Provider and patient perspectives
In spite of high efficacy rates, many clinicians are hesitant to provide IUDs due to misconceptions regarding patient populations and side effects. A 2013 global study by Black et al12 found that 1,862 obstetrician–gynecologists (OBGYNs), nurse practitioners (NPs), and physician assistants (PAs) reported not offering IUDs to nulliparous patients for the following reasons: (1) difficulty in insertion; (2) concern about PID; (3) insertion pain; and (4) infertility.
In a study by Harper and associates13 of 812 physicians, NPs, and PAs, more than half of respondents would not consider nulliparous women (54%), women who are postabortion (61%), or women who have had a sexually transmitted infection (STI) in the past 2 years (61%) to be candidates for IUDs; 31% would not offer IUDs to women with a history of ectopic pregnancy, and 48% would not offer IUDs to women who have had PID in the last 5 years.
A third study by Luchowski et al,14 which surveyed 1,552 OBGYNs, found that 46% did not agree that IUDs could be inserted immediately postpartum, 20.4% disagreed that IUDs could be inserted after an abortion or miscarriage, 33.2% would not consider nulliparous women to be appropriate candidates for an IUD, and 57% would not consider adolescents to be appropriate candidates for IUDs. In addition, 15.6% believed IUDs increase a patient’s chance of developing PID.
Many providers are hesitant to provide IUDs, and many women are reluctant to use them. A 2010 study of 1,665 women by Hladky et al15 illustrated that their major concerns included increased pelvic pain (33%-43%), infertility (20%-33%), and ectopic pregnancy (24%-31%). Another study concluded that adolescents and young adults identify pain with insertion and removal as the most feared side effect of IUDs.4
Studies demonstrate that patients and providers share similar concerns.4, 12-15 Both groups are concerned that IUD insertions in nulliparous and adolescent women are more difficult and painful. They are also concerned that IUDs increase a patient’s risk of ectopic pregnancy and infertility through an increased risk for PID.
- Difficult and painful insertions in nulliparous and adolescent women
- Increased risk of
- ectopic pregnancy
IUD, intrauterine device; PID, pelvic inflammatory disease
Some providers believe that nulliparous and adolescent women, women who are postpartum and postabortion/miscarriage, and women with a history of ectopic pregnancy, PID, or STIs are not candidates for IUD use.
The next section reviews the ACOG recommendations and data on contraindications for use and side effects that adds to the evidence that these concerns are largely unfounded.
Difficulty and pain with insertion
As discussed above, patients and providers are concerned about difficulty and pain with IUD insertion, especially in the adolescent and nulliparous population. Some nulliparous and adolescent women may have more pain upon insertion; however, providers should be able to perform the insertion without technical difficulty in most women in these populations.8 Difficulty with insertion is rare. In cases in which the provider has difficulty, misoprostol may facilitate the insertion.10,16 It is also possible that doses of ibuprofen greater than 600 mg may relieve some pain, although studies have yet to confirm this definitively.16
In adolescents, concerns about pain during insertion have been associated with increased fear before the procedure. Easing an adolescent’s expectation of pain before insertion may help reduce her anxiety and lead to a less painful experience.15 Adolescents often express anxiety about their first pelvic examination. Ensuring that the adolescent has had a gentle and painless pelvic examination prior to the visit during which the IUD is inserted is another way providers can ease anxiety about the insertion procedure.17 The patient will be more familiar with the pelvic examination before the IUD insertion, and the entire procedure will produce less anxiety.
In summary, providers should make every effort to inform patients about the insertion procedure during a preinsertion visit. Patients who are concerned about insertion pain should be told to take 600 mg to 800 mg of ibuprofen before the procedure and reassured that fear of pain is often worse than the actual pain.16,18 Patients should also be informed that the insertion will not be any more complicated if they are younger or nulliparous, and efforts should be made to ease their anxiety. If providers are able to convey these messages, patients’ fears associated with IUD insertions will likely be reduced.
Contraindications, infections, and infertility
In an effort to clarify common provider and patient misconceptions about contraindications, a summary of actual contraindications follows. IUDs are contraindicated in women with severe uterine distortion, who are or might be pregnant, who are experiencing unexplained abnormal bleeding, who have tuberculosis, and who are immunocompromised.6,19 Although no adverse effects related to Wilson’s disease or copper allergies have been reported, women with these conditions should not use the copper IUD.6
Women who have cervical cancer or untreated endometrial cancer also should not have an IUD inserted. However, in women with cervical cancer, the IUD usually does not need to be removed if it is already in place. Women with breast cancer should not use a LNG IUD.20
In addition to these contraindications, there is one from which many misconceptions stem—infection. IUD insertions are contraindicated in women with an active pelvic infection. However, women who develop PID while an IUD is in place usually do not have to have the IUD removed, as long as the PID is treated.20 The risk of PID is slightly higher in women who have an IUD inserted in the presence of an STI than in women who have an IUD inserted without an STI.8 However, an IUD can be inserted in the presence of a vaginal STI, as long as it is treated.8 The ACOG states that evidence does not support routine antibiotic prophylaxis or screening for STIs in most patient populations. However, because adolescents aged 15 years to 19 years are at high risk for STIs, they should be screened before insertion.9
Due to potential bacterial contamination from the insertion procedure, women with IUDs are 6 times more likely to contract PID in the first 20 days after an insertion.6 However, after that initial time period, women with IUDs are not at increased risk of PID.9 The LNG IUDs may even reduce PID rates. No studies have found an increased risk of infertility due to PID in nulliparous or adolescent IUD users compared with multiparous or older IUD users.9 It is important to note that, although certain patient populations are at increased risk for STIs and PID, the use of an IUD does not increase the risk of PID or infertility.9
Contrary to many providers’ and patients’ perceptions, IUDs are safe for use in women with a history of ectopic pregnancy6; they do not increase the risk of ectopic pregnancy. IUD users are 50% less likely to have an ectopic pregnancy compared with women who do not use contraception.20 Clarifying this fact and discussing concerns about infection and infertility with accurate and current information allows patients to make better-informed decisions about their contraception methods.