Intrauterine contraceptive devices are underused in developed countries

Misconceptions around intrauterine contraceptive devices (IUDs) mean that they are underused in developed countries, despite being a safe and effective form of contraception, says a women's health expert in this week's BMJ.

IUDs are suitable for most women, are cost effective when continued long term, and can have health benefits beyond contraception, writes Sally Rose, Research Fellow at the University of Otago, New Zealand.

Fertility is restored on their removal, and unlike other forms of contraception their efficacy does not depend on the user's behaviour. Consequently, such devices are an excellent alternative to female sterilisation (which women may later regret) and are a long term alternative to other methods of birth control prone to misuse or failure.

Side effects such as pain and heavy bleeding are common reasons for discontinuing use of an IUD within the first year, but can usually be managed with appropriate pain relief.

Despite this, data shows these devices are underused in developed countries, says the author.

Nearly half of all users are in China, while only 6% of women of reproductive age in the United Kingdom, 4.6% in Australia and New Zealand, and fewer than 1% in the United States use this method of contraception.

Reluctance to offer or use intrauterine devices seems to stem largely from the experience with the Dalkon Shield in the 1970s, she says, which caused pelvic infections that had serious health consequences for many thousands of women.

Legal action against manufacturers of that and other devices led to a sharp decline in the use of all intrauterine contraceptive devices and their subsequent withdrawal from the US market in the 1980s.

Since then, misconceptions based on outdated information have persisted, such as the belief that these devices cause pelvic inflammatory disease and infertility.

Evidence from trials suggests there might be a small increased risk in the first 20 days after insertion, but beyond that the risk of upper genital tract infection does not differ from that in non-users, she writes.

Pelvic inflammatory disease is frequently caused by untreated Chlamydia so testing for and treating any infection before inserting a device is recommended clinical practice along with and advice on the use of condoms to protect against sexually transmitted infections.