Motivation and Experience of Nulliparous Women Using Intrauterine Contraceptive Devices

WOMEN'S HEALTH WOMEN'S HEALTH

Motivation and Experience of Nulliparous Women Using Intrauterine Contraceptive Devices Ellen Ruth Wiebe, MD, CCFP, FCFP,1 Konia Jane Trouton, BSc, MD, CCFP, MPH, FCFP,1 Jennifer Dicus, BSc,2 1

Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver BC

2

Faculty of Medicine, University of British Columbia, Vancouver BC

Abstract

Résumé

Objectives: Use of an intrauterine contraceptive device (IUD) has not been recommended to nulliparous women in the past. There is now good evidence that there is no increased risk of pelvic inflammatory disease or infertility in nulliparas who use IUDs and the recommendations have changed. Our objective was to understand more about the motivations and experience of nulliparous women using IUDs.

Objectifs : Par le passé, l’utilisation d’un dispositif contraceptif intra-utérin (DIU) n’était pas recommandée aux nullipares. Nous disposons maintenant de bonnes données indiquant que le risque de syndrome inflammatoire pelvien ou d’infertilité chez les nullipares qui utilisent un DIU ne connaît pas de hausse; ainsi, les recommandations ont été modifiées. Notre objectif était de mieux comprendre les motivations et l’expérience des nullipares utilisant un DIU.

Methods: This was a mixed method study. First, we asked 44 nulliparous women who had had an IUD inserted within the previous six months about their reasons for seeking the IUD, their history with other forms of contraception, their perception of the insertion experience, and their feelings after insertion. Questionnaires were then distributed to 154 nulliparous women presenting for IUDs, asking about their past experience with hormonal contraception.

Méthodes : Il s’agissait d’une étude à méthode mixte. Tout d’abord, nous avons posé, à 44 nullipares s’étant vu insérer un DIU au cours des six mois précédents, des questions au sujet des raisons pour lesquelles elles se sont intéressées au DIU, de leurs antécédents en ce qui concerne d’autres formes de contraception, de leurs perceptions quant à l’expérience de l’insertion et de leurs sensations à la suite de l’insertion. Des questionnaires ont ensuite été distribués à 154 nullipares consultant leur médecin en vue d’obtenir un DIU; ce questionnaire se penchait sur leurs antécédents quant à la contraception hormonale.

Results: The main theme arising from the interviews was a desire to avoid hormonal contraception. Other reasons for choosing the IUD were greater contraceptive effectiveness than other methods, convenience of use, and lower cost. Responses to the questionnaire indicated that 138 women (89.7%) had used hormonal contraception in the past and, of those, 98 (63.0%) complained of mood side effects, 64 (41.6%) of sexual side effects, and 64 (41.6%) of physical side effects. Conclusion: The most important motivation for nulliparous women in this study to choose IUDs was to avoid the potential or actual side effects of hormonal contraception. Despite experiencing some discomfort at the time of insertion, this group of nulliparous women was very positive about using IUDs for contraception.

Résultats : Le fil conducteur révélé par ces entrevues concernait le souhait d’éviter la contraception hormonale. Parmi les autres raisons de choisir un DIU, on trouvait son efficacité contraceptive accrue par comparaison avec les autres méthodes, le côté pratique de son utilisation et son faible coût. Les réponses au questionnaire indiquait que 138 femmes (89,7 %) avaient utilisé une contraception hormonale par le passé et que, parmi celles-ci, 98 (63,0 %) s’étaient plaintes d’effets indésirables affectant l’humeur; 64 (41,6 %), d’effets indésirables de nature sexuelle; et 64 (41,6 %), d’effets indésirables de nature physique. Conclusion : Dans le cadre de cette étude, le facteur le plus important motivant les nullipares à choisir le DIU était le fait d’éviter les effets indésirables potentiels ou réels de la contraception hormonale. Malgré un certain inconfort au moment de l’insertion, ce groupe de nullipares entretenaient une attitude très positive envers l’utilisation d’un DIU à des fins de contraception. J Obstet Gynaecol Can 2010;32(4):335–338

Key Words: Intrauterine device, contraception, women’s health Competing Interests: None declared. Received on October 13, 2009 Accepted on October 30, 2009

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INTRODUCTION

I

ntrauterine devices are used by only 4.3% of Canadian women of reproductive age who are sexually active and who do not wish to become pregnant, according to a study published in 2009.1 This rate has increased since 2002, when the Canadian Contraception Study indicated that less than 2% of Canadian women in their reproductive years were using IUDs.2,3 The rate of IUD use in Canada is similar to the rate in use in the United States, but is much lower than most other countries; between 6% and 27% of European women use IUDs.4 The 2004 Canadian Contraception Consensus recommended use of IUDs as a contraceptive option for both nulliparous and multiparous women.1 Physicians and other health care professionals have been hesitant to recommend use of the IUD in nulliparous women despite evidence that it is a suitable option.5 For many years, IUD insertion and use were suspected of causing an increase in the occurrence of pelvic inflammatory disease, leading to possible tubal pregnancy or infertility.6 Younger women whose sexual behaviour included exposure to multiple partners and to sexually transmitted infections are at greater risk of PID.7 However, recent studies have shown that nulliparous women did not exhibit more complications with use of an IUD than multiparous women.8 IUD insertion can be more painful for nulliparous women and the insertions more difficult for physicians, so the use of IUDs in this population has been discouraged.9 The contraceptive effectiveness of the IUD is high, with a reported Pearl index for the copper IUD of 1.5 and for the levonorgestrel-releasing IUD of 0.11.4 More importantly, the typical use-effectiveness and perfect use-effectiveness are similar with IUDs, while the typical use-effectiveness rates of oral, transdermal, injectable, and transvaginal hormonal contraceptives are much lower than perfect use-effectiveness (8% and 0.8% pregnancies per year of use respectively).10 The purpose of the current study was to understand more about the motivations nulliparous women have for choosing and using IUDs, and their experiences with doing so. METHODS

We conducted a mixed method study using interviews and questionnaires. We recruited 44 nulliparous women who had an IUD inserted at one of two clinics. Participating women read and signed a consent form agreeing to participate in

ABBREVIATIONS IUD

intrauterine device

OC

oral contraceptive

PID

pelvic inflammatory disease

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this study. A research assistant contacted them and collected information by conducting a semi-structured interview over the telephone. These interviews took place between one and six months after the IUD insertion. The women were asked why they chose the IUD as their current contraceptive method and what problems they had experienced with other forms of contraception. Participants also provided information about any concerns they had with the insertion procedure and were asked for a pain score (0–10). They were also asked about how they currently felt about the IUD and what reactions they received from others about their use of an IUD. The interviews were audiotaped and transcribed, and baseline demographic data including age and pregnancy history were recorded. We used an interpretive approach that began with open-ended questions. Prompting was used to encourage more detailed answers. Data analysis occurred concurrently with collection so that insights from early interviews allowed more focus for later ones. Investigators met three times during the data collection period to discuss emerging themes from the interviews already transcribed. Theme saturation was reached by 28 interviews, but we continued to improve the richness of the data. After we learned the results of the interview study, we began the questionnaire study to obtain more detail about any side effects women had previously experienced while using hormonal contraceptives. Participants were nulliparous women presenting for IUD insertion, and the questionnaires sought information about their previous experience with hormonal contraception. The questionnaires were provided to women in the waiting room prior to their insertion appointment. The University of British Columbia’s Behavioural Research Ethics Board provided ethical approval for these projects. RESULTS

Forty-four women were successfully interviewed from a total of 56 recruited. The interviews were carried out in mid-2005 and mid-2008. No women refused to be interviewed, but some women were unavailable when the research assistant was available. The mean age of the women involved in the study was 26.8 years (Table 1). Although none of the women had had children, 16 women (36.4%) had had previous therapeutic abortions. The interview and questionnaire groups were similar in their characteristics. The reasons for choosing an IUD over another contraceptive method are listed in Table 2.

