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MD Consult: Books: Goldman: Cecil Medicine: TYPES OF CONTRACEPTIVES

Goldman: Cecil Medicine, 23rd ed.

Copyright © 2007 Saunders, An Imprint of Elsevier

TYPES OF CONTRACEPTIVES

Spermicides and Barriers

All spermicidal agents contain a surfactant, usually nonoxynol 9, that immobilizes or kills sperm on contact. They also provide a mechanical barrier and need to be placed into the vagina before each coital act. There is no increased risk of birth defects in the offspring of women who conceive while using spermicides.

Diaphragm

A diaphragm must be carefully fitted by the health care provider. The largest size that does not cause discomfort or undue pressure on the vagina should be used. The diaphragm should not be left in place for more than 24 hours because it may cause ulceration of the vaginal epithelium. Diaphragm users have an increased risk of urinary tract infection.

Male Condom

Use of the latex male condom by individuals with multiple sex partners should be encouraged because it is the most effective way to prevent sexually transmitted infections. The natural membrane condoms do not prevent sexually transmitted infections, but polyurethane condoms do.

Female Condom

The female condom consists of a soft, loose-fitting prelubricated sheath and two flexible polyurethane rings. The female condom can be inserted before beginning sexual activity and left in place for a longer time than the male condom after ejaculation occurs. Because the female condom covers the external genitalia, it may prevent transmission of genital herpes. Because polyurethane is stronger than the latex used in most male condoms, the female condom is less likely to rupture. Both polyurethane and latex do not allow virus transmission and should reduce the risk of acquiring human immunodeficiency virus infection.

Oral Steroid Contraceptives

There are three major types of OC formulations: fixed-dose combination, combination phasic, and daily progestin. The combination formulations are the most widely used and most effective. They consist of tablets containing both an estrogen and a progestin usually given continuously for 3 weeks. No steroids are given for the next 7 days (except for one formulation in which estrogen alone is given for an additional 5 days), after which time the active combination is given for an additional 3 weeks. Two recently introduced formulations provide active tablets for 24 days with 4 days inactive tablets. Another formulation provides active tablets for 84 days followed by 7 days without active tablets to allow with-drawal bleeding. The endometrium usually begins to slough 1 to 3 days after steroid ingestion is stopped, causing withdrawal bleeding, which usually lasts 3 to 4 days. The uterine blood loss with OC use averages about 25 mL per cycle, less than the 35 mL average for ovulatory cycles.

Constituents and Action

All formulations are made from synthetic steroids. There are two major types of synthetic progestins: derivatives of 19-nortestosterone (which are used in OCs) and derivatives of 17α-acetoxyprogesterone (pregnanes). Pregnanes are structurally related to progesterone and are used in injectable contraceptives but are not used in OCs.

The 19-nortestosterone progestins used in OCs are of two major types, estranes and gonanes, and both have androgenic activity. The estranes currently used in several OCs are norethindrone and its acetates, norethindrone acetate and ethynodiol diacetate. Gonanes have greater progestational activity per unit weight than estranes, and thus a smaller amount of these progestins is used in OC formulations. The parent compound of the gonanes is dl-norgestrel, but only the levo isomer is biologically active. Gonanes used in OCs include both norgestrel and levonorgestrel and three less androgenic derivatives of levonorgestrel: desogestrel, norgestimate, and gestodene. One other progestin that is structurally related to spironolactone has been formulated in an OC. This progestin is called drospirenone and has antimineralocorticoid and antiandrogenic activity as well as progestational activity without an-drogenic activity.

With the exception of two daily progestin-only formulations, the progestins are combined with varying dosages of two estrogens, ethinyl estradiol and its 3-methyl ether, called mestranol. All the older higher dosage OC formulations contained mestranol, and this steroid is still present in some 50-μg formulations. All formulations with less than 50 μg of estrogen (20 to 35 μg) contain ethinyl estradiol.

The estrogen-progestin combination is the most effective type of OC formulation because these preparations consistently inhibit the midcycle gonadotropin surge and thus prevent ovulation. The progestin-only formulations have a lower dose of progestin than the combined agents and do not consistently inhibit ovulation, even though they are ingested every day. Both types of formulations also act on the cervical mucus and tubal motility to interfere with sperm transport. Progestins also alter the endometrium so if fertilization occurs, implantation may be prevented. For contraceptive effectiveness to be maintained with the combination formulations, it is important that the pill-free interval be limited to no more than 7 days. This is best accomplished by ingestion of either a placebo or an iron tablet daily during the steroid-free interval.

