# Profiles of copper intrauterine devices and levonorgestrel intrauterine systems users in France in 2019: A national observational population-based study

Noémie Roland, Bérangère Baricault, Rosemary M. Dray-Spira, Alain Weill, Lise Duranteau, Mahmoud Zureik

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## To cite this version:

Noémie Roland, Bérangère Baricault, Rosemary M. Dray-Spira, Alain Weill, Lise Duranteau, et al. "Profiles of copper intrauterine devices and levonorgestrel intrauterine systems users in France in 2019: A national observational population-based study." International Journal of Gynecology and Obstetrics, 2023, 160 (2), pp.594-603. 10.1002/ijgo.14438. hal-04122324

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CLINICAL ARTICLE

Obstetrics

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WILEY

# Profiles of copper intrauterine devices and levonorgestrel intrauterine systems users in France in 2019: A national observational population-based study

Noémie Roland<fnref n="1" />,<fnref n="2" /> ID
Lise Duranteau<fnref n="3" /> ID

Bérangère Baricault<fnref n="1" /> ID
Mahmoud Zureik<fnref n="1" />,<fnref n="2" /> ID

Rosemary Dray-Spira<fnref n="1" /> ID

Alain Weill<fnref n="1" /> ID

Correspondence

Noémie Roland, EPI-PHARE, ANSM, 143/147 Boulevard Anatole France, 93285 Saint-Denis Cedex, France.

Email: noemie.roland@ansm.sante.fr

## Abstract

**Objective:** To assess the user profiles of copper intrauterine devices (Cu-IUD) and levonorgestrel intrauterine systems (LNG-IUS) in France in 2019 and the rates of continuation 1 year later.

**Methods:** A population-based study was conducted of all French women aged 13-49 years for whom an IUD was dispensed in 2019. Information was collected from the French National Health Data System about their characteristics at the time of dispensation and indicators of continued use 1 year later. Associations between these characteristics and the type of IUD were analyzed using multivariate regressions.

**Results:** A total of 477 705 Cu-IUDs and 355 242 LNG-IUSs (mean age 32.5 ± 7.3 and 36.4 ± 7.7 years, respectively) were dispensed in 2019. After adjustment, having a LNG-IUS rather than a Cu-IUD was associated with being aged 35-44 years compared to 25-35 years (odds ratio [OR<sub>35-44</sub>] 2.03, 95% confidence interval [CI] 2.01-2.05), having a prescription by a gynecologist rather than a general practitioner (OR<sub>35-44</sub> 1.09, 95% CI 1.08-1.11), and having a gynecological history (OR<sub>35-44</sub> 2.28, 95% CI 2.20-2.36). The continuation rates 1 year after dispensation were 86.4% for Cu-IUD versus 85.7% for LNG-IUS. A Cu-IUD dispensation rather than a LNG-IUS one was associated with a higher chance of continued use 1 year later.

**Conclusion:** Two different patterns of use of Cu-IUDs and LNG-IUSs in France are highlighted.

## KEYWORDS

contraceptive continuation, long-acting reversible contraception, pharmacoepidemiology, reproductive health

## 1 | INTRODUCTION

The vast majority of women aged 15-49 years worldwide were using contraceptive methods in 2019.<fnref n="1" /> In France, seven out of ten women

of childbearing age use medical contraception,<fnref n="2" /> a rate consistent with the high rates of contraceptive coverage in Western Europe.<fnref n="3" />

Three major cross-sectional phone surveys have been performed in France to assess changes in the use of contraception from 2010⁴

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

© 2022 The Authors. *International Journal of Gynecology & Obstetrics* published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.

<footnote n="1">¹EPI-PHARE (French National Agency for Medicines and Health Products Safety, ANSM; and French National Health Insurance, CNAM), Saint-Denis Cedex, France</footnote>

<footnote n="2">²University Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, Anti-infective Evasion and Pharmacoepidemiology, Center for Research in Epidemiology and Population Health (CESP), Montigny le Bretonneux, France</footnote>

<footnote n="3">³Adolescent and Young Adult Gynaecology Unit and Reference Center for Rare Diseases of Genital Development, APHP Paris Saclay University, Bicêtre Hospital, Le Kremlin Bicêtre, France</footnote>
to 2016.² These studies showed an important change in contraceptive behaviors since 2012. That year, a woman brought a lawsuit against a pharmaceutical company after suffering a stroke while taking a combined pill.⁵⁻⁷ Consequently, the use of oral contraception decreased from 50% in 2010 to 33.2% in 2016. Meanwhile, the use of intrauterine devices (IUDs) increased from 18.7% to 25.6%. This trend has been observed throughout the world.⁸

Little is known about the use of IUDs in real-life conditions, and the two types of devices have been rarely studied separately worldwide, although they do not have the same therapeutic indication. Copper IUDs (Cu-IUDs) are a first-line contraception, whereas, in France, levonorgestrel intrauterine systems (LNG-IUSs) are a second-line contraception (i.e. prescribed in case of dissatisfaction with a first contraception) and are recommended for some gynecological conditions such as endometriosis⁹ or heavy menstrual bleeding.¹⁰ It was hypothesized that users of Cu-IUDs and LNG-IUSs may be different and that is not relevant to describe the intrauterine contraceptives as a homogeneous group, while their indications differ. The fact that the two types of devices are confounded in previous studies does not send a clear message, as if the two types of users could be confounded. Highlighting two types of users' profiles may encourage both researchers and clinicians to study the two types of devices separately in the future to outline users' specific behaviors and needs.

