Adolescent Experiences with IUDs: a Qualitative Study

Abstract

Purpose

To improve understanding of adolescents’ reasons for choosing an intrauterine device (IUD) and to explore experiences that led to continuation or discontinuation of the levonorgestrel intrauterine system (LNG-IUS) and the copper intrauterine device (copper IUD).

Methods

We conducted focus groups with adolescents and young women who were current or former IUD users stratified by IUD type and 12-month IUD continuation or discontinuation. All subjects were participants from the Contraceptive CHOICE Project. Focus group data was supplemented with in-depth interviews. Data collection was continued until thematic saturation was reached. Transcripts were independently coded by two researchers and inter-rater reliability was calculated using a Kappa coefficient. Analysis followed a standard text-analysis approach.

Results

Thirteen focus groups and 7 in-depth interviews were conducted with 43 young women. Effectiveness, duration of use, convenience and potential bleeding changes emerged as themes for both choosing and continuing IUDs. Some women chose the LNG-IUS to achieve amenorrhea, while copper IUD users wanted a non-hormonal method and continued menses. Copper IUD users cited expulsion and bleeding irregularities as reasons for discontinuation, whereas LNG-IUS users reported bleeding irregularities and continued pain as reasons for removal. IUD users noted an adjustment period of weeks to months in which side effects were present before lessening.

Conclusions

Effectiveness, duration of use, convenience, and potential bleeding changes drove adolescents’ choice and continuation of an IUD. Bleeding changes and pain contributed to IUD discontinuation. Discussion of effectiveness, duration and convenience, and anticipatory guidance regarding post-insertion side effects may be important in counseling young women about IUDs.

The U.S. has one of the highest adolescent birth rates in the developed world [1]. Of the 6.6 million pregnancies that occur in the U.S. each year, half are unplanned and approximately 40% of those will end in abortion [2, 3]. Adolescents are at particularly high risk for unintended pregnancy - 82% of pregnancies in women age 15–19 are unplanned [4]. The two most commonly used forms of contraception in this age group, oral contraceptive pills (OCPs) and condoms, have failure rates of 9–18% and are often used ineffectively. Prior studies have demonstrated that adolescents have higher contraceptive continuation and lower pregnancy rates with methods that do not require daily maintenance or regular use at the time of intercourse [5]. These characteristics of long-acting reversible contraception (LARC), which includes the intrauterine device (IUD) and the implant, make these ideal methods for many adolescents.

Currently less than 7.7% of contracepting women use an IUD [6]. In 2009 only 4.5% of 15–19 year olds were using LARC, the majority were IUDs [6]. The American College of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention, and the American Academy of Pediatrics recommend that LARC should be offered as a first-line contraceptive method to all women and adolescents [7–10]. Despite this endorsement, physician concerns of pelvic inflammatory disease, infertility, and safety of the devices have limited IUD use in adolescents [11]. Additionally, younger women may be less aware of LARC as potential contraceptive methods. Health care providers who are uncertain about suitability of LARC may not educate patients about the methods, and then perceive low uptake as disinterest [12,13]. Prior qualitative work suggests that patient education by clinicians can increase use of certain contraceptive methods [14,15].

With less than 5% adolescents currently using an IUD, there is limited information on adolescent and young women’s contraceptive decision making and their experiences with IUDs. Prior qualitative research has examined young women’s knowledge and attitudes regarding LARC, but these studies have not included adolescents who were current IUD users or have centered around the time of pregnancy [12][14][16–18]. A qualitative analysis of women prior to abortion found that issues of cost, method awareness, and side effects impact contraceptive method choice [12]. Another qualitative analysis with post-partum adolescents found that older eligibility requirements, long wait times, and fear of side effects were obstacles to obtaining IUDs [14]. In a cross-sectional survey of teenagers, participants were similarly concerned about side effects, including irregular bleeding and insertion pain [16].

The purpose of this qualitative study is to explore why adolescents enrolled in the Contraceptive CHOICE Project chose an IUD and to explore the experiences of adolescents and young women that continue and discontinue this highly effective contraceptive method.

Methods

Participants

We conducted a qualitative study utilizing focus groups and in-depth interviews with young women enrolled in the Contraceptive CHOICE Project (CHOICE) who chose an IUD as an adolescent. CHOICE was a prospective cohort study in St. Louis, Missouri of 9,256 women designed to: 1) promote the use of LARC; 2) remove financial barriers to contraception; 3) evaluate continuation and satisfaction for reversible methods; and 4) reduce unintended pregnancies in the region [19].

Potential participants were identified through the CHOICE database, contacted by telephone, and screened for eligibility. Participants were eligible if they were current or former IUD users, had an IUD placed between the age of 14–19, English-speaking, currently living in the St. Louis area, and willing and able to give informed consent. Our potential population of CHOICE participants is somewhat unique in that most adolescents joined the project with parental consent, and a large proportion of these young women had a previous pregnancy. Eligible participants were offered one-time participation in a focus group or in-depth interview.

Procedures

There were 467 CHOICE participants who had an IUD placed between the age of 14 and 19 and were potentially eligible for participation. We planned to only contact the number of participants necessary to recruit an adequate sample for the focus groups. We followed a standard algorithm for participant recruitment. We first called potential participants on their listed home or cellular telephone number (if available) provided by the participant to the CHOICE Project and screened the participant by telephone. If the participant did not answer, we left a voicemail message. If no return telephone call was received within two days, we called the number again. If there was no response, we then called the provided alternate numbers (family members, friends, or partners). An email was also sent if an initial response was not obtained and if an email address was available. If, after three telephone calls, no contact was made, we used our electronic medical record (EMR) program to look for updated telephone numbers.

All focus groups were held at our university clinical research site where most CHOICE participants enrolled in the parent study. After providing informed consent, participants completed a brief demographic survey. All focus groups and in-depth interviews were recorded using a digital audio recorder and professionally transcribed.

We developed a semi-structured interview guide for the focus groups. Topics included the factors influencing choice of IUD (e.g. “Why did you choose an IUD?”), experience with the IUD (e.g. “Did you experience any side effects, if so what were they?”), factors influencing continuation or discontinuation e.g. “(If you continued your IUD, why?” “If you discontinued, why?”), and how their experience could have been improved (e.g. “What did you wish you knew prior to getting the IUD?”).

In qualitative research, a sample size is not determined beforehand. Rather, sampling is continued until no new themes are elicited. This is referred to as “thematic saturation”. We estimated that thematic saturation would be reached with a total of 60 participants We planned to stratify by IUD type, including 30 copper IUD users and 30 LNG-IUS users. The copper IUD and LNG-IUS groups were further stratified by continuation status; 15 adolescents who used the copper IUD or LNG-IUS for at least 12 months and 15 who had discontinued the copper IUD or LNG-IUS prior to 12 months. We planned to recruit a total of 60 participants and estimated that we would need to hold 2–3 focus groups with 5–8 participants each. If too few participants arrived to a focus group or if we were unable to recruit an adequate number of participants, the focus groups were supplemented with in-depth interviews. We followed the same semi-structured interview guide for in-depth interviews. We planned to end data collection when thematic saturation was reached.

Transportation costs were reimbursed in the form of a travel voucher if participants utilized public transportation. Participants received a gift card in appreciation for their time.

Data Analysis

We conducted our analysis of the transcripts concomitantly with data collection to identify emerging themes. These themes were then explored in subsequent focus groups. Analysis of the data included iterative reviews of the transcripts to identify themes and the creation of a master codebook with themes and definitions, so that coding was consistent across interviews. We used a qualitative data analysis software program (NVivo 10; QSR International, Victoria, Australia) to organize and code the transcripts. Transcripts were independently coded by two researchers (E.O.S. and K.M.C.) and inter-rater reliability was calculated using the Kappa coefficient and found to be 0.75–0.86. The analysis followed a standard text analysis approach [20]. Minor discrepancies were resolved by discussion and consensus between the two researchers and a senior member of the research team (T.M.).

Prior to any study activities, we obtained Institutional Review Board approval from the Washington University Human Research Protection Office. Written informed consent was obtained from all participants.

Results

We conducted 13 focus groups with a total of 36 participants. Due to difficulty recruiting copper IUD users and low show-rates for scheduled focus groups, focus groups were supplemented with 7 in-depth interviews for a total sample size of 43 participants. We conducted all focus groups and in-depth interviews between September 2013 and February 2014. We screened 112 young women of which 43 agreed to participate; 69 young women who did not participate failed to show up to their group or interview. The stratified groups were comprised of 14 LNG-IUS continuers, 12 LNG-IUS discontinuers, 11 copper IUD continuers, and 6 copper IUD discontinuers. Some of the focus groups were conducted with mixed IUD type and continuation status. We ended data collection when no new themes emerged and thematic saturation was reached.

As shown in Table 1, most participants were between 22–25 years of age at the time of focus group participation with the exception with copper IUD discontinuers who were slightly younger. Half (50%) of the copper IUD discontinuers were 18–21 years old at the time of participation. The mean age at IUD insertion was 18 +/− 1.4 years. With the exception of LNG-IUS continuers, the majority of participants had previously been pregnant at the time of study enrollment; 43% of LNG-IUS continuers, 66% of LNG-IUS discontinuers, 54% of copper IUD continuers, and 83% of copper IUD discontinuers reported at least one pregnancy. The median length of time participants had their IUD was 15 months (range: 1 – 72 months). The median amount of time IUD discontinuers had their IUD was 6 +/− 2.6 months.

Table 1.

demographic data by IUD type (n= 43)

	LNG-IUS continuer (%) n=14	LNG-IUS discontinuer (%) n=12	Copper IUD continuer (%) n=11	Copper IUD discontinuer (%) n=6
Age (years) *
18–21	4 (29)	3 (25)	5 (45)	3 (50)
22–24	7 (50)	8 (67)	4 (36)	2 (33)
25+	3 (21)	1 (8)	2 (18)	1 (17)
Race/ethnicity
Latina	1 (7)	1 (8)	1 (9)	1 (17)
African American	9 (64)	4 (33)	3 (27)	3 (50)
White	5 (36)	5 (42)	6 (54)	2 (33)
Other	0 (0)	3 (25)	2 (18)	1 (17)
Gravidity
0	8 (57)	4 (33)	4 (36)	1 (17)
1	3 (21)	1 (8)	4 (36)	5 (83)
2	0 (0)	3 (25)	2 (18)	0 (0)
3+	3 (21)	4 (33)	1 (9)	0 (0)
Parity
0	11 (79)	5 (42)	7 (63)	3 (50)
1	0 (0)	4 (33)	3 (27)	3 (50)
2	3 (21)	3 (25)	1 (9)	0 (0)
3+	0 (0)	0 (0)	0 (0)	0 (0)
Education
Less than high school	0 (0)	1 (8)	1 (9)	0 (0)
High school diploma	0 (0)	4 (33)	2 (18)	0 (0)
Some college	11 (79)	5 (42)	4 (36)	4 (67)
College degree	3 (21)	2 (17)	4 (36)	2 (33)
Trouble paying for basic Needs
Declined	1 (7)	1 (8)	0 (0)	0 (0)
Yes	2 (14)	4 (33)	3 (27)	1 (17)
No	11 (79)	7 (58)	8 (72)	5 (83)
Previous methods used**
Implant	4 (29)	5 (42)	4 (36)	3 (50)
OCPs	7 (50)	6 (50)	5 (45)	5 (83)
Patch	2 (14)	3 (25)	1 (9)	0 (0)
Ring	2 (14)	3 (25)	0 (0)	1 (17)
DMPA	4 (29)	4 (33)	1 (9)	4 (67)
Condoms	9 (64)	9 (75)	10 (90)	6 (100)
Diaphragm	1 (7)	0 (0)	0 (0)	0 (0)
Sponge	0 (0)	1 (8)	0 (0)	0 (0)
Other	4 (29)	6 (50)	4 (36)	3 (50)
BTL	0 (0)	0 (0)	0 (0)	0 (0)
Vasectomy	0 (0)	0 (0)	0 (0)	0 (0)

DMPA: depo medroxyprogesterone acetate, OCPs: oral contraceptive pills, BTL: bilateral tubal ligation

^*at time of study

^**multiple entries, does not total 100%

Reasons for Choosing the IUD

Several themes emerged as reasons for choosing both types of IUDs. Effectiveness, duration of use, and convenience were identified as important factors in the choice of an IUD. Both LNG-IUS and copper IUD users felt reassured by the high effectiveness of their device.

“It’s…almost 100% effective so…I never worried about getting pregnant” LNG-IUS continuer, focus group (FG) participant.

“I feel like it’s one hundred percent” Copper IUD continuer, FG participant.

Under the broad category of effectiveness, the subtheme of “peace of mind” emerged. Participants often used this specific phrase to describe how the IUD alleviated the anxiety of an unplanned pregnancy.

“And more than anything, the benefit that I got from it was just reassurance and just knowing it’s very, very, very unlikely that I will be pregnant until I want to be. And that gave me just ultimate peace of mind” Copper IUD continuer, FG participant.

“The biggest thing is… the peace of mind that comes with it… I could never do birth control pills…I take other medications, I have to take daily at the same time and I…never do it… there’s so much uncertainty…But it’s not there with the IUD” Copper IUD continuer, FG participant.

Copper IUD users identified the long duration of the use of the copper IUD as an important characteristic.

“The length of time that you can leave it in…it’s not like you have to take it out after three years or five years. That was awesome” Copper IUD continuer, FG participant.

“I chose it for the length of time… for the Mirena…if you don’t want to have a child in your three year or five year plan then get something that’s longer than that. So this was the only thing that was longer than that” Copper IUD continuer, FG participant.

In choosing a contraceptive method, LNG-IUS users also considered the length of time their IUD would last. Many spoke of wanting to delay childbearing until after obtaining further education.

“I knew it was going to be long-lasting and with me being in college… it would be a long time before I wanted to have a baby” LNG-IUS discontinuer, FG participant.

For users of both types of IUDs, having a low-maintenance birth control was important.

“I don’t have to think about it. I don’t have to worry about it” LNG-IUS continuer, FG participant.

“You didn’t have to like keep up with it…there wasn’t … an every day take a pill or every month change it…it was there and you didn’t have to worry about it” LNG-IUS continuer, in-depth interview (IDI) participant

Several women reported the importance of the information they received in contraceptive counseling in their decision-making.

“I feel like I was assisted properly in understanding the risk and benefits of each device or medication” Copper IUD continuer, FG participant.

The different bleeding profiles of the LNG-IUS and the copper IUD were important to adolescents in choosing the type of IUD. Women who chose the LNG-IUS viewed amenorrhea or lighter periods as an advantage.

“I do like not having my period so it’s very convenient. I don’t have to worry about what time of the month it is” LNG-IUS continuer, FG participant.

“I like not having my period… it simplifies everything” LNG-IUS continuer, FG participant.

In comparison, young women who chose the copper IUD desired regular cycles and/or a non-hormonal method. Some participants stated that having a monthly period provided reassurance that they were not pregnant.

“For me I had like[d] knowing that I’m going to have my period” Copper IUD continuer, FG participant.

Other young women wanted to avoid hormones due to perceived weight gain or side effects they had experienced with other hormonal methods of birth control (although less commonly experienced with the LNG-IUS given lower systemic hormone levels).

“I already had my mind made up because of the non-hormonal…this is something that is healthy for me and easy” Copper IUD continuer, FG participant.

“The reason why I got the ParaGard over the Mirena was because of the breast cancer – hormonal aspect” Copper IUD discontinuer, IDI participant.

The reported reasons for choosing an IUD did not appear to differ by those who continued or discontinued their IUD. In Table 2, we present quotes from both LNG-IUS continuers and discontinuers. Likewise, among the copper IUD users, reasons for choosing were similar between continuers and discontinuers (shown in Table 3).

Table 2.

Reasons for choosing the LNG-IUS: Continuer v. Discontinuer quotes

Continuer	“[The] Mirena lasts up to five years… I won’t get pregnant for five years straight… that’s good because I don’t want no kids ‘til I’m like 27 anyway” LNG-IUS continuer, FG participant.
	“It’s in and I’m not worrying about anything. You know not tracking stuff on your phone, not marking dates on the calendar trying to figure out… It was really nice” LNG-IUS continuer, FG participant.
	“This helps stop your periods too if you got bad cramps” so I went and got that” LNG-IUS continuer, FG participant.
Discontinuer	“I wanted something as less maintenance as possible. You know I didn’t want to have to remember to take the pills” LNG-IUS discontinuer, FG participant.
	“I liked the fact that it was very long term…what can I get that I just don’t have to worry about through college or through, you know, this relationship or whatever” LNG-IUS discontinuer, FG participant.
	“I picked the Mirena over the copper …because … it would help with cramps, it would help with your period and that’s pretty much – that was like music to my ears because I had both heavy periods and bad cramps” LNG-IUS discontinuer, FG participant.

Table 3.

Reasons for Choosing the Copper IUD: Continuer v. Discontinuer quotes

Continuer	“I found out I could actually get it, then I said, “Well sign me up.” Because I don’t want to take the pill anymore. I don’t want to remember anything. I know I don’t want to get pregnant” Copper IUD continuer, FG participant.
	“I chose it because it lasted for ten years, you didn’t have to come back and get it … checked up on. You didn’t have to … reinsert it. So … ten years, no hormones -- so you never gain weight” Copper IUD continuer, FG participant.
	“Because I don’t want to be pregnant. I’m not ready to have a baby. And that was the biggest reason why I got it. I was like, “I know the person that I am and I know I’m sexually active… I’m not ready to have a child.” And that’s why I got the ten years because I don’t want to have to worry about it” Copper IUD continuer, FG participant.
Discontinuer	“It lasts extremely long so I really didn’t have to worry about it” Copper IUD discontinuer, FG participant.
	“It’s more convenient for myself” Copper IUD discontinuer, FG participant.
	“I thought that it was a really great method of birth control seeing as how it lasts ten years…that was my number one thing that it lasts for so long and it’s also hormone free” Copper IUD discontinuer, IDI participant.

IUD Insertion and Adjustment After Insertion

Participants reported a wide range of experiences with the IUD insertion. Several participants reflected that they would have liked more information about the process beforehand.

“You did tell me but … I didn’t know it was going to be this bad!” LNG-IUS continuer, FG participant.

“When I first got the Mirena I was a virgin and it really didn’t hurt me” LNG-IUS continuer, FG participant.

In addition to the actual IUD insertion, some participants said they wished they had been better prepared for the side effects following the IUD insertion. Users of both types of IUDs described an “adjustment period” for these side effects. Participants also provided reasons for why they continued their method despite the side effects.

“My flow was a lot heavier, my cycle was a lot heavier for a couple of months. And then it went back to a regular…At first it was something that you have to get used to but once you go so many months, that’s something that you’ll like” Copper IUD continuer, IDI participant.

For this participant, her desire for a highly effective and low-maintenance method drove her willingness to wait out these side effects.

“…[T]he first two months there was a lot of spotting, which I didn’t like, but they told me that up-front that was going to happen” LNG-IUS continuer, FG participant.

Discontinuation

Reasons for discontinuation centered largely on bleeding, pain, and expulsion. Themes involving negative bleeding changes were noted among users of both IUDs and included increased volume and duration of bleeding. For some, bleeding changes were enough to request removal. Copper IUD discontinuers cited increased menstrual duration and flow as reasons for discontinuation; others experienced expulsion of the device.

“I also play volleyball ….we would…go on tournaments and I remember having to just … go and change my tampon … in the middle of a game…it was all consuming … interrupting my normal life and at that point I was like, “I just need to get this taken out” Copper IUD discontinuer, IDI participant.

“I came in and they said it’s [the IUD] coming out. So they had to remove it and I hadn’t got back since” Copper IUD Discontinuer, FG participant.

LNG-IUS discontinuers often cited frequent or irregular bleeding and continued pain as a bothersome side effect. These symptoms were enough to merit removal.

“I just kept dealing with the pain, thinking it was going to get better and then it never did” LNG-IUS discontinuer, FG participant.

