Extended Contraception

Army Col. Peter Nielsen, MD, director of clinical operations for the Western Regional Medical Command and the OB/GYN consultant to the Army Surgeon General, acknowledged that IUDs generally are “underutilized.” He told U.S. Medicine that, while IUDs may not necessarily be the ideal contraception for a woman who wants to get pregnant in the short-term, IUDs may be a very good choice for longer-term contraception.

“They are much more effective in reducing unintended pregnancies, because there is no compliance issue that you have to worry about,” he said.

For military women who are on deployment, an IUD can be an easier choice than remembering to take a birth-control pill, he said, although other issues may come up.

“There is no reason why you could not put an IUD in prior to deployment, but the potential problems with IUDs is that they may produce side effects that the patient doesn’t want to tolerate, so they have to be removed,” he said. “That can happen whether you are deployed or not. If you have it removed when you are deployed, then what are your other options while deployed? They may be more limited on deployment.”

The copper IUD might increase menstrual bleeding or cramps, although the hormonal IUD can reduce those. The hormonal IUD can cause benign ovarian cysts, which usually go away on their own, and side effects similar to those caused by oral contraceptives, such as breast tenderness, mood swings, headaches and acne. Those side effects tend to subside with time.

Side effects also are common in other types of prescribed contraceptives and can affect compliance. A 2009 study of 399 deployed military women in Iraq conducted by Nielsen and his colleagues underscored the challenges that women who use contraception in theater may face.

Among those who reported irregular bleeding, it was more common among soldiers using hormonal contraception than those not using a contraceptive method (54/172 vs. 29/218). However, among those women using hormonal contraception, 16% (27/172) reported forgetting to take pills or replace patches. Irregular bleeding was most common among depo-medroxyprogesterone acetate users, with 52% (14/27) reporting this problem.

In addition, “of the 35 soldiers using the Ortho Evra contraceptive patch, 15 (43%) had patches fall off under these conditions and climate, resulting in 9 of the users abandoning this method for another option. A total of 44% (172/392) of women used hormonal methods during deployment and 42% (30/172) of these women changed their form of contraception because of unavailability of their contraceptive method.”

The authors noted that the high rates of irregular bleeding from continuous oral contraceptive pills and the patch “may have been attributable to missed pills and/or patches falling off, as well as a consequence of continuous OCP use.”

Nielsen and his colleagues reported in the study that predeployment counseling about contraception and menstrual-cycle control was lacking for deploying women and emphasized the need to include it in predeployment screening.

“Only one-third of the servicewomen surveyed received information on these issues. Of these women who were counseled, only 13.5% were given several options for menstrual cycle control. It is clear that, as part of the predeployment counseling, providers should be prepared and well-versed in explaining the variety of realistic expectations of potential side effects from from all methods of contraception/menstrual cycle control,” they wrote.

Women in the military also have to face the realities of what birth-control options are possible during deployment, Nielsen pointed out.

“Some are not practical to keep in theater. Some of them [e.g. once-a-month birth control devices] require refrigeration and there are places where there are not refrigerators or electricity available,” he said.

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