STD and IUD for adolescent contraception

1
STD and IUD for adolescent contraception

• R.J.C.M.Beerthuizen MD PhD

2
Adolescents and STD

• Young women are at risk for STD
• Prevalence of chlamydia trachomatis about 10 in
  young population
• Henry-Suchet J. Cost-benefit of STD screening,
  HIV excluded, in family planning centers. In
  Contraception in the third millennium. 2001.The
  Parthenon Publishing Group, 75-79

3
Adolescents and contraception

• High discontinuation rate of oral contraceptives
• Dei M, Bettini P, Girau C, Leonetti R, Bruni V.
  Factors influencing oral contraceptive compliance
  in adolescent females results of a longitudinal
  study. In Contraception in the third millennium.
  2001.The Parthenon Publishing Group, 80-85
• Frequently forgotten pills
• Need for emergency contraception

4
IUD for adolescent contraception

• Infrequently considered because of
• Persistent myths and misunderstandings
• Misleading information in a number of recently
  published textbooks and manuals
• Espey E, Ogburn T. Perpetuating negative
  attitudes about the intrauterine device
  textbooks lag behind the evidence. Contraception
  200265389-395

5
Persistent myths and misunderstandings

• An IUD is unsuitable for nulliparous women
• An IUD causes PID
• More infertility after removal
• More ectopic pregnancies

6
IUD and nulliparity

• Pre-condition carefully taken patient history of
  STD-risk
• At higher risk for STD are
• Women below the age of 25
• With different sexual partners or having a
  partner with various sexual partners
• Regardless of parity
• Nulliparity per se is no contra-indication for
  IUD-use
• Grimes DA. Intrauterine device and infertility
  sifting through the evidence. Lancet 2001
  3586-7

7
Persistent myths and misunderstandings

• An IUD is unsuitable for nulliparous women
• An IUD causes PID
• More infertility after removal
• More ectopic pregnancies

8
IUD and PID History (1)

• Wishbone devices (1900)
• Continuous pressure on the endometrium
• Infection?sepsis?death

• Gräfenberg ring (gt1932)
• Gräfenberg no increased risk carefully selected
  women!
• Others no carefully selection ?PID?sepsis

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IUD and PID History (2)

• The Dalkon shield
• All deaths caused by sepsis during second
  trimester of pregnancy
• Mechanism retroplacental infection ?sepsis
  ?infected uterine cavity
• Consequence late diagnosis and late treatment

10
IUD and PID The Present (1)

• Risk of PID in women with IUD use is similar to
  the risk in women without IUD
• Ref Grimes DA. Intrauterine device and
  upper-genital-tract infection. Lancet 2000
  3561013-19
• Higher PID-rate in younger women using
  copper-IUDs, regardless of parity, is correlated
  with the age-related STD-rates ? not related to
  the method of contraception
• Ref Struthers BJ. Comparison of PID rates in
  parous and nulliparous women using copper IUDs.
  Summary of clinical studies. Adv Contracept
  19906257

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IUD and PID The Present (2)

• Risk of PID is related to the insertion process
  only.
• gt20 days after insertion the risk is simular to
  the risk in the general population regardless of
  the method of contraception
• Ref Farley et al. Intrauterine devices and
  pelvic inflammatory disease An international
  perspective. Lancet 1992339785-8.

12
Persistent myths and misunderstandings

• An IUD is unsuitable for nulliparous women
• An IUD causes PID
• More infertility after removal
• More ectopic pregnancies

13
Return of fertility

• All studies indicate no difference in fertility
  rates after removal of an IUD compared with users
  of other methods of contraception

14
Persistent myths and misunderstandings

• An IUD is unsuitable for nulliparous women
• An IUD causes PID
• More infertility after removal
• More ectopic pregnancies

15
Ectopic pregnancy

• No contraception 1350
• With copper-IUD in situ 11600
• P.I. 0.5 ? 1200 pregnant
• In case of pregnancy 18 ectopic
• With Mirena in situ 13000
• P.I. 0.1 ? 11000 pregnant
• In case of pregnancy 13 ectopic

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Which IUD for adolescent contraception

• Suitable are
• Flexi-T 300
• Gynefix standard
• Nova-Gynefix

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Intra-uterine contraceptionFlexi-T 300

• Characteristics
• Length of vertical stem 28 mm
• Width of IUD 23 mm
• 300 mm² copper surface
• Extreme flexibility
• Thread totally embedded in the frame
• P.I. 0.5

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Intra-uterine contraception Copperimplant
Gynefix

• Charasteristics
• No frame
• 6 coppersleeves fixed on a surgical thread (Nova-
  Gynefix 4 sleeves)
• Diameter of uterine sound (2,2 mm) diameter of
  inserter
• Implant ready to use in inserter
• P.I. 0.2
• 10 years??

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IUD as emergency contraceptive

• Copper-containing IUDs only!!
• Up to 5 days after the accident
• Prophylactic antibiotics waiting for the results
  of the cervical culture
• choices of prophylaxis (guidelines NVOG)
• 1 gr azitromycin (Zithromax)
• 200 mg doxycyclin
• 500 mg erytromycin (Erythrocin)
• 400 mg ofloxacin (Tarivid)

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Conclusions (1)

• PID among IUD-users is related to the insertion
  process and the background risk of STD
• Carefully screening of patient history, sexual
  behaviour and actual infection (taking cultures)
• Avoid replacement of the IUD before the
  recommended intra-uterine stay

21
Conclusions (2)

• Most at risk for STD are those women below the
  age of 25 either with multiple sexual partners or
  with a partner having multiple sexual partners
  regardless of parity AND regardless of method of
  contraception

22
Conclusions (3)

• In case of frequently missing pills or otherwise
  inadequate contraception an IUD should be offered
  to adolescents as a safe and reliable alternative
• IUDs suitable for adolescents are the Flexi-T 300
  and the (Nova-) Gynefix