Should We Offer IUDs to Adolescents and Young Adults?

When I was in training just the mention of IUD’s was enough to put a scowl on an attending’s face. The use of the word “IUD” in the same sentence as “adolescent” or “young adult” was an unthinkable oxymoron. Nonetheless, as an ob/gyn specializing in the care of these younger women for 15 years, I have found them to be an important addition to the contraceptive options I can offer.

The United States has a very uneasy relationship with the IUD since the unfortunate introduction of the Dalkon Shield and its very public demise in the mid 80’s. With the thousands of lawsuits driving the manufacturer of the Dalkon Shield into bankruptcy, other IUD manufacturers, fearing the same fate, withdrew their products from the US market. IUD’s were reintroduced into the US market in the 1990’s, though with little fanfare and little to no advertising. The rest of the world has continued using IUD’s and they have been proven to be among the most effective and safest contraceptive method available. In addition, many nations promote their use in adolescents and young adults.

In Europe, anywhere from 6-27% of women use IUD’s depending on the nation surveyed: in the United States fewer than 2% of women use them. According to the Alan Guttmacher institute, it is not just history that stands in the way of American women’s access to IUD’s. Fewer American doctors and nurse practitioners receive didactic instruction or training for insertion / removal than they do in Europe. There is also the issue of cost. The IUD is by far the most economical of contraceptive methods, both because of its low monthly costs amortized over 5-10 years of potential use and because of the very low rates of unintended pregnancies. In the United States, however, IUD’s are not universally covered by insurance and patients often need to make a large upfront payment for the device. This is an especially formidable barrier for adolescents and young adults.

In our practice, we discuss IUD’s along with all of the other contraceptive methods. Rarely have our patients under 22 heard of them. Most patients believe that condoms are at least 90% effective and put the contraceptive pill at about 99%. They are amazed and shocked when we discuss the difference between “typical use” and “perfect use” pregnancy rates with respect to withdrawal, condoms, contraceptive pills, Depo-Provera, and IUD’s. Once we discuss their fears with respect to pain at insertion, feeling it during sex, general unease about having “something in there,” many choose to try the IUD. Many more choose the IUD after realizing that they are not able to reliably use the other more common methods. Finally, we help to guide all of our patients through the maze of insurance and reimbursement so that their choice of contraceptive method is as affordable as possible.

At the moment, in our office, the vast majority of the IUD’s we place are in nulliparous women aged 18-26. These young women are fully aware that condoms are still necessary for STD protection, but they are invariably attracted to the efficacy rates of the IUD in terms of pregnancy prevention. Very few of our patients experience more than cramping during insertion given our use of a paracervical block and NSAIDS. We have not experienced a higher than average expulsion rate, nor do our younger patients request removal at a higher rate than do our patients over 25 years of age.

In short, we in the US underutilize this valuable and efficacious contraceptive method. It should be advertised, education should be offered both to professionals and to the general public, and insurance coverage should be simple. Finally we, as practitioners, need to move away from our outdated prejudice against offering IUD’s to younger women. Rather we need to empower younger women with a long acting method that will keep them safer from unintended pregnancy than anything else on the market.

References:

Popularity Disparity: attitudes about eh IUD in Europe and the United States: Guttmacher Policy Review Fall 2007, Vol 10, Number 4.
Contraceptive Technology, Hatcher.