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Why have I been given so much misinformation, especially about Mirena? Can I use an IUD even through I have never been pregnant? #773/6

Why are so many gynecologists so ill-informed?

Finding the right contraception has been hard for me, because I have some complicated concerns: (1) my dad has had multiple episodes of DVT, despite having no obvious risk factors, and is now on Coumadin for life -- so I worry about the risk about high-dose estrogen for me. (2) I have a history of severe major depression -- which makes me worry about mood effects. (3) I am on Trileptal (oxcarbaxepine) for partial-complex seizures -- which makes all oral contraceptives ineffective I told my first gynecologist about all of these, and he wanted to put me on a standard birth control pills anyway. I said no thanks and found a new one.

By the time I found a new ObGyn, I'd done more research (and was married), so I'd decided to get an IUD. She refused and said it would make me infertile by causing PID. I reasonably said I didn't have any STDs then and I was in a monogamous marriage, and she still refused. She said the tTileptal wouldn't have that big an effect on the pill unless I used a mini-pill. She also tried to "push" some form of birth control pill on me, which I again refused.

I finally went to Planned Parenthood and now I happily have a Mirena. I feel like previous doctors were willing to endanger my life and risk an unwanted pregancy, when they should've known better. I'm in medical school now, and this may inspire me to be a gynecologist myself, because we need more like all of you and less like the ones I've encountered.

Second year medical studen



Such an interesting history.  Sorry about the misinformation given to you.  I am glad you were served so well at Planned Parenthood. I am so glad your Mirena is serving you well.  Great choice in your situation.

The IUD is a safe and extremely effective contraceptive option for some women who have not yet been pregnant.  Below are two paragraphs by Dr. David Grimes of Family Health International and the University of North Carolina, Chapel Hill on the provision of IUDs for women who have not been pregnant:

 

Women who have not been pregnant.  Although "nulliparity" is often cited as a relative contraindication to IUD use, the real issue appears to be "nulligravidity," i.e., never having been pregnant before.  Uterine enlargement by pregnancy, even one lost through miscarriage or induced abortion, seems to promote successful IUD use.  Sexual lifestyle, e.g., number of sex partners, appears to be a more important risk factor for upper-genital-tract infection than age or parity per se.  After its review of the evidence, the WHO listed nulliparity (not having given birth) as category 2, meaning that; in general, the benefits of IUD use outweigh the potential or known risks.  However, the WHO noted that nulliparous women have an increased risk of expulsion.

 

Because of the small diameter of their cervical canals or size of their endometrial cavities, women who have not been pregnant may have a higher rate of mechanical problems with IUDs than do other women.  Several steps can facilitate IUD insertion in nulliparous women and thus minimize the risk of a vasovagal reaction.  Cervical priming with misoprostol 400 mcg either a few hours or the night before insertion can open the canal.  Similarly, one or more osmotic dilators, such as laminaria, left in overnight will gently dilate the canal to a small diameter.  Prophylaxis with an oral nonsteroidal anti-inflammatory drug and paracervical anesthesia can help as well. [Grimes, 2004]

 

 Your experience reminds me of a conference 10 or more years ago.  I asked participants to jot down on a page their experiences putting in IUDs for never-pregnant women.  The clinician who had inserted the most was a professor at a nearby medical school.  She had inserted 10-12 IUDs for nulligravida women.  All were inserted for medical students!

 

For further information look at the following questions:

What were the most important findings in the randomized study of pills and the Mirena IUD in nulliparous women?  Click here

 

What are the advantages of Mirena and ParaGard IUDs? Click here

 

Depression is such a difficult problem.  Stay on top of it because there are so many good treatments for depression that help you to live a successful, happy life.  Do please become a gynecologist!!!

See the boxed message below:

DEPRESSION

 

Depression can recur many times.  Depression is complex.  Sometimes it is a normal reaction to a life event and not severe.  Treatment may or may not be necessary.  Major depressions are serious.  There are 40,000 to 50,000 deaths due to suicide each year in the United States and in up to 70% of these suicides, clinical depression is the proximal cause.  About 20% of women and 10% of men will have a major depression in the course of their lifetime.

 

Depression is a mood disorder, but in some cases it presents as any number of symptoms and is not recognized by the effective person as "depression".  The signs and symptoms of depression range from change in mood (depressed, sad, blue), lack of pleasure from things that used to be pleasurable, fatigue, and decreased activity, TO changes in sleep patterns, weight loss or gain, decreased motivation, decreased attention to or interest in job, family, friends or appearance, decreased sex drive, and decreased concentration.