Motivation and Experience of Nulliparous Women Using Intrauterine Contraceptive Devices

Table 1. Characteristics of nulliparous women using IUDs Characteristic

Interviews n = 44

Questionnaires n = 154

Age, years, mean ± SD

26.8 ± 4.7

25.9 ± 5.7

Ethnicity, n (%) White/Caucasian East Asian South Asian

29 (78.4)

114 (74.0)

3 (8.1)

17 (15.6)

0

8 (5.2)

5 (13.5)

15 (9.7)

Education, years, mean ± SD

15.6 ± 2.4

15.7 ± 2.6

Any previous pregnancies, n (%)

16 (36.4)

51 (33.0)

Previous hormonal contraceptive use, n (%)

40 (90.9)

138 (89.6)

Other

Note: some interviews missing ethnicity data

Table 2. Reported reasons for choosing the IUD (interviewees only) n = 44 Reason

n (%)

Aversion to hormone use

28 (63.6)

Wanted more efficacy

32 (72.7)

More convenient compared with other contraceptives

29 (65.9)

Low cost

9 (20.5)

Note: many women gave multiple reasons

of hormonal contraception and any associated side effects. In the interview group, women were asked open-ended questions about the same issues. They readily described the physical side effects but were much less likely than the women in the questionnaire group to mention emotional or sexual side effects. (Table 3).

Satisfaction Of the 44 interviewees, 43 were satisfied with their decision to use an IUD, despite some complaints of bleeding and cramping. Motivation The main theme arising from the interviews was an aversion to use of hormones. Twenty-eight women (63.6%) chose to use an IUD because they did not want to take, or were advised not to use, combined oral contraceptives. Forty women (90.9%) had previously tried OCs. Some of the women had experienced side effects, and others stated that they were unable to use OCs because of a family medical history or a medical contraindication. Some women felt that OCs were unnatural, and they felt uncomfortable using hormones to prevent pregnancy. Many women also mentioned the need to feel more confident in the efficacy of their contraceptive and the convenience and the lower costs of using an IUD, but the issue that generated the most conversation and the most emotion in the interviews was avoiding use of hormones. Women were often surprised that the IUD was not more popular. Experience For all but one woman, the IUD remained the current form of contraception at the time of the interview, and all except this woman were positive about their experience and about IUDs in general. The average worst pain score reported when recalling the insertion was 4.1 on a 10-point scale. Previous Use of Hormonal Contraception Of the interviewees, 40/44 (90.9%) had previously used hormonal contraception, and of the questionnaire respondents 114/128 (89.0%) had done so. In the questionnaire group, women were asked specifically about their past use

DISCUSSION

The main theme that emerged from the analysis of the interviews was an aversion to the systemic use of hormones. Approximately 90% of participants had previously used hormonal contraception. They were unhappy with the way hormones influenced their bodies and feelings. In a study of 107 women in stable committed relationships who were followed for one year after starting OC use, 79 women completed the study, 38% continued using OCs, 47% discontinued use, and 14% switched to use of another OC. Using logistic regression, the authors determined that the effects of OCs most likely to predict discontinuation were emotional side effects, worsening of PMS, decreased frequency of sexual thoughts, and decreased psychosexual arousability.11 Our findings in the questionnaires were similar, in that many of the women requesting IUD insertion described having had emotional or sexual side effects from use of hormonal contraception in the past. Since only 4% of Canadian women use IUDs,1 these responses are unlikely to give a balanced view of side effects associated with hormonal contraception and likely do not reflect the experience of the general population. Open-ended questions used in the interviews elicited disclosure of fewer sexual and emotional side effects than did specific questions in the questionnaire. When treating patients, it may be useful to ask specifically about sexual and emotional side effects, or to have these questions written on a general entrance questionnaire. Of the women in this study, 36.4% had terminated a prior pregnancy. This may have motivated them to seek a more reliable method of birth control or to lose confidence in APRIL JOGC AVRIL 2010 l