The aim of the present nationwide register-based study was to analyze separately the use of Cu-IUDs and LNG-IUSs in France in 2019 and to assess the association between the choice of device and the women's sociodemographic and medical characteristics. A secondary aim was to assess the continuation rates of the Cu-IUDs and the LNG-IUSs up to 1 year after dispensation of the device and its underlying correlates using a medico-administrative database.

## 2 | MATERIALS AND METHODS

The French National Health Data System (SNDS) provides information on health insurance claims for 99.5% of the population living in France (about 67 million people). Each individual living in France is given a unique anonymous identifier that is linked to information from two principal data sources in the SNDS database: the national health insurance claims database (DCIR) and the national hospital and discharge database (PMSI). The DCIR database includes individual information on outpatient medical care and reimbursed drugs. Drugs are coded according to the Anatomical Therapeutic Chemical (ATC) classification, and medical devices according to the Reimbursed Products and Benefits List (LPP). The PMSI database contains details of all hospital admissions in France and hospital diagnoses according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10). These databases have been fully described elsewhere and are regularly used for the monitoring of drugs.¹¹,¹²

All dispensations of Cu-IUDs and LNG-IUSs concerning women living in France and aged 13–49 years were extracted in 2019.

The following information was collected about the women on the date of dispensation of Cu-IUD/LNG-IUS in 2019: age; affiliation to the Universal Health Insurance (which provides health insurance cover for people with low incomes); social deprivation index (a geographic indicator of social deprivation); arterial (high blood pressure, dyslipidemia, myocardial infarction, stroke); venous (thrombosis, pulmonary embolism); gynecological history (gynecological conditions diagnosed according to the ICD-10 for which LNG-IUSs are recommended in France: heavy menstrual bleeding, endometrial hyperplasia, endometriosis, polyp, and myoma); oncological history (breast, endometrium, and ovarian cancers); number of deliveries in the 10 years before; prescriber's specialty; use of Cu-IUD/LNG-IUS before 2019; pregnancy; and the use of antidepressants and anxiolytics in the previous year.

The following information was also collected during the year after the device was dispensed: existence of a removal act code; pregnancy indicator; or dispensation of another contraceptive. In the absence of these three criteria, a woman was considered to still be using a Cu-IUD/LNG-IUS 1 year after dispensing.

Analyses were performed with SAS Enterprise Guide software 7.1 (SAS Institute). The frequency of dispensations of Cu-IUD and LNG-IUS were first described in a bivariate analysis with social, demographic, and health characteristics. Missing data were included.

Logistic regression was then performed to study the association between dispensation of Cu-IUD/LNG-IUS and women's characteristics by calculating odds ratios (OR) and their 95% confidence intervals (CI), first with bivariate models, then with models adjusted for age in four age groups (13–24, 25–34, 35–44, ≥45 years), and, finally, in a multivariate model using stepwise regression with the backward selection of variables (selection criterion *p* < 0.05). The proposed variables before selection were as follows: age (in four age groups); gynecological history; previous dispensation of an IUD (5–6 years before); Universal Health Insurance; deprivation index; pregnancy in the year before dispensation; pregnancy in the last 10 years; type of physician; history of breast/endometrial/ovarian cancer, arterial disease, or venous disease in the last 10 years; dispensation of anxiolytics or antidepressants in the preceding year.

Finally, associations between use of Cu-IUD/LNG-IUS 1 year after dispensation and sociodemographic and medical characteristics were characterized by logistic regressions, with a bivariate analysis, a model adjusted for age in four age groups, and a multivariate model using backward stepwise regression to select variables (*p* < 0.05). The proposed variables before selection were the same as those detailed before.

The present study was authorized by decree 2016-1871 on December 26, 2016.¹³ As a permanent user of the SNDS, the author's team was exempt from approval from the institutional review board.