 

Take home message: depression may present in many, many ways.

 

Depression deserves careful attention.  Some people feel ashamed or embarrassed to have been depressed.  Depression can be successfully treated in most women and should not be neglected.

 

Sometimes women using one of the hormonal methods find that their depression improves.  Occasionally it becomes worse.  If depression clearly starts or becomes worse while using a hormonal method, you must tell your clinician.

 

Women whose depression occurs in a cyclic pattern-either premenstrually or at the time of the menstrual period-may find that their depression improves if the contraceptive they use eliminates monthly menstrual periods.

 

The contraceptives that may eliminate or decrease the number of monthly menstrual periods are:

  • Combined pills taken continuously
  • Patches used continuously (Ortho Evra patches)
  • Vaginal rings used continuously (NuvaRing)
  • Depo-Provera injections
  • Contraceptive implants (Implanon will soon be available)
  • And the levonorgestrel IUD (Mirena)

 

 

 Her reply (8-3) to our first email: "Thank you for your kind message.  It is always good to hear that someone agrees that a decision really was the most sensible one." 

Comments from Dr. Timothy Johnson:  I found this very interesting, the evidence of issues we need to deal with in the education and professionalization of physicians.

1.      Clearly some of the physicians consulted were not up to date on the facts on IUD safety, and this is inexcusable.  In order to provide appropriate and ethical care, physicians must first and foremost be thoroughly knowledgeable about the science, and this could not be more apparent or important than in contemporary times when patients have access to cutting edge scientific and medical education on line and use it in their medical decision making.  (Although the variable quality of this information is something that patients and doctors must be vigilant about.)

2.      Physicians, in my opinion, too often still provide paternalistic care from their "white-coated" position, rather than truly engaging their patients in what should be a partnership - a partnership that includes an exchange of facts, preferences, advice, uncertainly and recommendations.  Making sure that doctors are trained to be competent, respectful, professional partners when they have the incredible privilege of being in "doctor-patient" relationships (I have been a physician for 30 years, and still am in awe of this wonderful opportunity that the Hippocratic Oath gave me and gives me every day) is a responsibility that medical educators and physician leaders need to give serious attention.

Comments from Dr. Lynn Borgatta:  I thought it was terrific.  I crawled through all the links and they were all relevant and nicely done.

Comments from Dr. Kimberly R. Looney:  YES! An IUD may be used in a nulliparous patient though those with a more traditional training and/or philosophy may practice otherwise.  However, where evidence-based medicine is concerned, there are no clear and significant contraindications to use of the IUD in nulliparous women.  In fact, I as well as a number of my colleagues, fall into that category.  My own personal experience has been that it is becoming a more readily used form of contraception among younger, professional/career oriented women who are looking to simplify their contraceptive regimens without loss of effectiveness or fertility.

 

I think your concerns about your own and family health risks are very valid.  I applaud your motivation to research your options and advocate for a method that you clearly feel would work best for you and your lifestyle.  A patient's satisfaction and motivation to use a product only translates into a higher degree of compliance and desired outcomes.   

  

 I wish you much success in your future endeavors and by all means give ObGyn strong consideration as you seem to have a high aptitude for it and would be a great patient advocate.

 

Comments from Dr. Carrie Cwiak:  I think this a great response by Dr. Kim Looney!  I would only clarify that P450 metabolism affects estrogen and progestin metabolism - so the mini-pill is affected as well.  Depo-Provera's efficacy is not affected due to its high dose.  Mirena will likely not be affected since it acts by local release of hormones that bypass first pass metabolism - small trials with a few meds have suggested this is so, but more study needs to be done on Mirena, and likewise the ring for the same reason.


Key Words:  contraceptives, complicated concerns, multiple episodes, DVT, risk factor, high-dose estrogen, severe major depression, mood swings, Trileptal, seizures, ineffectiveness, birth control pills, IUD, infertile, PID, monogamous marriage, mini-pills


Posted 8-12-2006, Updated 8-14-2006, Updated 8-19-2006, Updated 10-3, 2006, Updated 2-11-2009 

Robert A. Hatcher MD, MPH
Emeritus Professor of Gynecology and Obstetrics
Emory University School of Medicine
Atlanta, GA
---2009-02-12

The directors and owners of this website and any publications and information concerning health matters offered here advise a person with a particular problem to consult a primary-care clinician or a specialist in obstetrics, gynecology, or urology (depending on the problem or the contraceptive) as well as the product package insert and other references before diagnosing, managing, or treating the problem.
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