CONTRACEPTION

These early studies also equated nulliparity with high-risk sexual behavior. As young women are more likely to acquire sexually transmitted cervical infections, and because young age is associated with nulliparity, many studies erroneously concluded that the increased risk of PID and infertility was attributed to nulliparity.

A case-control study in nulliparous Mexican women who were seeking treatment for primary infertility found no association between tubal infertility and past copper IUD use. In this study, 358 women with primary infertility and documented tubal occlusion (cases) were compared with two sets of controls: 953 nulliparous women with primary infertility and no tubal occlusion, and 584 primigravid women. Past use of a copper IUD was not associated with tubal occlusion, compared with either infertile women without tubal occlusion or primigravid controls (P values 1.0 and 0.9, respectively).¹⁴ However, tubal infertility was associated with a past infection with Chlamydia (as evidenced by Chlamydia antibodies). This study further supports an association between PID and infertility and cervical infection—not IUD use.

Protective effect of progestin

The levonorgestrel-releasing intrauterine system (LNG-IUS) may even protect against PID. One of the primary physiologic effects of progestin contraception is thickening of the cervical mucus, which protects against ascending genital tract infection. This protective effect results in a decreased incidence of PID in women who use combination oral contraceptive pills, progestin implants, and progestin injectables.¹⁵ A randomized controlled trial found that the cumulative 36-month rate of PID was lower in users of a LNG-IUS contraceptive than in users of a copper IUD (Nova-T) (0.5 and 2.0, respectively; P< 0.013), in both parous and nulliparous women.¹⁶ This finding was more marked in women under the age of 25.

Prescribing IUDs in young women

When considering an intrauterine contraceptive for a young woman, it is therefore important to assess her risk of a STI, based on her and her partner’s sexual behavior, and not on parity or age. It is important to screen for STIs at the time of or prior to insertion of an intrauterine contraceptive, and to treat cervicitis prior to insertion.

Nulliparous women who are at low risk of STIs can be offered the intrauterine contraceptive as an effective, long-term, user-independent contraception.

The labeling for levonorgestrel intrauterine contraceptives should also reflect the evidence that the risk of pelvic infection is more related to a patient’s and/or her partner’s sexual behavior than to her age, contraceptive choice, or parity.

REFERENCES

Direct access to Plan B does not promote high-risk behavior

Raine TR, Harper CC, Rocca CH, et al. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized controlled trial. JAMA. 2005;293:54–62.

• Advance provision of emergency contraception results in increased usage of emergency contraception without an associated change in risky sexual behavior, sexually transmitted diseases, or use of long-term contraception
• Clinicians should provide emergency contraception in advance of need to ensure timely and appropriate emergency contraceptive use

Emergency contraception could significantly reduce the risk of unintended pregnancy after contraceptive method failure, or unprotected or forced sex. The newer progestin-only emergency contraceptive pills have now largely replaced the older combined (estrogen and progestin) pills because they are more effective and have fewer side effects.

Various emergency contraception regimens are effective

The only dedicated progestin-only emergency contraception pill product in the United States is Plan B, which contains 2 tablets of 0.75 mg of levonorgestrel. Although the recommended treatment schedule is an initial dose within 72 hours of unprotected intercourse and a second dose 12 hours later, a single dose of 1.5 mg of levonorgestrel is as effective as and causes no more side effects than 2 tablets of 0.75-mg doses 12 hours apart.^17,18

The sooner the better?

Emergency contraception pills are more effective the sooner after sex that they are initiated. Both combination oral contraceptive pills and progestin-only regimens are moderately effective even if initiated more than 72 hours after unprotected intercourse. ^18-20 No data are available on the efficacy of emergency contraception pills taken more than 120 hours (5 days) after unprotected intercourse.

Randomized trial

“It seems unreasonable to restrict access”

Raine et al²¹ added significantly to our knowledge of emergency contraception. This is the first randomized trial addressing the question of the effect of access on emergency contraceptive usage. A total of 2,117 young women (age 15 to 24 years) were randomly assigned to these 3 groups: