MOH Brief 5 Minimal Associated Health Risks
Publication date: 2003
Sexually transmitted infections When IUCDs are inserted in women who do not have cervical infections, the risks of IUCD-related complications are low. But research conducted in Kenya has shown that women with cervical infections, including sexually transmitted infections (STIs), at the time of IUCD insertion are at more than twice the risk of complications related to IUCD use. Therefore, ideal candidates for the IUCD are women in stable, mutually monogamous relationships in which both partners are free of STIs. Providers can help rule out STIs by talking with clients about their sexual histories, examining clients for symptoms of STIs, and performing laboratory tests to diagnose specific infections, as indicated. Prospective IUCD users who do not fit the ideal profile should be counselled about STI prevention and about using condoms. Pelvic inflammatory disease Pelvic inflammatory disease (PID) is an infection of the female upper reproductive tract (uterus, fallopian tubes, and ovaries) that occurs when an STI or other infection in the vagina or cervix migrates into the upper reproductive tract. Untreated, PID can scar the fallopian tubes, sometimes leading to pelvic pain, ectopic pregnancy, or infertility. Most cases of PID are caused by gonorrhoea or chlamydia. If a woman has these infections at the time of IUCD insertion, the IUCD can carry them into the upper reproductive tract, sometimes causing PID. But even in settings with high STI prevalence, the risk of PID in IUCD users is estimated to be below 1 percent. Any risk of PID after IUCD insertion decreases over time. Twenty days after an IUCD has been inserted, the IUCD user is no more likely to develop PID than is a nonuser. Therefore, a client’s one-month follow-up visit is an important opportunity to detect PID, as well as any other problems. According to the World Health Organization’s selected practice recommendations for contraceptive use, if a woman develops PID at any time during use of the IUCD, the device need not necessarily be removed. Removal may be considered, however, if the PID does not respond to antibiotic treatment. Ectopic pregnancy An ectopic pregnancy is any pregnancy that occurs outside the uterus, such as in the fallopian tubes, abdomen, ovaries, or cervix. While this type of IUCD Method Brief No. 5 Minimal Associated Health Risks KEY POINTS FOR PROVIDERS: ����� Providers should screen clients for STIs before inserting an IUCD and counsel them to use condoms if they are at risk of STIs. ����� The risk of HIV acquisition or transmission through IUCD insertions is minimal. KEY POINTS FOR POLICY-MAKERS: ����� The IUCD is a safe component of a national family planning method mix. ����� Health risks associated with the IUCD are minimal. ����� Proper STI screening and provider training further reduce risk. KEY POINTS FOR CLIENTS: ����� The IUCD is an extremely safe contraceptive, especially when clients and their partners are free of STIs. ����� The one-month follow-up visit is especially important to confirm that the IUCD is properly in place and the client is both free from infection and satisfied with the method. Facts about PID: ����� The risk of PID after IUCD insertion is estimated to be below 1 percent. ����� After 20 days, IUCD users are at the same risk of developing PID as any other woman. ����� The presence of STIs — not the IUCD itself — increases risk of PID after IUCD insertion. ����� Being in a mutually monogamous relationship and using condoms when necessary can help prevent STIs, and thus PID. These briefs were produced by the Kenya Ministry of Health and its collaborating partners. This work is supported by the U.S. Agency for International Development (USAID). The contents do not necessarily reflect USAID policy. For more information or additional copies, please contact: Head, Division of Reproductive Health, Kenya Ministry of Health Old Mbagathi Road, P.O. Box 43319, Nairobi, Kenya Telephone: 254-2-2725105 Fax: 254-2-2716814 or Regional Director, Population and Reproductive Health Programs Family Health International, The Chancery, 2nd Floor, Valley Road P.O. Box 38835, Nairobi, Kenya E-mail: email@example.com Telephone: 254-2-2713913-6 Fax: 254-2-2726130 February 2003 pregnancy is dangerous, it is uncommon. Because the IUCD is so effective at preventing pregnancy in general, women who use the IUCD are actually at lower risk of ectopic pregnancy than are sexually active women who use no method of contraception. Uterine or cervical perforation Although perforation of the uterus or cervix can occur during an IUCD insertion, it is extremely rare. If it does occur, the IUCD should be removed (sometimes surgically) as soon as possible after perforation is detected, since an IUCD in the abdominal cavity can cause scarring. The risk of perforation can be minimised if providers are well trained in IUCD insertion techniques, as the skill and experience of the providers is the most important factor for minimising perforation. Provider acquisition of HIV The most frequent way health care providers or clients become infected with HIV is through sexual intercourse, just like any other person in Kenya. In a clinical setting, there is also a small chance that providers will become infected with HIV through sticks with contaminated needles. However, since no needles are necessary for an IUCD insertion or removal, providers of these services may be at even lower risk of HIV infection than are health care providers of other common, more invasive procedures. The risk that health care providers have of acquiring HIV from an HIV-positive client is the same risk they have of acquiring any other blood-borne disease (such as hepatitis B) from an infected client. Overall, trained health care providers are at extremely low risk of being infected with HIV during IUCD insertion, or of transmitting HIV from an infected IUCD user to an uninfected client, if they use proper infection-prevention precautions. These infection-prevention precautions are the same universal precautions recommended for providers to use for all their clients, regardless of their HIV status. No cases of HIV acquisition or transmission by a provider of the IUCD have ever been reported. Summary Health risks associated with IUCD use are minimal for both clients and providers. The greatest risk occurs if a client has an STI at the time of insertion, which can lead to PID and related complications. However, IUCD use does not increase a woman’s long-term risk of PID. All health risks can be even further minimised if providers are well trained and perform careful STI screening before IUCD insertion. The benefits of the IUCD — including its overall safety, effectiveness, cost, and convenience — far outweigh the health risks for most women. Training in and implementation of universal infection- prevention precautions are critical to successful IUCD provision.