutually monogamous relationships should use condoms for protection from STDs

Prevention

• Perforations of the uterus are less likely if insertion is performed slowly, with care taken to follow directions applicable to each type of IUD