Discussion

In this qualitative study, we found that effectiveness, duration, and convenience were important reasons for adolescents selecting an IUD. Participants reported wanting a low-maintenance, highly effective, and long-lasting method. When choosing between an IUD and other methods of contraception, many young women in our study desired contraception that will last several years. We also found that changes in bleeding patterns may be perceived as an advantage of the LNG-IUS.

Changes in bleeding patterns were an important contributor to both the decision to use an IUD and the decision to discontinue the device. Young women who wanted less bleeding or amenorrhea chose the LNG-IUS while those who did not want hormones due to a previous history of negative side effects or a desire to have “natural” contraception with monthly periods chose the copper IUD. Some LNG-IUS users felt that continued bleeding or pain drove them to have their IUD removed while copper IUD users cited increased bleeding and expulsion of the IUD for their removals.

Participants stated that they want to be well informed what to expect during the insertion. Counseling on what to expect prior to and during the procedure could potentially help in this regard. Outside of the initial IUD visit, participants want to be prepared for the discomfort that may occur after insertion.

Both IUD users reported an “adjustment period” in the weeks to months following insertion, in which they experienced side effects that gradually lessened. Participants who continued through the adjustment period often cited their original reasons for choosing the IUD as motivation for continuing the method. Some young women simply waited for the symptoms to resolve, others took medication or used heating pads for cramps, and others used the informational materials provided at their IUD insertion or visited websites to confirm that their side effects were normal. A small number of discontinuers felt ill-equipped to handle side effects such as bleeding and continued discomfort and became tired of the persistent symptoms. This eventually led to discontinuation. However, as the median length of time discontinuers kept their IUD was 6 +/− 2.6 months, it appears many participants worked through the adjustment period.

Brown et al. performed 20 semi-structured interviews with nulliparous adolescents at a family planning clinic in San Francisco [21]. These young women felt that tailoring counseling to fit their lives was helpful in choosing the IUD. Our findings are consistent with those of Brown, et al., participants chose the IUD based on their specific needs.

The role of the clinician on IUD use has been shown previously by Fleming et al. They found that participants were almost three times more likely to be interested in using an IUD if they heard about it from a health care provider [16]. It is also likely that providers have an impact on IUD continuation by providing pre-insertion counseling and anticipatory guidance about short- and long-term side effects and potential treatment options to help young women with these side effects. Prior to IUD insertion, providers can use pictures and models to explain the procedure. Pamphlets, handouts, and interactive websites may be employed also.

There are several strengths to our study. We had a relatively large sample of adolescent participants who had experience with an IUD, in comparison with other qualitative studies in which participants had not used an IUD. In addition, we were able to examine teen experiences with both types of IUDs, which have different side effect profiles. Despite initially not planning to use in-depth interviews, this format allowed adolescents to disclose opinions that might not be socially desirable.

However, our study was not without limitations. Our population was drawn from young women who participated in the CHOICE Project who had a unique (and less generalizable) experience as part of the larger research study. These women received structured contraceptive counseling and their method of choice at no cost which may have impacted their decision to use an IUD. Additionally, data collection occurred remotely from the decision to choose an IUD; and the reported experience may be subject to recall bias. Eight participants who were minors at the time of the interview (comprising less than 1% of the total sample) were excluded due to requirements to include minors in the study. Given the small pool of potential copper IUD users, we had challenges in recruitment and held in-depth interviews. This interview style may have elicited different information than that obtained in focus groups.

Our findings suggest that effectiveness, duration, convenience, and potential bleeding changes are important to young women when choosing an IUD. However, not all adolescents are well prepared for the immediate and future side effects they may experience with the IUD. Health care providers play a vital role. By counseling young women on the short- and long-term anticipated side effects and providing post-insertion support (including management of pain and bleeding changes), we can potentially increase the use and continuation of the IUD in this population.

Implications and contribution.

This study provides information about adolescent and young women’s contraceptive decision-making around IUDs as well as their experiences with the IUD that led to continuation or discontinuation. Discussion of potential side effects and time required for many of these side effects to resolve may be important during counseling young women.