Never underestimate the force of reproductionBMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7259.461 (Published 19 August 2000) Cite this as: BMJ 2000;321:461
All rapid responses
I was interested to read the editorial by Professor Basil Donovan,
regarding effective contraception for teenagers requiring a change of
medical culture. I am in agreement with his belief that we as medical
practitioners must constantly re-examine our own biases and prejudices in
order to deliver the best possible medical care to all our patients. I
found myself disagreeing strongly however with Professor Donovan's
contention that the Intrauterine Device (IUD) may well be the ideal
method of contraception for teenagers at risk of pregnancy because of
their difficulty in using the Combined Pill consistently.
John Guillebaud states in his book "Contraception - your questions
answered"2 with regard to Pelvic infection in IUD users that it is
primarily a 'self or partner inflicted wound'. There is no doubt that the
greatest risk of pelvic infection is in the first 20 days after the
insertion of the IUD, and is caused by pre-existing sexually transmitted
infection (STI) carriage. In most cases adequate pre-insertion screening
and treatment can indeed ameliorate this risk. The risk thereafter
however relates to the patient's background risk of STI's, and I would
contend that teenagers engaging in "sporadic, unexpected, or coerced"
intercourse could hardly be considered to be in a low risk category. Some
US studies have found a carriage rate for chlamydia in asymptomatic female
Seattle teenagers of 8.6%.3 The asymptomatic nature of the infection means
the majority of these young women would be unlikely to present for
screening or treatment. While the progestogen bearing IUD has a
theoretical benefit in increasing cervical mucus viscosity and thereby
possibly preventing ascending pelvic infection, this is as yet by no means
proven and manufacturers continue to advise that the device be used only
in those at low risk of STI's.
I agree that we in the medical profession perhaps need to look
"outside the square" when discussing contraception with young people, and
that recommending the pill as "99.9% effective" is a significant over-
statement in teenagers where non-compliance is a real issue. Thankfully
in many countries now we have long acting progestogen-based contraception
which may fact provide a possible solution to the compliance issue for
many young contraceptors since it does not have to be taken daily. One
option is Depot medroxyprogesterone acetate (DMPA) which many of us
working in the field of contraception have found a very useful choice for
our adolescent patients whose lives can undoubtedly be somewhat chaotic.
The availability of progestogen implants such as Implanon also allows for
long-term and convenient contraception for adolescents without the risks
associated with IUDs. In many countries also monthly combined injections
are available, overcoming to some extent at least the irregular bleeding
associated with progestogen-only contraception.
There is no doubt that unwanted, unplanned adolescent pregnancy has
significant social and psychological and economic effects for the young
mother, and for the family, community and society in which she lives. It
would be a pity however, if in a zealous attempt to prevent such
pregnancies we were to recommend contraceptive methods like the IUD which
might well compromise her ability to achieve a desired pregnancy later in
life and increase the ever-growing demand for assisted conception
1 Donovan B. Never underestimate the force of reproduction.
Editorial BMJ 2000, 321: 461-462.
2 Guillebaud J. Contraception - your questions answered. Edinburgh:
Churchill Livingstone, 1999.
3 Marrazzo JM, White CL, Krekeler B, Celum CL, Lafferty WE Stamm WE,
Handsfield HH Community-based urine screening for Chlamydia trachomatis
with a ligase chain reaction assay. Ann Intern Med 1997, 127(9): 796-803.
Competing interests: No competing interests
Editors of medical journals need to tighten up on the titles used in
printed articles. For editorials and letter, the only information Medline
searchers get about an article is the heading.
In this case the article provides evidence and discussion for the
'Never underestimate the force of sex' not 'reproduction.'
Let's have evidence based titles - not titles designed to sell
Competing interests: No competing interests