Long-term contraception is proving a reliable, effective alternative to sterilisation
A SHARP FALL in the number of women opting for sterilisation operations has been accompanied by a decline in hysterectomies, according to the authors of new research.
The study, conducted by three consultant obstetricians - Dr Richard Horgan, Prof John Higgins and Dr Gerry Bourke - found a 65 per cent decrease in female sterilisations from 1999 to 2004. The research was based on data from the Hospital Inpatient Enquiry Scheme (HIPE).
The number of female sterilisation operations or tubal ligations fell from 2,566 in 1999 to 910 in 2004.
In the same period, sales of a hormone-containing intrauterine device, with the trade name Mirena, increased by 350 per cent. Sales data obtained from the manufacturers found that some 20,000 Mirena devices were being sold in the Republic per year.
The study, which is published in the current issue of the Irish Medical Journal, details the decline in sterilisation operations, but other data, which has yet to be analysed in detail, showed a marked decrease in hysterectomies. While these figures have yet to be published, one of the authors, Dr Gerry Burke, says use of the Mirena was reducing the need for hysterectomies among women experiencing very heavy periods.
"Among this group - women who had hysterectomies because of heavy periods - we believe the numbers have fallen by about two-thirds over the past 10 years. In my own practice, I would have been doing about 100 such hysterectomies 15 years ago, whereas now that has reduced to less than 20 a year," Burke says.
Horgan says he hopes to publish results on the hysterectomy data at a later point but it would have to take into account the different sub-categories of patients getting hysterectomies, as there are different reasons why women need the surgery.
Overall, the important result of the introduction of the Mirena and other long acting forms of contraception is that two groups - those who wanted sterilisations and those who needed hysterectomies because of heavy periods - are being kept out of hospital, Burke says.
The Mirena, which was first used here in the late 1990s, and implants, such as Implanon, which is inserted under the skin of the arm, can be fitted by GPs in a matter of minutes.
Burke said gynaecologists were actively discouraging women from having tubal ligation because there were "more reversible and safer alternatives" and in terms of effectiveness they were "virtually the same".
A big advantage of using a long-acting contraceptive device is that it is reversible, he says. "It has been found that 11 per cent of women who get a sterilisation regret it and 1 per cent will seek a reversal. It is a very big issue because any amount of counselling will not necessarily identify those who will regret it later or will not predict how people will feel in the future or what is going to happen in their relationships," says Burke.
The other major advantage of these newer contraceptive devices is that they save women from surgery. Tubal ligation requires a general anaesthetic and involves an abdominal operation which carries the risk of internal bleeding, infection or damage to other organs. It involves blocking or clipping the Fallopian tubes. Burke says there has been "at least one death" from tubal ligation over the past 10 years in Ireland.
Burke, who works in the Mid Western Regional Hospital in Limerick, says that in the 1990s gynaecology waiting lists were very long, with women seeking sterilisation, but that they were "now cut dramatically" because of the newer contraceptive devices.
The Mirena lasts for five years and the device, which is made of plastic, is placed in the uterus. It works by slowly releasing small amounts of the hormone levonorgestrel, which is a synthetic progestogen. It is generally only recommended for women who have had a baby.
In most women it does not stop ovulation but it does change the lining of the womb, which is the reason periods become much lighter. The effect of the Mirena is more localised than with Implanon, which stops ovulation.
While there are some side effects, Burke says it has been found that "90 per cent of women find it very satisfactory and would recommend it to their friends".
He says he believes such options are now generally available to all women, as very many GPs are trained in inserting these devices and are pointing out their advantages to their patients.
Dr Jacek Kisielewicz of the Irish Family Planning Association says that generally women do not have any problems with devices such as Mirena or Implanon but it is important they receive the correct advice when they are being inserted.
This could be a minor point, such as the importance of keeping hydrated. He says women could go to specialist family planning centres to ensure they were aware of the full range of options available.
"If they are unhappy, it is important they know that there are niggling problems that can be solved very easily. Sometimes when they have problems, they are told there are no other options, but a doctor with specialist training in family planning would have more knowledge of the options available," he says.
Dr Kisielewicz says sterilisation would only be recommended now where a pregnancy could threaten the life of the woman or where contraceptive devices were causing serious side effects.
He says in the 10 years he has worked in Dublin he has also seen a decline in the number of male sterilisations, or vasectomies. While it is a much less invasive procedure than tubal ligation and only requires a local anaesthetic, Dr Kisielewicz says he believes many men are opting not to have a vasectomy because they feel their circumstances might change.
Vasectomies are not included in the HIPE data as they are not generally done in hospitals, but in clinics on an outpatient basis. Burke sas he expected the rate of vasectomies would be falling as usage of long-acting contraceptive devices rises.
Alison Begas of the Well Woman Centre says it is important that women are aware of the many different options available to them, as there are now up to 20 different forms of contraception. "Everybody should be able to find something that suits them," she says.
While there are a lot of options available, there are "huge gaps in service provision outside Dublin and the main cities", as many women are not comfortable discussing contraception with their family doctor and many GPs do not have specialist training.
She says it is still the case that women from as far away as Kerry and Donegal are travelling to the Well Woman clinics in Dublin for certain services and she says what is needed is "joined-up thinking" in the provision of family planning services.