Although IUD use in the United States lags behind that in other developed countries, recent changes to medical eligibility criteria might lead to increased utilization, Dr. Cwiak stated. “The use of IUDs in women younger than 20 is now considered safe. Also, removal of the IUD is not required in patients with actinomyces, bacterial vaginosis, Trichomonas, or cervicitis,” she said. “If pelvic inflammatory disease occurs in an IUD user, treatment is the same as in nonusers and removal is not necessary.”
In addition, the new package insert for ParaGard states that eligible candidates now include nulliparous and nulligravid women, women not in a mutually monogamous relationship, women with a history of sexually transmitted infection or pelvic inflammatory disease who do not have current risks, and women with history of ectopic pregnancy—all previously considered contraindications.
“The important thing to remember here is that we don't want to have an active infection at the time of insertion because of its placement through the cervix into the uterus,” said Dr. Cwiak. “We don't want to make an existing infection worse.”
The Mirena levonorgestrel intrauterine system, which releases levonorgestrel to the endometrium over 5 years, has been associated with improvement in menorrhagia and decreased uterine size and bleeding with fibroids, “which is probably why we're seeing it being used more and more,” Dr. Cwiak noted. “Also, [insertion of the device] is an easy in-office procedure that takes only a few minutes.”
The only implantable contraceptive currently approved for use in the United States is Implanon, a progestin-only single rod implant that delivers 40 mcg of etonogestrel per day and is effective for 3 years. With only one rod to implant, the subdermal insertion and removal of this contraceptive is markedly easier than that of its six-capsule predecessor, Norplant.
On the Horizon
In terms of future contraceptive developments, there are a number of short-term and long-term prospects, said Dr. Cwiak. One is the Nestorone/ethynyl estradiol vaginal ring for cyclic monthly use, which is not yet on the market in the United States. “The ring delivers 150 mcg of Nestorone and 15 mcg ethinyl estradiol and has an extremely high rate of ovulation inhibition and low rates of breakthrough bleeding,” she said.
Another promising product on the horizon is the invisible condom, a microbicide that offers both a physical barrier, in the form of a gel that blocks the entry of pathogens into the mucosa, and a chemical barrier—sodium lauryl sulfate—within the gel that kills sexually transmitted pathogens including HIV, Dr. Cwiak said.
According to the findings of a recent phase I trial, the gel, which is applied with a special applicator that delivers the product uniformly throughout the vagina and cervix, does not disrupt vaginal epithelium or pH, and it is well tolerated. The product is currently being investigated in a phase I/II placebo-controlled trial (Contraception 2007;76:117–25).