Cardiovascular Risk Factor Prevalence, Treatment, and Control in US Adults

Abstract

It seems unlikely that a significant proportion of individuals, who paid for a long-acting levonorgestrel IUS and had the device inserted, would deliberately pursue removal within the first year of use with the intent of conceiving. In fact, a study cited by Jugl and Winterstein concluded that the main reason for levonorgestrel IUS discontinuation within the first year of insertion is adverse effects from the IUS, such as pain and abnormal bleeding, not the desire to conceive. 2 Individuals choosing to remove a recently inserted IUS due to adverse effects would likely switch to another hormonal contraceptive method, which was accounted for in our Research Letter. 1 Jugl and Winterstein request an analysis on all pregnancy outcomes. Using the same cohort and the same statistical model to calculate the incidence of conceiving (instead of incidence of ectopic pregnancy) within the first year of a filled levonorgestrel IUS prescription, the adjusted incidence rate ratios were 0.5 (95% CI, 0.4-0.6) for the 52-mg levonorgestrel IUS, 0.4 (95% CI, 0.4-0.5) for the 19.5-mg levonorgestrel IUS, and 0.6 (95% CI, 0.5-0.7) for the 13.5-mg levonorgestrel IUS compared with other hormonal contraceptives. Thus, this real-world effectiveness of levonorgestrel IUS use confirms a reduced risk of conceiving with levonorgestrel IUS compared with other hormonal contraceptives, thereby dismissing the concern expressed by Jugl and Winterstein that time of levonorgestrel IUS use represented misclassified time of nonuse in individuals intending pregnancy.In conclusion, in the first year of use, we found an increased risk of ectopic pregnancy with levonorgestrel IUS compared with use of other hormonal contraceptives despite a decreased overall risk of conceiving with levonorgestrel IUS compared with other hormonal contraceptives. This finding indicates a causal relationship between levonorgestrel IUS use and the occurrence of ectopic pregnancy.