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Check opportunities for long-acting methods
How often do you include counseling on long-acting reversible contraceptives in your discussions of birth controls? Look for new opportunities, according to a recent presentation by Michael Policar, MD, MPH, medical director of the University of California San Francisco/Family PACT Program Support and Evaluation in Sacramento.
The methods considered top tier due to their effectiveness are intrauterine devices (IUDs) [ParaGard Copper T 380A IUD, Duramed Pharmaceuticals, Pomona, NY, and the Mirena levonorgestrel (LNG) intrauterine system, Bayer HealthCare Pharmaceuticals, Wayne, NJ] and the contraceptive implant (Implanon, Schering-Plough Corp.; Kenilworth, NJ), Policar says. According to Policar, such methods are:
Jeffrey Peipert, MD, MPH, MHA, professor of obstetrics and gynecology at the Washington University School of Medicine in St. Louis, is leading a cohort study of 10,000 women in the St. Louis region. The Contraceptive Choice Project is designed to promote reversible long-term methods of contraception such as subdermal implants and intrauterine devices and to assess satisfaction and discontinuation rates with various contraceptive methods.
About 50 patients are enrolled per week. Some 5,000 women had been recruited for the study by January 2010. At the present time, 65% of women are choosing long-acting reversible contraceptives; 54% are choosing IUDs, Peipert reports.
Long-acting reversible contraceptive methods are particularly desirable for women who have experienced previous failures with other forms of birth control, such as oral contraceptives, says Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta. While many women have good success with pills, 1 in 12 women (8%) will become pregnant in the first year of typical use, he notes. Missed pills are often the culprit. One study showed more than 50% of women missed three or more pills in the third cycle of use.2
When can intrauterine devices be inserted? As most clinicians know, such devices can be inserted at any time during the menstrual cycle, as long as the provider is reasonably certain the woman is not pregnant, says Policar.
Intrauterine contraception may be safely inserted following an abortion, says Policar. Evidence indicates there is no difference in complications for immediate vs. delayed insertion after a therapeutic abortion.3,4 Evidence indicates the risk for expulsion is greater when an IUD is inserted following a second trimester vs. a first trimester abortion. Data suggests there are no differences in safety or expulsions with insertion of an LNG IUD compared to a Copper T 380A IUD.3,4
Inserting an intrauterine device post-abortion offers several advantages, Policar says. Post-abortion insertion is convenient. Once the procedure is completed, the steps involved with inserting the ParaGard or the Mirena are easy to do, says Policar. Insertion is convenient for the patient, because it avoids the need for a second visit for contraceptive placement. Studies that have looked at safety and infection rates of post-abortal intrauterine device insertions indicate that such rates tend to be the same after a procedure as it would with an interval insertion.4 "From the point of view of the patient experiencing cramps and discomfort, it really only happens once, at the time of the procedure, and then it is really nothing extra, because she's already had a local anesthetic," notes Policar. "By avoiding that second visit, which can be uncomfortable, I think that is kind of the main convenience factor."
Women who choose to have an IUD inserted following an abortion procedure are selecting a method when their motivation to avoid unwanted pregnancy is at its highest, observes Policar. With an intrauterine device inserted post-procedure, they benefit from immediate, long-acting protection, he notes.
Of the 1.3 million abortions performed in the Unites States each year, about half are repeat procedures; 40% percent of women who are scheduled for a delayed intrauterine device insertion following an abortion do not return for the procedure.4 Immediate post-abortal IUD insertion is a safe, practical, and underutilized intervention than can reduce repeat unintended pregnancy and repeat abortion by two-thirds, as evidenced in a 2008 study,5 says Policar.
Disadvantages of placing an IUD post-abortion include the higher risk for device expulsion, notes Policar. In general, the overall expulsion rate in the first year is 1%-3% for all insertions; for post-procedure, it rises to about 5%-6%.
Providers also must present information about IUDs, as well as other contraceptive options, prior to the abortion procedure in providing the groundwork for informed consent for use of the method, says Policar. The decision to choose any contraceptive is voluntary. Make sure women are well motivated and that they have thought about and are committed to using their chosen method, he notes.