Ashley, a 20-year-old nulliparous patient presents to your office for contraceptive counseling.  She has a history of irregular heavy periods that began around age 15, approximately two years after menarche (age 13).  

She has been sexually active for approximately two years with her “steady” boyfriend. They use condoms “most of the time”. 

She reports having periods that are becoming more painful and heavier. She takes ibuprofen but it doesn’t seem to be working as well.

Ashley has a negative health history with the exception of migraine headaches that began around age 16.  They are associated with “flashing lights” and a “really bad headache” that is often accompanied by nausea and vomiting. 

She fears that she would not be “good” at taking the birth control pill. You inform Ashley that, as a result of her migraine headache history, she is not a candidate for estrogen containing contraception (combined oral contraceptives, patch, or ring). 

Given her history, you discuss methods that do not contain estrogen including the implant, progestin injection, and the IUD.  She expresses concern about the safety of the IUD.

Nulliparous women are candidates for the IUD. Pap tests are not initiated until age 21 but, if sexually active, she should be screened for chlamydia.  Since she has never been pregnant, her innate fecundity is unknown but the inert IUD device will not impact her fertility.  The levonorgestrel IUD will help in alleviating heavy menstrual bleeding. 

Ashley decides that the levonorgestrel IUD is the best choice for her.

Insertion during menses allows for increased cervical dilation and helps rule out pregnancy (although a urine test is recommended).  Insertion is generally well tolerated and recent data suggests that use of estrogen creams, misoprostol or anti-prostaglandins prior to placement offer no benefit.  

Neither is prophylactic use of antibiotic therapy recommended as appropriate screening and patient education have increased women’s understanding of what causes pelvic infection. Historically, patients were improperly screened for the risk of STD’s prior to insertion of IUDs in the past, hence the association with infection. 

You discuss safe sex practices with Ashley, reminding her that use of condoms is the best way to prevent transmission of chlamydia, the most common cause of pelvic infection.  The IUD is effective immediately so you reassure Ashley that back up contraception is not needed.

Ashley asks about medication use following IUD insertion.

Antibiotic therapy has not been found to be necessary compared with placebo in prevention of post insertion infection.  Vaginal medications, tampons, etc can be safely used with an IUD in situ.  Douching is universally discouraged. Ashley should be reminded to check for IUD strings periodically.  

Although spontaneous expulsion is unlikely it can, on rare occasions, occur.  A pregnancy with an IUD in situ is also very rare but, should it occur, clinicians should be reminded that the gestation could be ectopic. 

Intrauterine contraception is a safe, highly effective method of contraception that is underutilized in the US.  Myths still exist regarding appropriate candidates for the method, pain experienced during the procedure, and safety.  

Clinicians should make themselves aware of the newest data that reaffirms the utility, convenience, and acceptability of these methods in an effort to decrease the high rate of unintended pregnancy in our country.