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Modern Intrauterine Contraception: a better option

J.V.Hamerlynck and M.Knuist (dept. Obstetrics and Gynaecology, Academic Medical Center,
University of Amsterdam, the Netherlands) (email: [email protected])
Abstract

Users of oral contraceptives have an increased risk of developing venous thromboembolism as
well as mammary cancer. This raises the question as to whether locally applied (intrauterine)
contraceptives can offer a valuable alternative with respect to efficiency and safety. During the
past decade the use of modern intrauterine devices (IUDs) has made substantial progress in
comparison with the IUDs during the 1970s and 1980s. Modern IUDs have become more
efficient than oral contraception. Arguments against the use of IUDs (problems and
complications in IUD insertion, the risk of pelvic inflammatory disease, ectopic pregnancy and
infertility as well as side effects such as menorrhagia, pelvic cramps and IUD expulsion)
generally appear to be based on a lack of awareness with respect to recent developments and on
misunderstandings derived from bad experiences during the 1980s and earlier.

Article
At present, on a world-wide scale, intrauterine contraception appears to be applied more often
than any other method of reversible contraception.(1-3) The application of intrauterine
contraceptives continues to increase rapidly. In some western countries intrauterine devices
(IUDs) are used by 20-25% of sexually mature women. In the Netherlands, however, 1-2% only
use IUDs.(4,5) Oral contraceptives are used by 40%, even by 70% of women in the age-group of
20-24 years.(5)
There are no doubts anymore about the harmful effect of systemic (oral) contraceptives on
haemostasis.(6,7) It is estimated that in the Dutch population every year several hundreds of
healthy oral contraceptive users are affected by sometimes life-threatening thrombo-embolic
complications. Moreover, on epidemiological grounds it is assumed that oral contraceptives are
responsible for several thousands extra cases of breast cancer in (former) oral contraceptive users
before the age of 70.(8) Finally, some side-effects of oral contraceptive use, such as persistent
vaginal bleeding, loss of libido and a row of other non-specific complaints, not only are felt as
being very troublesome but also do contribute to incorrect use of the method.(9,10)
Contrarily to oral contraception intrauterine contraception has gone through spectacular
developments during the last two decades. Therefore, time has come for reflection and re-
evaluation of advantages and disadvantages of different methods of contraception. Not only
qualities as reliability and safety are important, but also the occurrence of side-effects, the
interaction with libido or any other aspect of sexuality, the practical implications of application
and use, the reversibility and last but not least the cost-effectiveness of the method.
Also, it should be kept into consideration that local applications, if effective, are preferable to
systemically applied medications with potentially inherent ill side-effects.
So it goes without saying that local anaesthesia, if effective, is preferable to general anaesthesia. The same goes for local de-infection which, if effective, is self-evidently preferable to antibiotic therapy, and local tumour excision, if effective, is definitely preferable to chemotherapy. It is up to the reading public to determine whether systemically administered contraceptives, in comparison to the local application of intrauterine contraceptives, still deserve a status of exception to a fundamental rule in medicine. Indeed, it may be wondered why The Netherlands, for decades a most progressive country in the field of contraception, currently appears not to follow in providing adjusted information on intrauterine contraception. Many physicians obstinately keep pointing at outdated disadvantages of IUDs such as less efficacy and reliability, increased risk of infection, risk of infertility after removal of the IUD, increased risk of ectopic pregnancies.(11) Some doctors point at the painful insertion of the IUD and the risk of complications such as perforation of the uterine wall, at heavy bleedings and abdominal cramps in particular during the menstrual periods, at the risk of expulsion or of just loosing the IUD. Having been informed in this way only strong women can keep to their request for obtaining intrauterine contraception. Again it should be emphasized that intrauterine contraception, contrarily to oral contraception, has undergone important improvements. The mechanism of action of a modern copper IUD, containing much copper, appears to be at least partially different from old-fashioned IUDs. The excess of Cu-ions, which are known to be very cytotoxic to spermatozoa, appears to affect many spermatozoa. Consequently fertilisation generally does not occur. Flushing the uterine cavity did not reveal any blastocyst.(12) Also, human choriongonadotropins in the urine invariably appeared to be immeasurably low.(13,14) Reliability It has been established that the percentage of pregnancies developed in the first year of use of a modern copper IUD (Cu-surface of 300 mm2 or higher) is less than 0.6 pregnancies compared to 2 pregnancies in case of use of an old-fashioned copper IUD (Cu-surface of 200 mm2).(15) Moreover, it was found that the reliability of the IUD increases every following year of use, at least up to the twelfth year. The cumulative pregnancy rate during eight years of use of modern IUDs is 2.2; this figure remains unchanged up to the twelfth year.(16) At present, in the American literature the reliability of the IUD in the general population is considered to be much greater than the reliability of oral contraception, certainly in the first year of use (0.8 pregnancies per 100 IUD users versus 5.0 pregnancies per 100 oral contraceptive users.(17) New understanding of the mechanism of action of IUDs and their higher efficacy also explain why IUD users are protected against ectopic pregnancies. These women even have 90% less risk of having an ectopic pregnancy in comparison to women using no contraception.(18,19) Risk of infection Another almost ineradicable misunderstanding is that IUD users have a higher risk of ascending infections. Apart from the first twenty days after insertion the risk of infection does not appear to be higher in comparison to the sexually active population not using contraception.