Long-term contraception in young women: special focus on nulliparous women and contraception following abortion

A. E. Gebbie

Lothian Primary Health Care Trust, Family Planning and Well Woman Services, Edinburgh, UK

Many young women in the western world plan to delay childbearing until they feel established in their chosen career and financially able to cope with children. The average age for first birth in the UK is now over 29 years. Young women have traditionally used the combined oral contraceptive pill and/or condoms but, for those in established, stable relationships, it is entirely appropriate to consider a longer-term method of contraception which offers high efficacy but a rapid return to fertility at the time when pregnancy is desired. A longer-term method of contraception gives a young woman freedom from having to remember contraception on a daily basis. Careful counselling and selection of suitable women are the key to success for longterm methods of contraception.

The options to consider include the depot injection of medroxyprogesterone acetate, the subcutaneous implant (Implanon®), an intrauterine device (IUD) or hormone-releasing intrauterine system (IUS). The IUD and IUS have traditionally been mainly reserved for parous women but may be entirely appropriate methods of contraception for young nulliparous women within stable relationships. Insertion of an IUD or IUS can often be achieved without difficulty in a nulliparous woman, particularly if the operator is experienced and willing to use local anaesthesia and cervical dilatation. IUD continuation rates in nulliparous and parous women are not dissimilar.

Following abortion, women may be optimally motivated to prevent a further unplanned pregnancy. The timely provision of contraceptive advice and supplies is vital as the return of fertility is rapid and low numbers of women attend follow-up visits following abortion. However, it has been shown that most women discontinuing combined oral contraception are likely to do so in the first 2 months of use and therefore offering a longer-term method may be associated with a possible reduction in repeat abortion rates. Immediate post-abortal insertion of an IUD has been found not to be associated with an increased risk of perforation, expulsion, pelvic inflammatory disease or failure compared to an interval insertion. The well-informed woman will accept the higher incidence of amenorrhoea associated with an IUS.

In summary, longer-term methods of contraception may offer the younger woman significant advantages in terms of reliability and high efficacy. Women embarking on these methods should receive careful counselling and be given good back-up support from their health-care advisors.