Long-acting reversible contraceptives, such as intrauterine devices (IUDs), are the most effective forms of birth control available and doctors should recommend them to adolescent girls before any other method, according to a new position statement from the Canadian Paediatric Society (CPS).
The statement, published on Thursday – the first of its kind from the CPS – reflects the best evidence about which birth-control method is least likely to result in unintended pregnancy, said Dr. Giuseppina Di Meglio, an author of the statement and an adolescent-medicine specialist at Montreal Children’s Hospital. While IUDs have traditionally not been recommended to young people, the evidence shows it’s time for that to change, she said.
“The first line of contraception should be the most effective method and we should be talking about them first,” said Dr. Di Meglio, who is also an associate professor of pediatrics at McGill University.
The society’s announcement is designed to counter long-standing myths and misunderstandings about the safety and effectiveness of IUDs, she said. Since they must be inserted into the uterus by a doctor and stay in place for years, many parents get “creeped out” by them, and health-care providers have typically avoided offering them, despite evidence showing how well they work, according to Dr. Di Meglio.
Long-acting reversible contraceptives, or LARCs, include IUDs as well as subdermal implants, which are not available in Canada. The implant, such as Nexplanon, manufactured by Merck, is a small plastic rod implanted in the arm that works by suppressing the release of eggs.
Wendy Norman, who holds a chair in family planning public-health research at the University of British Columbia, said she and other experts are puzzled about why the subdermal implant is still not available in Canada. Norman said she has spoken to Health Canada and the department said it is willing to receive an application from Merck to approve Nexplanon.
IUDs, which use either copper or hormones to prevent pregnancy, can stay in place for years. While other contraceptive methods, such as the hormonal birth-control pill, can be highly effective when used perfectly, in the real world that doesn’t always happen. According to data provided by the CPS, nine out of every 100 females taking the pill will have an unintended pregnancy after one year. With IUDs, that number falls to less than one.
A study published last year in the journal Contraception found the risks of IUDs to be small: Uterine perforation rates ranged from 0-0.1 per cent and cases of pelvic inflammatory disease were also low, the study found.
The medical community has been slowly moving to embrace use of long-acting reversible contraceptives in young people. In 2014, the American Academy of Pediatrics endorsed LARCs as the first-line contraceptive option for young women. The Society of Obstetricians and Gynaecologists of Canada (SOGC) published guidelines in 2016 that recommend IUDs as a first-line option for all women and said that health professionals shouldn’t restrict access to them because of “theoretical or unproven risks.”
Norman said she hopes this new guidance, plus similar recommendations from other medical groups, will increase uptake of IUDs. The long-standing reluctance to offer them to young people is not based on good medical evidence, she noted. For instance, it was once believed that IUDs could be linked to a higher risk of STIs. But that's because of studies that compared STI rates among people who used either IUDs or condoms, Norman said. That doesn't mean IUDs are somehow linked to infections – rather, they must be used in combination with barrier methods to offer protection, she said.
Similarly, past advice said women who had not given birth should not use IUDs. . Norman said she has never been able to find a scientific basis for this recommendation.
A 2017 survey released by the SOGC found that fewer than 4 per cent of Canadian women said they used a copper IUD, while 7 per cent had used a hormonal one. The SOGC also reported in 2017 that about 44 per cent of Canadian women using contraception take the combined hormonal birth-control pill, which contains estrogen and progestin.
After LARCs, forms of hormonal birth control, including the pill, transdermal patch, vaginal ring and injectable contraceptive, are the second-line options, according to the new position statement. Third-tier options include condoms, diaphragms, cervical caps and spermicide.
The new guidance also states that doctors should give contraceptive prescriptions without performing pelvic exams, except in cases where they are necessary, such as inserting an IUD.
The position statement notes that some young people won’t be comfortable using an IUD and that health-care providers should ensure discussions about contraception take an individual’s preferences and needs into account as a way of promoting respect and adherence to the chosen method.
Carly Weeks