News Highlights
Copper IUD an effective contraception option for women with cardiac disease
Women with cardiac diseases face an increased risk of complications related to pregnancy—which can be fatal—and they need access to contraception that is safe, reliable, and does not contain estrogen. For such women, the contraception method of choice may be the intrauterine devices (IUDs), but clinicians are concerned about infection of the heart valves (infective endocarditis) which is a small risk associated with insertion.
Combined hormonal contraception is not recommended for women with cardiac diseases, since the estrogen hormone increases the risk of blood clots and puts them at an increased risk of adverse effects.
A study performed in India examined the use of IUDs containing copper in 40 women who had cardiac diseases—32 had rheumatic heart disease, 7 had congenital cardiac disease, and one had dilative cardiomyopathy. Most of the women had given birth about six weeks before the study.
Once the IUDs were inserted, there were no cases of uterine perforation, expulsion or pregnancy, and the only case of pelvic inflammatory disease occurred one year after insertion. At six months, four women (10%) had heavy periods that did not cause significant anemia, and resolved after medical treatment. Only two women requested their IUDs be removed after three years because they wanted to become pregnant.
Although this is a small study, the results are reassuring with respect to IUD use in this population, which generally has a limited list of contraceptive options and very high risks associated with pregnancy.
Suri et al. Safety of intrauterine contraceptive device (copper T 200 B) in women with cardiac disease. Contraception Oct 2008;78(4):315-8.
Increasing awareness of emergency contraception among diverse demographics of women
Access to emergency contraception (EC) has improved recently as Canada and the United States have made it available without a prescription. But there is still a need for improving awareness among diverse groups of women about the use and availability of this pregnancy prevention method.
The findings of a new study of women’s sexual behaviours are being used to develop educational programs that improve awareness of EC and how to access it. This study compared the characteristics of women seeking emergency contraception, with those who had never used EC who desired family planning (FP) services.
The study found that the tendency to engage is risky sexual behaviours was similar in both groups of women. The women seeking EC were more likely to have had unprotected sexual intercourse during their last encounter, but less likely to have had a sexually transmitted infection in the past. A higher percentage of women had postsecondary education than those seeking family planning counselling, were unmarried, and had higher incomes, though fewer of them had regular medical care.
Emergency contraception works up to three to five days after the act of unprotected sex, but the sooner it’s used, the better the chance it works. There has been controversy about its use, but allegations that its availability will increase sexual risk taking in users have repeatedly been proven false.
Phipps et al. Characteristics of women who seek emergency contraception and family planning services. Am J Obstet Gynecol Aug. 2008;199(2):111.e1-e5.
FOR HEALTH PROFESSIONALS
IUDs safe and effective in women who have never been pregnant more than 24 weeks
Many health professionals are reluctant to recommend intrauterine systems (IUSs) and devices (IUDs) to women who have never been pregnant beyond 24 weeks (nulliparous women). The devices can be more difficult to insert in women who have never given birth and there is an increased risk of it falling out of place (expulsion) among other complications.
A study recently published in The European Journal of Contraception & Reproductive Health Care indicates that IUDs and IUS should be offered to nulliparous women, for it is generally well tolerated with high satisfaction rates. Both these devices are safe and effective long-term forms of reversible contraception, though they are used by a small percentage of women. In Canada, the copper IUD is marketed as Nova-T® or Flexi-T®, and the IUS containing hormones is marketed as Mirena®.
The study recruited 117 nulliparous women to have IUD/IUSs fitted by health professionals who assessed their experiences over the course of one year. The patients filled out questionnaires after insertion and then they were given the option to follow-up with a clinic visit, by postal questionnaire, or by phone at three and twelve months.
Inserting the devices
In total, 113 (97%) women had an IUD (92%) or IUS (8%) inserted– two women decided not to proceed and in another two, the clinician was not able to insert the device. Local anaesthetic was used in 23% and a dilator, the instrument used to stretch a closed cervix, was used in 9% of insertions. When asked about ease of insertion, clinicians reported that 39% were easier than expected, 48% were as expected and only 8% were more difficult than expected
- Almost two thirds of the women likened the experience to period pain and only 19% felt the insertion was more painful than expected.
- Many women who ranked their pain as 7 or 8 on a scale of 10 still had positive comments when asked about how they felt the insertion went.
Following up with women who had an IUD or IUS
The original IUD/IUS was still in place in most the women who provided follow-up after one year. Overall, women were satisfied and were happier with the device after 12 months compared to 3 months, even though close to half of the women reported heavier bleeding, a known side effect of the copper IUD.
