Three examples of intrauterine devices: the Paragard, Mirena and SKYLA. (Photo courtesy of Navy and Marine Corps Public Health Center).

Options in Female Contraceptives

By Michael R. (Bob) MacDonald, MS, CHES, manager, Sexual Health and Responsibility Program (SHARP), Navy and Marine Corps Public Health Center

Three examples of intrauterine devices: the Paragard, Mirena and SKYLA. (Photo courtesy of Navy and Marine Corps Public Health Center).
Three examples of intrauterine devices (IUDs): the Paragard, Mirena and SKYLA. (Photo courtesy of Navy and Marine Corps Public Health Center).

One goal of the Sexual Health and Responsibility Program (SHARP) of the Navy and Marine Corps Public Health Center is to increase the proportion of pregnancies among Sailors and marines which are planned. An unplanned pregnancy is one which was not wanted or was mistimed. Among women in the U.S. aged 20-24, only 1 of 3 pregnancies were planned. Navy enlisted women share this experience.

Many of these unplanned pregnancies occur among women who were using contraception – either birth control pills and/or male condoms. These methods work very well when used perfectly, but perfection can be hard to maintain. Typically, these methods fail for about one in six couples. The good news is that there are a few other reversible methods available which are much more reliable. They are called the Long-Acting Reversible Contraceptives (or LARC for short). They are over 99% reliable.

LARCs available in the U.S. include intrauterine devices and the hormonal implant. In general, LARCs are:

  • extremely effective in preventing pregnancy (>99% effective)
  • low maintenance for doctors and users
  • discreet
  • provide continuous contraception for 3-12 years
  • safe for most women, including teens and HIV positive women and women who have had a cesarean section, sexually transmitted infection (STI), pelvic inflammatory disease (PID), ectopic pregnancy and for non-monogamous women
  • well tolerated by adolescents and most women who have never had a baby
  • enjoy very high user satisfaction
  • enjoy very high user continuation rates
  • cost-saving when compared to oral contraceptive pills
  • enjoy easy placement and removal
  • enable rapid return to fertility after removal

There are three IUDs available. They are:

Copper T 380A (TCu380A) (Paragard) – The Paragard is inserted by a doctor into a woman’s uterus. This is a quick procedure that can be done in a doctor’s office. The IUD is over 99% effective at preventing pregnancy, and has a very high user satisfaction rate – 85-90% of women were still using the IUD after the first year. The IUD may reduce a women’s risk of developing endometrial cancer and is effective for up to 10 years after placement. Common but benign side effects include menstrual disturbances, cramping and pain, and expulsion of the device. Spontaneous expulsion rate in the first year is 2-10%. Rare but serious health risks include infection, pregnancy complications, and uterine perforation (among skilled doctors, the rate is 1 per 1000). Women who can safely use the IUD include those who have had a prior sexually transmitted infection, pelvic inflammatory disease, an ectopic pregnancy or are currently non-monogamous. Most women, including those that have never had a baby, experience rapid return to fertility after the Paragard is removed.

Levonorgestrel (LNg) IUC (Mirena) – The Mirena is inserted by a doctor into a woman’s uterus. This is a quick procedure that can be done in a doctor’s office. The Mirena is over 99% effective at preventing pregnancy. Over 81% of Sailors and Marines who received Mirena while in boot camp were still using it 12 months later – a very high satisfaction rate. The Mirena may reduce a women’s risk of developing endometrial cancer and is effective up to 5 years after placement. Common but benign side effects include menstrual disturbances, cramping and pain, and expulsion of the device (2-10% in the first year of use). Rare but serious health risks include infection, pregnancy complications and uterine perforation (about 1 in 1000 when placed by an experienced health care provider). Women who can safely use the IUD include those who have had a prior STI, PID, ectopic pregnancy or are currently non-monogamous. Most women, including those that have never had a baby, experience rapid return to fertility after Mirena is removed. Like some other hormonal contraceptives, the Mirena has many non-contraceptive benefits.

Levonorgestrel (LNg) IUC (SKYLA) – Skyla is new in 2013 and is effective up to three years after placement. SKLA contains the hormone progestin, and is inserted into the uterus by your doctor. SKLA is smaller than Mirena and contains less hormone. SKLA is very safe. Uterine perforation and spontaneous expulsion are very rare. The incidence of perforation during clinical trials was < 0.1%.

nexplanon2_w
Nexplanon hormonal implant. (Photo courtesy of Navy and Marine Corps Public Health Center)

Nexplanon hormonal implant. The implant is a single rod containing the hormone etonogestrel, and is placed under the skin of the upper arm. It is over 99% effective in preventing pregnancy and lasts for three years. Over 91% of Sailors and marines who received the hormonal implant while in boot camp were still using it 12 months later – a very high satisfaction rate. The implant can be inserted in just a couple minutes in your doctor’s office. Removal is also quick and easy. Disadvantages include changes in a woman’s period, rare insertion and removal complications, possible weight gain, ovarian cysts in a small proportion of users, and possible decrease in bone density. Users may experience multiple non-contraceptive benefits. Most women experience rapid return to fertility after implant removal (most ovulate within six weeks).

Sailors and Marines who are using a less reliable form of birth control might consider talking with their doctor about switching to a LARC. I encourage everyone interested to read more at the NMCPHC SHARP- “LARC” webpage at: http://www.med.navy.mil/sites/nmcphc/health-promotion/reproductive-sexual-health/Pages/larc.aspx

Myths and Truths about Intrauterine Contraceptives (IUCs)?

Myth Fact*
IUCs should not be used in women who have not had a child IUCs are safe for women who have never had a baby; and most have a rapid return of fertility after removal
IUCs expose the provider to medicolegal risk Litigation related to IUCs has virtually disappeared
IUCs increase the risk of PID The IUC itself appears to have no effect on risk. Rather, placement carries a small, transient risk of post-procedure infection.
IUCs increase the risk of ectopic pregnancy IUCs significantly reduce the risk of ectopic pregnancy compared to not using contraception.
IUCs increase the risk of Sexually Transmitted Infections (STIs) IUC users are not at increased risk for STIs. Women at risk should be advised to use condoms but are generally still good candidates for IUCs
IUCs are too expensive By 5 years of use, IUCs and Implanon are the two most cost-effective methods of reversible contraception.