Side effects and complications
Providing counseling about the side effects of IUDs correlates with satisfaction and continuation rates.19 In her 2013 review, Hillard17 shows that adolescents, early adolescents in particular, tend to disregard warnings unless they are overstated. She suggests counseling adolescents to expect side effects rather than warning them that they may experience side effects. It is important that adolescents are informed that bleeding will decrease with LNG IUDs and that cramping from the copper IUD will most likely decrease over time and can be subdued with nonsteroidal anti-inflammatory drugs.18
Providers should explain the side effects of each type of IUD, paying close attention to common concerns among all patient groups and with a particular focus on clarifying those concerns. Providers should note that the LNG IUDs have been shown to reduce bleeding and pain from dysmenorrhea17; however, the copper IUD will likely increase bleeding and cramping, especially in the first few months after insertion. Patients with a history of menorrhagia or dysmenorrhea may be better served by one of the LNG IUDs.6 If patients are informed of side effects ahead of time, they will be less likely to react strongly to them if they occur.
Providers are less concerned about IUD expulsion and uterine perforation.12-14 However, IUD expulsions and uterine perforations can develop into severe complications and are consequences for which providers should be vigilant. Of the two complications, expulsion is more common, occurring in approximately 5% of IUD users.19 Providers should be aware that IUD expulsion rates may be slightly higher in adolescent women, women with severe dysmenorrhea, most women with a history of expulsions, women who have had an immediate insertion after an abortion or miscarriage in the first trimester (when compared with an abortion or miscarriage in the second trimester), and women who have an immediate postpartum insertion (when compared with delayed insertion). Immediate insertion of an IUD after vaginal delivery also has a higher rate of expulsion than after cesarean deliveries; however, the ACOG states that the benefits of immediate postpartum insertion may outweigh the risks because delayed insertion requires another office visit that patients may not attend.6,9,22 It is also important to note that a previous expulsion is not a contraindication for the use or insertion of an IUD.9
The risk of uterine perforation is rare. Recent studies estimate that as few as 0.4 to 1 perforation occurs in every 1000 insertions. When they do occur, the perforations are rarely dangerous.16,17,22,23 Perforation in an asymptomatic patient is not an emergency.19 A recent study showed that breastfeeding at the time of insertion created a 6-fold increase in the risk of perforation.24 Other risk factors include clinician inexperience in IUD insertion, myometrial defects, an immobile uterus, or a retroverted uterus.25 A previous perforation is not a contraindication for IUD use or insertion.
Surveys and studies have shown that many common provider misconceptions are unfounded. Common misconceptions include the belief that nulliparous women, adolescent women, women who are postpartum or postabortion/miscarriage, women who have a recent history of PID or STIs, and women who have a history of ectopic pregnancy are not appropriate candidates for IUDs. In the United States, providers are often hesitant to offer IUDs to nulliparous and adolescent women because they have concerns about difficult insertions, pelvic pain, infertility, and PID. The data above illustrate that most of these concerns are unsubstantiated.
In addition to a gap in provider knowledge regarding IUDs, there is also an educational gap among patients. In one survey, only 50% of adolescents had heard of LARC.26 Patients frequently fear infertility and an increased risk of ectopic pregnancy, as well as increased pelvic pain and pain upon insertion. However, many of these concerns are unsupported, or can be ameliorated, if providers explain the potential side effects in advance. Providers also note that patients are more satisfied with LARC methods than any nonLARC method.
In order to potentially increase the use of this efficacious and well-tolerated form of contraception, it is important to clarify the facts for both patients and providers alike and to address the most common concerns. In spite of the ACOG and MEC recommendations and numerous studies, many continue to hold on to misinformation. Among NPs, PAs, and doctors, it should be reinforced that (1) IUD insertions in nulliparous and adolescent women are not more difficult than in any other group; (2) IUDs do not increase a patient’s risk of PID or infertility; (3) women who are nulliparous, adolescent, postpartum, or postabortion/miscarriage can safely use IUDs; and (4) a history of ectopic pregnancy, PID, or STIs does not preclude IUD use. Disseminating accurate information that addresses the specific concerns many providers and patients have about IUDs will empower women to make informed decisions and may increase use of IUDs to a rate that is closer to the rest of the world.
