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.