(20,21) Even in the first three weeks after insertion the risk of infection is still very low: 0.5 per thousand (out of 22,908 only 12 women developed salpingitis).(20) Still the risk of infection can be reduced further by adequate asepsis at insertion, by preceding investigation for Chlamydia and other pathogens, and possibly by antibiotic prophylaxis in women from risk groups for having sexually transmitted disease. It has been shown that insertion of an IUD leads to a temporary contamination of the uterine cavity. Also, intrauterine manipulations such as D&C for abortion have a decreased risk of infection if antibiotic prophylaxis is used. On the other hand in non-risk-women antibiotic prophylaxis appeared to be of no benefit.(22,24) In risk-populations antibiotic prophylaxis at insertion led to a significant reduction of extra consultations due to vaginal bleedings, abdominal cramps and other complaints suggesting endometritis.(25) Future fertility As new small and flexible IUDs can be obtained which are very suitable for insertion in young nulliparous women, there is no good reason anymore to discourage these women to choose for intrauterine contraception, the risk of expulsion being now considerably lower.(26,27) Also, it has been shown that the interval between removal of an IUD and the onset of a pregnancy than the interval after discontinuing any other form of contraception.(28-31) So the physician has to know that “a higher risk of future infertility in IUD users” is a wrong assertion.(40) Insertion Some physicians shrink from the small medical intervention which is necessary for the insertion of an IUD. Some of them fear a failure of the insertion itself or complications such as perforation of the uterine wall. Others fear to hurt the patient or fear a vasovagal collapse during or directly after the IUD insertion. It has been demonstrated that neither failures nor complications occur when the physician has had a training.(3) A short training can be obtained everywhere. So it is not longer acceptable for a physician to transmit his own fears to the patient by providing incorrect information. Also vasovagal collapses do not occur if the patient has been pre-treated with atropin. Pain can be prevented by providing a NSAID painkiller 30-60 minutes before the insertion procedure, by anaesthetising the cervix one minute before grasping it and eventually by infiltrating the paracervical tissue with a local anaestetic. Such a paracervical block is generally not necessary in multiparous women if the insertion is scheduled during the days of a menstrual period. The copper IUD always causes an inflammatory response in the uterine cavity and induces synthesis and activation of prostaglandins. These may provoke painful uterine contractions and increased vaginal blood loss during the days after insertion and during the following menstrual periods. Therefore it is advisable to treat the patient with NSAID painkillers during the first few days after insertion and during the following menstrual periods. In this way dysmenorrhoea and hypermenorrhoea are generally prevented.(32,33) With the elapse of time such potential complaints usually disappear; if not, replacement of the copper IUD by a hormone releasing IUD should be considered.(34,35) Hormone releasing IUDs Hormone releasing IUDs are extremely efficient (0.1% pregnancies in the first year of use) and they are a safe alternative for the copper IUD.(10) The vertical segment of the IUD contains a progestagen (levonorgestrel) instead of copper. A continuous release of a small amount of
levonorgestrel in the uterine cavity has a local effect only: the endometrium becomes atrophic.
Due to the lack of prostaglandin production in the endometrium dysmenorrhoea and
hypermenorrhoea do not occur. In fact, hypomenorrhoea and even amenorrhoea may occur
within six to twelve months whereas the hypothalamus-pituitary-ovary axis continues to function
normally. The hormone releasing IUD should be replaced every five years, or maybe only after
eight years.(35)
Hormone releasing IUDs also protect against ectopic pregnancies and even against ascending
infections. (36,37)
Inconvenient irregular vaginal blood loss may occur during the first few months after insertion of
the IUD. In general, due to the big stem, this IUD is not a first choice in young nulliparous
women. At present the hormone releasing IUD is widely applied as an effective method of
treatment of menorrhagia, even in women without a need for contraception.(38)
Cost effectiveness
In order to evaluate adequately the cost aspect of different methods of contraception it is
necessary not only to add up the cost of use of the method during a certain period of time (for
example five years) and the medical costs during that time, but also the costs arising from
complications and side-effects and last but not least the costs ensuing from failures of the
method.
From this addition sum in different contraceptive methods the application of intrauterine
contraception turned out to be less expensive than the use of any other method including
vasectomy, oral contraception, coitus condomatosus and sterilisation of women.(39)
In conclusion, the application of the intrauterine contraceptive method can essentially be
considered as being suitable for all women provided that the physician observes the necessary
precautions and care. As it is a locally applied method solely locally active infections, such as
cervicitis, endometritis or salpingitis, should be treated properly before inserting an IUD.
The use of intrauterine contraceptives nowadays has become reliable and safe which bans all
prejudices against it. Also, potential side-effects or problems can adequately be prevented or
solved, respectively. Moreover, intrauterine contraception is the most cost-effective method of
contraception including sterilisation.
Time has come that physicians cease to be misled by improper or non-readjusted information on
intrauterine contraception.
Translated with permission of the editorial board of the Nederlands Tijdschrift voor
Geneeskunde solely for publication in the Chinese journal Reproduction and Contraception.
Original Dutch article: Hamerlynck JVTH, Knuist M. Moderne intrauteriene anticonceptie: het
betere alternatief. Ned Tijdschr Geneesk 2001;145:1621-1624


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