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Table 3. Side effects on previous hormonal contraception Interviews, n = 40

n (%)

Questionnaires, n = 138

Mood side effects

3 (7.5)

Crying more easily

78 (56.5)

Depressed or sad

81 (58.7)

Angry or irritated

80 (58.0)

More anxious

54 (39.1)

Less interest in sex

53 (38.4)

Less desire and sexual thoughts

49 (35.5)

Less arousability

53 (38.4)

Pain or dryness with sex

41 (29.7)

Acne

20 (14.5)

Nausea

26 (18.8)

Headaches

21 (15.2)

Bloating or swelling

32 (23.2)

Weight gain

51 (37.0)

Breakthrough bleeding

21 (15.0)

Sexual side effects

Physical side effects

1 (2.5)

19 (47.5)

their previous choice of contraception. Even though most of the women reported discomfort, such as cramping, during insertion of the IUD or post-insertion, almost all of the women were completely satisfied with their choice of an IUD, and this remained their primary option as a contraceptive within one year of insertion. One limitation of the interview portion of the study was that the women in the study had had less than six months’ experience of the IUD. We know from other studies that about 20% of women have their IUDs removed within 12 months of insertion.8 Follow-up of the subjects for a longer time period would provide insight into long-term satisfaction with the IUD. A larger study involving more women and more study sites would provide a broader spectrum of experience. The questionnaire participants and the interview participants had similar baseline characteristics, confirming that we had a representative sample of patients in the interviews.

n (%)

ACKNOWLEDGMENTS

This research was supported by the Vancouver Foundation through a BC Medical Services Foundation grant to the Community Based Clinical Investigator (CBCI) Program at the University of British Columbia’s Department of Family Practice. We thank Nicole Deagan for help with thematic analysis, Dr Jonathan Berkowitz for help with statistical analysis, and Cheryl Couldwell for reviewing and revising drafts. REFERENCES 1. Black A, Francoeur D, Rowe T, Collins J, Miller D, Brown T, et al. Canadian contraception consensus. J Obstet Gynaecol Can 2004;26:347–87, 389–436. 2. Fisher W, Boroditsky R, Morris B. The 2002 Canadian contraception study: part 1. J Obstet Gynaecol Can 2004;26:580–90. 3. Fisher W, Boroditsky R, Morris B. The 2002 Canadian contraception study: part 2. J Obstet Gynaecol Can 2004;26:646–56. 4. Weir E, Society of Obstetricians and Gynaecologists of Canada. Preventing pregnancy: a fresh look at the IUD. CMAJ 2003;169:585. 5. Johnson BA. Insertion and removal of intrauterine devices. Am Fam Physician 2005;71:95–102. 6. Hubacher D. Copper intrauterine device use by nulliparous women: review of side effects. Contraception 2007;75(6 Suppl):S8–11.

CONCLUSION

The most important motivation for nulliparous women to choose an IUD for contraception was to avoid the potential or actual side effects of hormonal contraception. Convenience and efficacy were also important. The experience of the IUD insertion was tolerable, and quality of life since insertion had been positive, confirming that it is an acceptable option to suggest to nulliparous women for contraception. 338

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7. Grodstein F, Rothman KJ. Epidemiology of pelvic inflammatory disease. Epidemiology 1994;5:234–42. 8. Veldhuis HM, Vos AG, Lagro-Janssen AL. Complications of the intrauterine device in nulliparous and parous women. Eur J Gen Pract 2004;10:82–7. 9. Suhonen S, Haukkamaa M, Jakobsson T, Rauramo I. Clinical performance of a levonorgestrel-releasing intrauterine system and oral contraceptives in young nulliparous women: a comparative study. Contraception 2004;69:407–12. 10. Trussell J. Estimates of contraceptive failure from the 2002 national survey of family growth. Contraception 2008;78:85. 11. Sanders SA, Graham CA, Bass JL, Bancroft J. A prospective study of the effects of oral contraceptives on sexuality and well-being and their relationship to discontinuation. Contraception 2001;64:51–8.