Dr. Roey Malleson (biography and disclosures)
What I did before
IUDs have long been known to be a spectacularly effective method of contraception. Surprisingly, IUDs are the contraceptive with the worst reputation EXCEPT amongst users. They provide long term reversible birth control, rivaling tubal sterilization in contraceptive efficacy. They are associated with few complications, have excellent adherence records and are very cost effective. In addition contemporary IUDs have important non contraceptive and therapeutic benefits as well.
However, the list of contraindications for their use was lengthy and concern about upper genital tract infection related to IUD use lingers (as a result of the Dalkon Shield fiasco in the 1970s) resulting in a general reluctance to use them, particularly when there is a possibility of compromising future fertility in young women who have not had children.
What changed my practice
Over the past 10 years, studies have confirmed the impressive safety of the IUD and evidence now exists to show no important effect of the IUD on infection or infertility.(1) To summarize the current evidence:
Early flawed observational studies reported a link between PID and IUDs. Reanalysis no longer supports this.
New and better studies show only a 1/1000 risk of infection confined to the first 20 days after insertion. This transient risk is due to contamination at insertion.
The IUD itself has no risk of infection. (Tubal infertility is linked to the presence of antibodies to Chlamydia but NOT to a history of IUD use).
The Mirena IUS protects against PID
IUDs REDUCE the risk of ectopic pregnancy
1.2-1.6 per 100 women years in sexually active women aged 15-44.
0.25 per 100 women for users of Nova-T and
0.02 per 100 women years for users of Mirena
What I do now
The new evidence has led to label changes for the devices and expanded patient profile recommendations in the international literature (2) and closer to home (3). It is now accepted practice to screen for STIs and insert the IUD at the same visit. Moreover, it is safe to treat STIs and PID with an IUD in place.
|Old Indications||New Indications||Message|
|IUDs are recommended for women who have had at least 1 child||Nullips||IUDs are appropriate for Nulliparous women|
|IUDs are recommended for women who are in a stable monogamous relationship||Women not in mutually monogamous relationships||IUDs are appropriate for women without a relationship requirement|
|IUDs are not recommended for women who have had a previous ectopic pregnancy||Women with a previous history of Ectopic pregnancy||IUDs significantly reduce the risk of ectopic pregnancy|
|IUDs are recommended for women who have had no history of previous pelvic infection||Women with a previous history of STIs or PID||There is no link between IUDs and PID|
To update your knowledge on IUDs there will be 2 workshops this year at the Family Medicine Forum and another one next May at the Women’s Health Conference.
References: (Note: Article requests require a login ID with the BC College of Physicians website or UBC)
2. The World Health Organization: Improving access to quality care in family planning: medical eligibility criteria for contraceptive use. 3rd edition Geneva: WHO; (Full article)
3. SOGC Clinical Practice Guidelines: Canadian Contraception Consensus: No 143 Part 2 of 3; Mar 2004 (Full article)