Metabolic Effects

The synthetic steroids in OC formulations have many metabolic effects in addition to their contraceptive actions. These effects can cause the more common, less serious side effects as well as the rare, serious complications. The magnitude of these effects is directly related to the dosage and potency of the steroids in the formulations.

Symptoms Due to Estrogen and Progestin

The most frequent symptoms produced by the estrogen component include nausea, breast tenderness, and fluid retention (bloating). The progestins can produce certain androgenic effects, such as weight gain, acne, and nervousness. Because estrogens decrease sebum production, women who have acne should be given a formulation with a low progestin-estrogen ratio. Unscheduled (breakthrough) bleeding is usually produced by insufficient estrogen, too much progestin, or a combination of both. This problem is more common with formulations containing 20 μg of estrogen than with those containing 30 to 35 μg and is increased in women who also smoke cigarettes. Shortening the pill-free interval to 3 or 4 days should prevent ovarian follicular development and may decrease the incidence of unscheduled bleeding with low-estrogen formulations.

The synthetic estrogens used in OCs cause an increase in the hepatic production of several proteins. The progestins do not affect protein synthesis except to reduce levels of sex hormone–binding globulin. Some of the proteins that are increased by ethinyl estradiol, such as factors V, VIII, and X and fibrinogen, have the potential to enhance thrombosis, whereas an increase in angiotensinogen levels may elevate blood pressure in some users. Blood pressure should be monitored in all users of OCs and the agent discontinued if there is a clinically significant increase. The incidence of both venous and arterial thrombosis in OC users is higher with 50-μg estrogen formulations than with those with 20 to 35 μg of estrogen. Changes in the coagulation parameters with most low-dose OCs are small or nonexistent.

Glucose Metabolism

The effect of OCs on glucose metabolism is directly related to the dose, potency, and type of progestin. Although high-progestin formulations caused peripheral insulin resistance, the low-progestin formulations in current use do not significantly alter levels of glucose, insulin, or glucagon after a glucose load. The risk for development of diabetes mellitus is not increased in women with a history of gestational diabetes who take OCs compared with control subjects. The risk for development of type 2 diabetes is not increased among current or former OC users compared with age-matched control subjects.

The estrogen component of OCs causes an increase in high-density lipoprotein cholesterol levels, a decrease in low-density lipoprotein cholesterol levels, and an increase in total cholesterol and triglyceride levels. The progestin component causes a decrease in high-density lipoprotein levels, an increase in low-density lipoprotein levels, and a decrease in total cholesterol and triglyceride levels. High-progestin formulations have an adverse effect on the lipid profile; because of the direct beneficial effect of estrogen on the arterial wall, however, users of these agents do not have an increased risk of cardiovascular disease. The newer combination formulations with less androgenic progestins have a more favorable effect on the lipid profile.

Complications and Risk Factors

Thrombosis

The cause of the increased incidence of both venous and arterial cardiovascular disease in users of OCs is thrombosis, not atherosclerosis. The background rate of venous thrombosis and embolism in women of reproductive age is about 0.8 per 10,000 woman years. Among users of OCs with 30 or 35 μg of ethinyl estradiol, it is 3 per 10,000 woman years, about four times the background rate but half the rate of 6 per 10,000 woman years that occurs in association with pregnancy. Although the risk of venous thrombosis and embolism is higher among women ingesting OCs with 50 μg of ethinyl estradiol than those with 30 to 35 μg, studies to date indicate that the risk of venous thrombosis and embolism with OCs containing 20 μg of ethinyl estradiol is similar to that of OCs with 30 to 35 μg of ethinyl estradiol. In the presence of an inherited coagulopathy disorder, the risk of venous thrombosis is increased several-fold. Because only 1 in 300 women with activated protein C resistance will develop venous thrombosis with OC use, it is not recommended that screening for coagulation deficiencies be undertaken before patients are started on OC use unless the individual patient has a personal or strong family history of thrombotic events. Women with known inherited or acquired thrombophilic conditions should not use estrogen-containing steroid contraceptives in pills, rings, or patches as each of these agents has thrombophilic effects.

