Long-acting IUDs: Gaining Control of Fertility
By BECKY GILLETTE
Greater use of long acting reversible contraception (LARC) such as intrauterine devices (IUDs), which can provide five to ten years of fertility control, could help prevent large numbers of unintended pregnancies, give women control over spacing of pregnancies, reduce abortion rates and save taxpayers the costs of providing assistance to low-income mothers and children, said Nirvana A. Manning, MD, OB\GYN, who is an associate professor at the University of Arkansas for Medical Sciences (UAMS) Department of Obstetrics and Gynecology.
"It helps prevent unintended pregnancies in an economical and efficient way," Manning said. "If I were to break down the benefits of this in a younger population, it is a way to control the frequency with which you have children in an easy to adhere to way. You don't have to remember to take a pill every day. It has been liberating for women. It is the most effective form of birth control because there is no user error. And it is completely reversible. As soon as you decide you want a child, you have it removed in a clinic visit, and fertility is immediately restored."
However, although it is becoming the standard of care, misconceptions about IUDs have kept them from being adopted more widely.
"I tell patients, 'This it's not your mother's IUD,'" Manning said. "There have been so many improvements to this form of contraception in the past 20 years. Education would help people understand the many benefits to this option. I do think it has several great points. IUDs are my first-line contraception solution."
Some IUDs release hormones and some don't. Nexplanon, which is a small rod that is inserted into the inside of a woman's arm, lasts for three years and releases the hormone progesterone. The LARCs with hormones can have other benefits such as reducing heavy menstrual bleeding. The wall of the uterus is thinned, so there is less bleeding frequency and duration. The hormonal LARCs are FDA-approved for women with heavy, painful menstrual circles.
"When people go into it with appropriate expectations, they are happy with it," Manning said. "If the device has progesterone only, you can expect a period of up to three months of irregular spotting. It is not heavy bleeding, but a nuisance. It is enough for using a panty liner or teen tampon. After about three months, the vast majority of people will bleed less frequently and less heavily. About 30 to 40 percent of people will have no bleeding at all, but unfortunately I can't guarantee that."
Manning believes another advantage of using an IUD is that there would be significantly fewer hysterectomies because it can help prevent heavy bleeding in the peri-menopausal stage.
Another misconception about IUDs is that it can't be used with women who have not had children. It is effective in nulliparous, as well as adolescent women.
"It is safe and effective," Manning said. "It should be routinely offered to younger women because the adolescent and teenage population is not historically good at taking birth control pills. We always have a conversation with patients that even with a LARC, they still need condoms to prevent STIs."
Often parents bring daughters to have an LARC implanted before college so the women can get five years of protection without having to take a pill every day. There is also one IUD that offers ten years of protection that is non-hormonal for those who don't necessarily want any hormones.
"It doesn't offer some of the benefits like the bleeding reduction," Manning said. "But it is a very effective and safe contraception for ten years. Most all insurance including Medicaid will cover the device and visit. Another advantage is you don't have to go to a pharmacy and get birth control every single month."
There is another common misconception that an IUD can't be offered after an ectopic pregnancy. That is false.
There are also some women who can't take oral contraceptives because of high blood pressure. The combined hormonal pills have the propensity to make hypertension worse.
"That is a benefit of progesterone-only agents," Manning said. "Women can use these and their blood pressure will not be elevated. There is also a subset of the population at risk for deep vein thrombosis and pulmonary embolism from oral contraceptives."
Manning advocates women consider having an LARC implanted immediately after delivering a baby. Several private insurance companies have started providing coverage for these immediate post-partum IUDs.
"Medicaid covers this option in 43 other states, so we are hoping we can get them to cover this option in Arkansas, as well," Manning said. "It could really have a profound social and health impact in these women's lives. Unintended pregnancy rates are five times greater at the poverty line or lower. And there is a higher unintended pregnancy rate the first year post-partum. By helping with birth control post-partum, women can space pregnancies at a rate they feel comfortable with and that they can control."
Manning said it is the wave of the future for people to be able to control their family size in a safe and effective way giving women empowerment over their reproduction.
"If we can get more buy in and make sure people are informed about this, the fears and misconceptions will be dispelled and that would make a profound impact on our teen pregnancy rates and the spacing of pregnancies, especially for those at-risk poverty line women. This could make a profound impact downstream, for sure."
Manning recommends that physicians who provide women's health from menarche to menopause should offer this as an option to patients. If they receive the appropriate training, family practice doctors can perform the procedure. If a family practice doctor doesn't feel comfortable providing the service, patients can be referred to an OB\GYN.
"There are many family practice doctors who specialize in women's care," she said. "The risk is low, but we certainly want it to be done under trained hands."
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