When women think birth control, pills and condoms might be their first choice, but new guidelines from the nation’s leading group of obstetricians and gynecologists advise that all women, including teenagers, should look to IUDs and implants instead.
Intrauterine devices and hormonal implants should be viewed as “first-line” recommendations for all females -- adult women and teen girls -- seeking to avoid pregnancy.
That’s the word from the American College of Obstetricians and Gynecologists, or ACOG, which today is replacing 2007 guidelines that instructed doctors to view the devices as good options, but didn’t stress a preference for them in younger women and girls.
IUDs and implants have been proven to be safe and more effective at preventing pregnancy than other, more widely used contraception methods such as birth control pills and condoms, according to ACOG’s Long-Acting Reversible Contraception Working Group, part of its Committee on Adolescent Health Care.
“There is a great deal of emerging data that these should be the top tier, the first line,” said Dr. Tina Raine-Bennett, research director for the Women’s Health Research Institute at Kaiser Permanente Northern California and the chair of the ACOG committee. “We’re saying to doctors, ‘Here is compelling evidence that should guide your practice.’”
Pills, condoms, and sterilization are by far the preferred option for birth control in the U.S. Of the nearly 62 percent of adult women who use some form of contraception, 17 percent use the pill, nearly 17 percent use sterilization and about 10 percent use condoms, according to a National Center for Health Statistics study conducted between 2006 and 2008.
The problem is, both pills and condoms rely on perfect user compliance. But many women, especially young women and girls, tend to use them inconsistently. Partly as a result of improper or inconsistent use of birth control, the vast majority of pregnancies among adolescent girls are unplanned, accounting for about 20 percent of the unintended pregnancies in the U.S. each year. Roughly half of all pregnancies in the U.S. are unintended according to research from the Guttmacher Institute.
But current IUD and implant use is very low, especially among the youngest girls and women. Only about 4.5 percent of young women in the U.S. ages 15 to 19 use IUDs, according to a recent Guttmacher Institute study. Even fewer use an implant. Overall use rates by women of all ages in other developed countries are much higher.
IUDS are small, T-shaped devices made of plastic, some wrapped with copper, others coated with a hormone, which are placed inside the uterus. The copper IUDs can alter the chemistry of the uterus, making it inhospitable for sperm. Progestin on hormonal IUDs works to thicken the mucus lining of the uterus, also inhibiting pregnancy.
Hormonal implants are matchstick-sized rods that are inserted under the skin of the arm. They work by releasing a tiny amount of levonorgestrel, a progestin hormone that prevents egg release from the ovaries. The hormone can impede the sperm’s passage to the egg, and can increase the thickness of the uterine lining.
Both are regarded as more than 99 percent effective at preventing pregnancy, about as effective as being sterilized. According to a May study in the New England Journal of Medicine, the failure rate of contraceptive pills, patches or rings was 4.55 per 100 person years. The rate was .27 for IUDs and implants.
Cost, old fears get in the way
Despite their effectiveness, there are two important barriers to IUD and implant use. The first is cost.
“The cost varies, but an IUD device itself is anywhere from $500 to $700,” said Raine-Bennett. The office visit to place an IUD, or to inject an implant, could add hundreds more.
Meanwhile, one pack of birth control pills can run as low as $10 to $25. In the long run, the implant and IUDs, each of which lasts years, are cheaper, but the up-front costs still deter many patients.
A 2010 Guttmacher Institute study supports that. When a large group of women in St. Louis were given information about various forms of contraception, and told they could choose any one, for free, two-thirds picked IUDs or implants.
Under the nation's new health reform law, the Affordable Care Act, most insurers must include all contraceptive methods as part of benefits packages with no co-pay. That mandate took effect last month, but it may not help those young women and girls who desire contraception but don’t want to try to use insurance carried by their parents.
There’s also a long shadow hanging over IUDs. In the 1970s, an IUD called the Dalkon Shield was sold to millions of women. But many later claimed the device led to pelvic inflammatory disease (PID), caused by infections. Some of the data was disputed, but lawsuits erupted, and the device’s maker, A.H. Robins, filed for bankruptcy.
“That was one single brand,” Raine-Bennett said, “but it left a huge mark … There’s still a huge misperception, more on the part of providers. Reproductive-age women now don’t even know what Dalkon Shields were.”
But doctors, especially older doctors, do, and they can be reluctant to recommend any IUD now.
In fact, IUDs have a very low risk of infection. According to the ACOG guidelines, “the risk of PID with IUD placement is 0–2% when no cervical infection is present and 0–5% when insertion occurs with an undetected infection.”
Another risk of IUDs and hormonal implants is that neither device protects against sexually transmitted diseases like condoms can. Users, their contraceptive need satisfied, may be tempted to skip condoms when they shouldn’t.
Raine-Bennett acknowledged that, but said the same risk applies to any non-condom contraceptive, making it imperative that doctors counsel women on the need for condoms, especially if they’re uncertain of a partner’s STD status.
In the case of IUDs, some critics argue that both types of IUDs may prevent a fertilized egg from implanting. So a few, like the Roman Catholic church, which grants personhood to any fertilized egg, regard IUDs as “abortifacients.”
That definition is rejected by most scientists and medical experts, and Lawrence Finer, director of domestic research for Guttmacher, doesn’t think that cost, or any other issue, will derail the trend toward increasing use. Demographics and changing lifestyles will drive more and more women to choose the long-acting methods.
“People are having children later, so the period of being sexually active before children is longer,” Fine said. “These longer-acting methods are well suited for that longer period.” He thinks more and more American women will adopt them.
Brian Alexander (www.BrianRAlexander.com) is co-author, with Larry Young PhD., of "The Chemistry Between Us: Love, Sex and the Science of Attraction," (www.TheChemistryBetweenUs.com), now on sale.
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