Myocardial Infarction

The use of high-dose OCs by women who smoke cigarettes significantly increases the risk of myocardial infarction. Therefore, combination OCs should not be prescribed to women older than 35 years who smoke cigarettes or use alternate forms of nicotine. Epidemiologic studies indicate that use of low-dose OCs by nonsmoking women without hypertension is not associated with a significantly increased incidence of either myocardial infarction or hemorrhagic or thrombotic stroke.

Delayed Fertility

For about 2 years after the discontinuation of contraceptives, the rate of return of fertility is slightly lower for users of OCs than for users of barrier methods. OCs do not cause permanent infertility or adversely affect pregnancies that occur after their discontinuation. OCs are not teratogenic if they are accidentally ingested during pregnancy.

Breast Cancer

An analysis of worldwide epidemiologic data in 1988 showed that the risk of breast cancer diagnosis was increased by about 25% in young women who were currently using OCs, but this increased risk was no longer present 10 years or more after they stopped using OCs. A large case-control study reported that if OC use was started before 1974, the year when formulations with less than 50 μg of estrogen were first introduced, the relative risk of breast cancer was 3.1 in OC users. However, if OC use was initiated in 1974 or later, the relative risk for development of breast cancer in OC users was 0.74. Furthermore, there was no significant increase in risk of breast cancer with initiation of OC use at a very young age, use before a first birth, or use by women with a family history of breast cancer ( Chapter 208 ). A large study of women aged 35 to 64 years in the United States reported that there was no significantly increased risk of breast cancer among current and former OC users compared with women who had not used OCs.

Cervical Cancer

The epidemiologic data regarding the risk of invasive cervical cancer as well as cervical intraepithelial neoplasia and OC use are conflicting. Nonetheless, the majority of well-controlled studies indicate that there is no change in risk of cervical intraepithelial neoplasia and OC use. However, it is likely that a causal relationship exists between OC use and a reported increased risk of cervical adenocarcinoma. OC users need annual cervical cytologic screening ( Chapter 209 ).

Endometrial Cancer

Several studies have shown that the use of OCs has a protective effect against endometrial cancer. Moreover, the decrease in risk persists for many years after OCs are stopped. Women who use OCs for at least 1 year have a 50% reduced risk of endometrial cancer development between the ages of 40 and 65 years compared with nonusers. This protective effect is related to duration of use, increasing from a 20% reduction with 1 year of use to a 60% reduction with 4 years of use.

Epithelial Ovarian Cancer

In addition, OCs reduce the risk for development of epithelial ovarian cancer as well as cancers with low malignant potential. The magnitude of the decrease in risk is directly related to the duration of OC use, increasing from about a 40% reduction with 4 years of use to a 60% reduction with 12 years of use. The protective effect continues for at least 20 years after the use of OCs ends. As with endometrial cancer, the protective effect occurs only in women of low parity (fewer than four), who are at greatest risk for this type of cancer. Studies have reported that OCs significantly reduce the risk for development of colorectal cancer by about 20%.

Benign Hepatocellular Adenoma

The development of a benign hepatocellular adenoma was a rare occurrence in long-term users of high-dose OCs containing mestranol, but it is not increased by use of ethinyl estradiol OCs. There is no increased risk of liver cancer associated with OC use. OC use also does not increase the risk for development of malignant melanoma or prolactin-secreting pituitary adenomas.

Contraindications

The OCs can be prescribed for the majority of women of reproductive age. An absolute contraindication is a history of vascular disease, including systemic diseases that affect the vascular system, such as lupus erythematosus and diabetes with retinopathy or nephropathy. Cigarette smoking by OC users older than 35 years and uncontrolled hypertension are also contraindications, as are a personal history of cancer of the breast or endometrium and cholestatic jaundice of pregnancy. Pregnancy and any undiagnosed cause of uterine bleeding are also contraindications. Women with functional heart diseases should not use OCs because the fluid retention could result in congestive heart failure. There is no evidence, however, that individuals with asymptomatic mitral valve prolapse should not use OCs. Women with active liver disease should not take OCs. However, women who have recovered from liver disease, such as viral hepatitis, and whose liver function test results have returned to normal, can safely take OCs. The presence of migraine headaches without aura is not a contraindication to OC use, but if auras are present, combination OCs should not be prescribed because of a possible increased risk of stroke. Relative contraindications to OC use include undiagnosed causes of amenorrhea and depression. Use of OCs does not cause enlargement of prolactin-secreting pituitary microadenomas or worsen functional hyperprolactinemia ( Chapter 242 ) as was previously believed.