At one year, information was available for 77% of patients, and 72% of these still had the IUD/IUS in place. Fifteen of the women had the device removed within the first year; 11 women for bleeding and pain. Women who had heavy or painful periods prior to insertion were no more likely to request removal. The IUS, which slowly releases a hormone that acts on the lining of the uterus, has actually been shown to decrease pain and bleeding, but there were very few of these devices placed in this study.
The IUD can also be used for emergency contraception, and women who used it for this reason were also more likely to have it removed. Similar to other published rates (6% over five years, with most in the first year), six women experienced expulsion of their IUD. No pregnancies or uterine perforations occurred.
Brockmeyer et al. Experience of IUD/IUS insertions and clinical performance in nulliparous women – a pilot study. The European Journal of Contraception & Reproductive Health Care. 2008;13(3):248-54.
FOR HEALTH PROFESSIONALS
The birth control pill and blood clots
One of the side effects of combined hormonal contraceptives (CHC) that is caused by the estrogen hormone is an increase in the risk of blood clots such as DVT (deep venous thrombosis) which is a blood clot in the deep large veins of the leg, and PE (pulmonary embolus), a blood clot that travels from the leg up to the lung. A woman’s risk of having a blood clot is said to increase by 3-4 times if she is taking the pill—but that’s not nearly as bad as it sounds.
Although regulatory authorities have used estimates of background venous thromboembolism (VTE)—the process of the blood clots travelling through the veins—the rates in women of reproductive age are as low as 0.5-1 out of 10,000 women years. This figure probably significantly underestimates the true incidence of VTE in this population, which a recent review suggests may be closer to 5-10 out of 10,000 women years.
Active surveillance studies, which provide the most accurate means to evaluate risk of rare consequences in OC users, have found an incidence of leg blood clots of 8-9 in 10,000 and clots travelling to the lung of 2 in 10,000 women years of OC use.
Taken together these findings suggest that the thromboembolic risks of modern low dose OCs may not be as great as previously believed and that the risks are small, and therefore acceptable, for most women. There are exceptions, including women who have a history of a clot, women with a thrombophilia (a predisposition to form clots already), and women with a history of stroke, heart attack or known vascular disease, including those with eye, kidney or nerve damage secondary to diabetes. These women should consider other contraceptive options.
Heinemann LA. Dinger JC. Range of published estimates of venous thromboembolism incidence in young women. Contraception May 2007; 75(5):328-36
Dinger JC. Heinemann LA. Kuhl-Habich D. The safety of a drospirenone-containing oral
contraceptive: final results from the European Active Surveillance Study on oral contraceptives based on 142,475 women-years of observation. Contraception May 2007; 75(5):344-54
Ask Sexualityandu
I will be turning 35 this year and I have been on the birth control pill for about 10 years now and it works well for me. Is there any way that I can keep taking the pill after 35?
Women can continue taking the pill after 35, since age alone is not a contraindication to taking it. But there may be other reasons to stop taking it depending on your health. For instance, taking combined hormonal contraceptives—namely the pill, the patch, or the ring—is unsafe for women older than 35 who smoke more than 15 cigarettes per day. Talk to your doctor about your options.
I have been using the Depo-Provera® for the last five months. I really like it except I am still spotting irregularly. How long will this continue?
Half of women will be amenorrheic (have no periods) after one year on Depo-Provera®. Chances are, the spotting will settle in the next 6-7 months. If it does not, there are a few things to try to make it stop. These include increasing the dose or decreasing the time between shots for a few doses. If you are a smoker, stop smoking.
See your doctor for a Pap smear and test for sexually transmitted infections, if these have not been done recently. Your doctor can provide you with the appropriate advice and prescriptions as needed.
Are there any restrictions regarding birth control in women who have sickle cell disease?
Women with sickle cell disease have an increased risk of stroke. The most recent evidence suggests that oral contraceptives have little, if any, impact on the risk for stroke in the general population, so it is unlikely that OCs will magnify the risk in sickle cell disease.
Many women with sickle cell disease have some form of a cyclical sickle cell crisis related to menses where the use of medications to reduce or eliminate menses is often beneficial. The use of Depo-Provera® and the oral contraceptive pill (OC) have actually been shown to decrease the occurrence of cyclical crises, with a greater improvement associated with Depo-Provera® than the pill. Hormonal contraception is not contraindicated and may in fact be helpful in these women.