Libby Levine, MS, AGNP-BC, received her Masters in Nursing from Columbia University in February 2015. She can be reached at firstname.lastname@example.org
- World Contraceptive Patterns 2013. United Nations Web site. Available at un.org/en/development/desa/population/publications/family/contraceptive-wallchart-2013.shtml
- American College of Obstetricians and Gynecologists. ACOG Practice bulletin no. 133: Benefits and risks of sterilization. Obstet Gynecol. 2013;121(2 Pt):392-404.
- Contraception for adolescents: what’s new? U.S. Department of Health & Human Services Web site. Available at hhs.gov/ash/oah/oah-initiatives/ta/experience_expertise_curtis.pdf
- Kavanaugh ML, Frohwirth L, Jerman J, et al. Long-acting reversible contraception for adolescent and young adults: Patient and provider perspectives. J Pediatr Adolesc Gynecol. 2013;26(2):86-95.
- Sklya [package insert]. Wayne, NJ: Bayer HealthCare Pharmaceuticals Inc; 2013.
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- Peipert JF, Zhao Q, Allsworth JE, et al, Continuation and satisfaction of reversible contraception. Obstet Gynecol. 2011;117(5):1105-1113.
- OʼNeil-Callahan M, Peipert JF, Zhao Q, et al. Twenty-four-month continuation of reversible contraception. Obstet Gynecol. 2013;122(5):1083-1091.
- Committee on Adolescent Health Care Long-Acting Reversible Contraception Working Group, The American College of Obstetricians and Gynecologists. Committee opinion No. 539: adolescents and long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol. 2012;120:983-988.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol. 2011;118(1):184-196.
- Grunloh D, Casner T, Secura GM, et al. Characteristics associated with discontinuation of long-acting reversible contraception within the first 6 months of use. Obstet Gynecol. 2013;122(6):1214-1221.
- Black KI, Lotke P, Lira J, et al. Global survey of healthcare practitioners’ beliefs and practices around intrauterine contraceptive method use in nulliparous women. Contraception. 2013;88(5):650-656.
- Harper CC, Blum M, De Bocanegra HT, et al. Challenges in translating evidence to practice: the provision of intrauterine contraception. Obstet Gynecol. 2008;111(6):1359-1369.
- Luchowski AT, Anderson BL, Power ML, et al. Obstetrician–gynecologists and contraception: Long-acting reversible contraception practices and education. Contraception. 2014; 89(6):578-583.
- Hladky KJ, Allsworth JE, Madden T, et al. Women’s knowledge about intrauterine contraception. Obstet Gynecol. 2011;117(1):48-54.
- Smith E, Daley AM. A clinical guideline for intrauterine device use in adolescents. J Am Acad Nurse Pract. 2012;24:453-462.
- Hillard PJ. Practical tips for intrauterine devices use in adolescents. J Adolesc Health. 2013;52(4 suppl):S40-S46.
- Brakman A, Gold M. Teen topic: Consider IUC method for teen contraception. AHC Media Web site. Available at ahcmedia.com/articles/21171-teen-topic-consider-iuc-method-for-teen-contraception
- Yoost J. Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United States. Patient Prefer Adherence. 2014;8:947-957.
- Dean G, Goldberg AB. Intrauterine contraception: Devices, candidates, and selection. UpToDate Web site. Updated September 1, 2015. Available at uptodate.com/contents/intrauterine-contraception-devices-candidates-and-selection
- Medical eligibility criteria for contraceptive use. World Health Organization Web site. Available at who.int/reproductivehealth/publications/family_planning/MEC-5/en
- Hardeman J, Weiss BD. Intrauterine devices: An update. Am Fam Physician. 2014;89(6):445-450.
- Kaislasuo J, Suhonen S, Gissler M, et al. Uterine perforation caused by intrauterine devices: Clinical course and treatment. Hum Reprod. 2013;28(6):1546-1551.
- Heinemann K, Westhoff CL, Grimes DA, Möhner S. Intrauterine devices and the risk of uterine perforations: Final results from the EURAS-IUD study. Obstet Gynecol. 2014;123(suppl 1):3S.
- Dean G, Goldberg AB. Intrauterine contraception: Management of side effects and complications. UpToDate Web site. Updated July 14, 2015. Available at uptodate.com/contents/intrauterine-contraception-management-of-side-effects-and-complications
- Teal SB, Romer SE. Awareness of long-acting reversible contraception among teens and young adults. J Adolesc Health. 2013;52(4 suppl):S35-S39.
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