Initiation of Therapy and Surveillance

If a healthy woman has no contraindications to OC use, it is unnecessary to perform any laboratory tests, including cervical cytology, before use unless these are necessary for routine health maintenance. Routine use of laboratory tests is not indicated unless the woman has a family history of diabetes or arterial vascular disease at a young age, in which case a fasting glucose or lipid panel should be obtained. After the first three cycles of OC use, a nondirected history should be obtained and blood pressure measured. After this visit, the woman should be seen annually; at each visit, a nondirected history should again be taken, blood pressure and body weight measured, and a physical examination (including breast, abdominal, and pelvic examination with cervical cytology) performed. It is not necessary to measure lipids, other than the routine cholesterol screening every 5 years, in women with no cardiovascular risk factors, even if they are older than 35 years. There is no reason to discontinue OC use unless pregnancy is desired. Intermittent discontinuation is unnecessary and may result in an unwanted pregnancy.

Although synthetic sex steroids can retard the biotransformation of certain drugs (e.g., phenazone and meperidine) as a result of substrate competition, such interference is usually not important clinically. However, some drugs can interfere clinically with the action of OCs by inducing liver enzymes that convert the steroids to more polar and less biologically active metabolites. These drugs include barbiturates, sulfonamides, cyclophosphamide, griseofulvin, and rifampin. There is a high incidence of OC failure in women ingesting rifampin, and these two agents as well as systemic griseofulvin should not be given concurrently. There is no reliable evidence that other antibiotics (including ampicillin and tetracycline), analgesics, or barbiturates inhibit OC effectiveness. Products containing St. John’s wort reduce contraceptive effectiveness and cause breakthrough bleeding. Women taking medication for epilepsy should be treated with 50-μg estrogen formulations because many antiepileptic medications lower ethinyl estradiol levels and cause breakthrough bleeding, which may cause premature discontinuation of use. Because of their many health benefits, including reduction in risk of endometrial and ovarian cancer and induction of regular cyclic uterine bleeding, the continued use of OCs until menopause should be encouraged in women without contraindications.

Transdermal and Intravaginal Steroid Contraceptives

Transdermal Patch

Two novel long-acting methods of delivering contraceptive steroids other than the oral route have recently been marketed in the United States. One of these is a transdermal patch with an area of 20 cm2, which delivers 150 μg of the progestin norelgestromin, the active metabolite of norgestimate, and 20 μg of ethinyl estradiol daily into the systemic circulation for 7 days. After this time span, the patch is removed and another is attached to a different area of the skin. The steroids are absorbed into the circulation at a constant rate, yielding fairly constant circulatory levels of each steroid while the patch is attached. This pharmacodynamic pattern differs from the peaks and valleys of steroid levels that occur after ingestion of an OC. After three patches are applied, no patch is used for the fourth week to allow withdrawal bleeding. Contraceptive efficacy, bleeding patterns, and side effects are similar to those associated with OCs, but in one comparative study, compliance was better with the patch than with the OC.

Intravaginal Ring

Another method of administering contraceptive steroids at a constant rate is by use of a flexible vaginal ring, which is 58 mm in outside diameter and 4 mm thick. The ring is composed of ethinyl vinyl acetate and contains the progestin etonogestrel and ethinyl estradiol. The rings are all the same size and do not have to be fitted. The ring is inserted and removed by the woman herself and is left in place for 3 weeks, after which time it is removed for 1 week to allow withdrawal bleeding. Each day, 120 μg of etonogestrel and 15 μg of ethinyl estradiol is released from the ring, and bleeding with the ring in place is uncommon. Contraceptive efficacy and side effects are similar to those of OCs.

Injectable Steroid Contraceptives

Constituents and Use

Several types of injectable steroid formulations are in use for contraception throughout the world. The one most widely used in the United States is depot medroxyprogesterone acetate (DMPA). The initial formulation of this contraceptive was administered as an intramuscular injection of 1 mL of an aqueous suspension containing 150 mg of crystalline medroxyprogesterone acetate once every 3 months. A recently developed formulation that is administered subcutaneously (DMPA-SC) contains 105 mg of DMPA in 0.15 mL of solution. This lower dose formulation has a lower peak medroxyprogesterone acetate concentration than DMPA and a long duration of action that suppresses ovulation for at least 13 weeks and is not affected by body mass. Other injectable contraceptives include norethindrone enanthate, given in a dose of 200 mg every 2 months, and several once-a-month injections of combinations of different progestins and estrogens. DMPA has a low failure rate, 0.1% at 1 year and 0.4% at 2 years. There were no pregnancies during 1 year in two large trials of DMPA-SC (16,073 woman cycles of exposure). The major contraceptive action of both formulations is inhibition of ovulation. These agents also impede sperm transport by keeping the cervical mucus thick and inhibit endometrial growth and glycogen production. With DMPA and DMPA-SC, serum medroxyprogesterone levels rapidly increase to contraceptively effective blood levels (>0.5 ng/mL) within 24 hours after the injection. With DMPA, medroxyprogesterone levels plateau for about 3 months, after which there is a gradual decline until levels become undetectable 7 to 9 months after the injection. With DMPA-SC, medroxyprogesterone levels steadily decline after the initial peak and reach 0.2 ng/mL 3 to 4 months after the injection.

Side Effects

With both formulations, mean endogenous estradiol levels remain above the postmenopausal range (40 to 60 pg/mL), and symptoms of estrogen deficiency do not occur. Although many women using DMPA have a decreased amount of bone mineral density during use, bone mineral density increases to normal levels after DMPA is stopped, and there are no reports of an increased risk of fracture with DMPA use. It is unnecessary to measure bone mineral density or to administer bone antiresorptive agents in DMPA users because the bone loss is temporary.

Because of the lag time it takes to clear DMPA from the circulation, resumption of ovulation is delayed for a variable time after the last injection. It may take as long as 1 year for ovulatory cycles to return. After this initial delay, fecundity resumes at a rate similar to that found after discontinuation of a barrier contraceptive.

Disruption of the Menstrual Cycle

The major side effect of DMPA is complete disruption of the menstrual cycle. Since this formulation contains only a progestin, without an estrogen, endometrial integrity is not maintained and uterine bleeding occurs at irregular and unpredictable intervals. The bleeding is usually light in amount and does not cause anemia. As duration of therapy increases, the incidence of frequent bleeding steadily declines and the incidence of amenorrhea steadily increases, so that at the end of 2 years, about 70% of users are amenorrheic. Women who use this method of contraception should be counseled that with time, the irregular bleeding episodes will cease and amenorrhea will most likely occur. Most DMPA users gain between 1.5 and 4 kg in their first year of use and continue to gain weight thereafter. If weight gain occurs, calorie intake should be decreased. Because there is no estrogen in DMPA, its use does not cause hypertension or thromboembolism.

In cycling women, the initial injection should be given no later than day 5 of the cycle to be certain to inhibit ovulation in the initial treatment cycle. The first injection should be given within 5 days after delivery in nonlactating women but not until after 6 weeks in lactating women.

Because the major reason for discontinuance of all progestin-injectable contraceptives is menstrual irregularity, several combined progestin-estrogen injectables that are given once monthly and produce regular withdrawal bleeding have been developed. A combination of medroxyprogesterone acetate, 25 mg, and an estradiol ester, estradiol cypionate 5 mg, was marketed for use in the United States after extensive clinical trials but is currently unavailable. A 0.5-mL aqueous suspension of this formulation is injected intramuscularly into the deltoid, thigh, or gluteal muscle once every 28 days ± 5 days. Pregnancy rates are reported to be about 0.1% after 1 year of use. The estradiol is cleared about 2 weeks after the injection, and withdrawal bleeding usually occurs between 2 and 3 weeks after each injection. Because the amount of medroxyprogesterone is markedly less than that used in DMPA, the progestin is cleared more rapidly, and ovulation and resumption of fertility occur within a few months of discontinuation.

Subdermal Implants

Constituents and Use

Several types of subdermal implants containing only progestins are effective long-acting methods of contraception. The initial formulation that was marketed consisted of six 3.4-cm polydimethylsiloxane (Silastic) capsules, each containing 36 mg of levonorgestrel, and was very effective. Subcutaneous insertion in the upper arm is performed in an outpatient setting by a small skin incision with local anesthesia. The capsules are removed when desired by the user or at the end of 5 years, which is the duration of maximal contraceptive effectiveness. Return to ovulation is prompt after implant removal. These capsules are no longer marketed in the United States.

Side Effects

The major side effect is the totally irregular pattern of uterine bleeding. Bleeding episodes are more prolonged and irregular during the first year of use, after which they become more regular as ovulatory cycles occur.

Pregnancy Rates

Annual pregnancy rates for the first 5 years of use are about 0.2 per 100 women. The cumulative 5-year pregnancy rate is 1.1%.

Silastic Rods

A formulation containing levonorgestrel in two 4-cm Silastic rods has a pharmacologic pattern similar to that of the six capsules with similar effectiveness and side effects. The two rods are easier to insert and to remove than the six capsules. A single 4-cm by 2-mm ethylene vinyl acetate rod containing 68 μg of etonogestrel, the active metabolite of desogestrel, provides effective contraception for 3 years. This rod is packaged in a disposable metal trocar inserter and does not require a skin incision for insertion, only for removal. Ovulation is inhibited by the circulating etonogestrel levels, and no pregnancies were reported in three large clinical trials. As with other progestin-only implants, irregular bleeding is the most common clinical complaint. This implant has recently become available in the United States and is the only implant marketed in the United States.

Emergency Contraception

For a woman not using contraception, if emergency contraception is given within 72 hours after a single coitus in midcycle, about 75 to 85% of pregnancies will be prevented. If more than one episode of coitus has occurred, or if treatment was initiated later than 72 hours after coitus, the method is less effective. Until recently, the most commonly used regimen was ingestion of four tablets of the OC containing 50 μg of ethinyl estradiol and 0.5 mg DL-norgestrel, in doses of two tablets 12 hours apart. The pregnancy rate with this regimen is 2%, about one fourth that of the 8% expected rate. Another formulation consisting of a 750-μg single tablet of levonorgestrel given once every 12 hours is more effective than the two tablets of the combination steroid formulation without the estrogenic side effects. This formulation is marketed for use as an emergency contraceptive in the United States and elsewhere and prevents about 85% of the expected pregnancies, for a pregnancy rate of 1%.

Intrauterine Devices

Constituents and Use

The main benefits of IUDs are a high level of effectiveness, a lack of systemic metabolic effects for copper IUDs, and the need for only a single act of motivation for long-term use. Despite these advantages, only about 1% of reproductive-age women use the IUD in the United States, compared with 15 to 30% in most European countries and Canada. The copper T380A IUD is the only copper-bearing IUD currently marketed in the United States, but the Multiload CU 375 is widely used in Europe. The copper T380A is approved for use in the United States for 10 years and maintains its high levels of effectiveness for at least 12 years. A levonorgestrel-releasing IUD is also marketed in the United States and elsewhere. A dose of 20 μg of levonorgestrel diffuses from the device into the endometrial cavity each day. Because of the progestational effect on the endometrium, the amount of uterine bleeding is markedly reduced with use of this device, and it has been used therapeutically to treat menorrhagia. This device has a high level of effectiveness for 5 years, which is the approved duration of use.

The main mechanism of contraceptive action of copper-bearing IUDs is spermicidal. This effect is caused by a local sterile leukocytic response produced by the copper as well as the plastic IUD itself. Because of the spermicidal action of IUDs, few if any spermatozoa reach the oviducts, and the ovum usually does not become fertilized. The levonorgestrel-releasing IUD acts mainly by preventing transport of spermatozoa through the cervical mucus and thus preventing fertilization of the ovum. After removal of each type of IUD, the inflammatory reaction rapidly disappears and resumption of fertility is prompt.

Pregnancy Rate

In the first year of use, IUDs have less than a 1% pregnancy rate, a 10% expulsion rate, and a 15% rate of removal for medical reasons, mainly bleeding and pain. The incidence of each of these events, especially expulsion, diminishes steadily in subsequent years. Mefenamic acid ingested in a dosage of 500 mg three times a day during the days of menstruation has been shown to significantly reduce the amount of uterine bleeding in IUD users.

Side Effects

Development of acute salpingitis more than a month after insertion of the IUD is due to infection with a sexually transmitted pathogen and is unrelated to the presence of the device. All IUD-related upper genital tract infections occur only during the insertion process. If there is clinical suspicion that cervicitis is present, the endocervix should be cultured and the insertion delayed until the results reveal that no pathogenic organisms are present. It is not cost-effective to routinely administer antibiotics with IUD insertion.

The IUD is not associated with an increased incidence of either endometrial or cervical carcinoma. The IUD is a particularly useful method of contraception for women who have completed their families, and its effectiveness is similar to that of tubal sterilization. It was calculated that after 5 years of use, the IUD is the most cost-effective of all methods of contraception, including sterilization.

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