## 3 | RESULTS

In 2019, a total of 477 705 Cu-IUDs and 355 242 LNG-IUSs were dispensed to French women aged 13–49 years. The sociodemographic
<table><caption>TABLE 1 Sociodemographic and medical characteristics of the women (n = 832 947) at inclusion according to insertion of Cu-IUD or LNG-IUS in 2019ª</caption><thead><tr><th></th><th>Cu-IUD (n = 477 705)</th><th>LNG-IUS (n = 355 242)</th></tr></thead><tbody><tr><td>Mean age (y)</td><td>32.5 ± 7.3</td><td>36.4 ± 7.7</td></tr><tr><td>Median age (y) (IQR)</td><td>32 (27–38)</td><td>37 (31–43)</td></tr><tr><td>Age (y)</td><td></td><td></td></tr><tr><td>13–24</td><td>74 128 (15.5)</td><td>31 541 (8.9)</td></tr><tr><td>25–34</td><td>217 668 (45.6)</td><td>103 351 (29.0)</td></tr><tr><td>35–44</td><td>156 696 (32.8)</td><td>159 748 (45.0)</td></tr><tr><td>≥45</td><td>29 213 (6.1)</td><td>60 602 (17.1)</td></tr><tr><td>Universal Health Insurance cover</td><td>56 612 (11.9)</td><td>36 282 (10.2)</td></tr><tr><td>Missing</td><td>94 (0.0)</td><td>1 (0.0)</td></tr><tr><td>Social deprivation index</td><td></td><td></td></tr><tr><td>1 (least deprived)</td><td>100 873 (21.1)</td><td>68 639 (19.3)</td></tr><tr><td>2</td><td>101 643 (21.3)</td><td>73 991 (20.8)</td></tr><tr><td>3</td><td>93 776 (19.6)</td><td>71 044 (20.0)</td></tr><tr><td>4</td><td>83 077 (17.4)</td><td>67 300 (18.9)</td></tr><tr><td>5 (most deprived)</td><td>71 911 (15.1)</td><td>58 141 (16.4)</td></tr><tr><td>Missing</td><td>26 425 (5.5)</td><td>16 127 (4.5)</td></tr><tr><td>Physician</td><td></td><td></td></tr><tr><td>Gynecologist</td><td>217 718 (45.6)</td><td>195 282 (55.0)</td></tr><tr><td>General practitioner</td><td>131 251 (27.5)</td><td>98 250 (27.6)</td></tr><tr><td>Midwife</td><td>101 466 (21.2)</td><td>41 874 (11.8)</td></tr><tr><td>Other</td><td>12 486 (2.6)</td><td>17 511 (4.9)</td></tr><tr><td>Missing</td><td>14 784 (3.1)</td><td>23 252 (0.7)</td></tr><tr><td>History of insertion of Cu-IUD or LNG-IUS in the previous 6 years</td><td>232 969 (48.8)</td><td>206 891 (58.2)</td></tr><tr><td>Pregnancy in the year before insertion</td><td>175 673 (36.8)</td><td>77 840 (22.0)</td></tr><tr><td>Abortion/medical termination in the year before insertion</td><td>25 390 (5.3)</td><td>12 855 (3.6)</td></tr><tr><td>Delivery in the year before insertion</td><td>150 283 (31.5)</td><td>64 985 (18.4)</td></tr><tr><td>History of arterial disease<sup>b</sup></td><td></td><td></td></tr><tr><td>High blood pressure</td><td>11 067 (2.3)</td><td>14 431 (4.1)</td></tr><tr><td>Dyslipidemia</td><td>2477 (0.5)</td><td>3552 (1.0)</td></tr><tr><td>Myocardial infarction</td><td>307 (0.1)</td><td>436 (0.1)</td></tr><tr><td>Stroke</td><td>1938 (0.4)</td><td>1661 (0.5)</td></tr><tr><td>History of venous disease<sup>b</sup></td><td></td><td></td></tr><tr><td>Thrombosis</td><td>286 (0.1)</td><td>969 (0.3)</td></tr><tr><td>Pulmonary embolism</td><td>1226 (0.3)</td><td>711 (0.2)</td></tr><tr><td>Gynecological history<sup>b</sup></td><td></td><td></td></tr><tr><td>Heavy menstrual bleeding</td><td>1698 (0.4)</td><td>3251 (0.4)</td></tr><tr><td>Endometrial hyperplasia</td><td>655 (0.1)</td><td>1473 (0.2)</td></tr><tr><td>Endometriosis</td><td>2224 (0.4)</td><td>4985 (0.6)</td></tr></tbody></table>

<table><caption>TABLE 1 (Continued)</caption><thead><tr><th></th><th>Cu-IUD (n = 477 705)</th><th>LNG-IUS (n = 355 242)</th></tr></thead><tbody><tr><td>Polyp/myoma</td><td>1610 (0.3)</td><td>3091 (0.4)</td></tr><tr><td>Breast cancer<sup>b</sup></td><td>4027 (0.8)</td><td>207 (0.1)</td></tr><tr><td>Endometrial cancer<sup>b</sup></td><td>3 (0)</td><td>7 (0)</td></tr><tr><td>Ovarian cancer<sup>b</sup></td><td>103 (0)</td><td>36 (0)</td></tr><tr><td>No. of deliveries<sup>b</sup></td><td></td><td></td></tr><tr><td>0</td><td>180 161 (37.7)</td><td>156 096 (43.9)</td></tr><tr><td>1</td><td>146 564 (30.7)</td><td>101 133 (28.5)</td></tr><tr><td>2</td><td>122 728 (25.7)</td><td>82 187 (23.1)</td></tr><tr><td>3</td><td>24 624 (5.2)</td><td>14 000 (3.9)</td></tr><tr><td>≥4</td><td>3628 (0.7)</td><td>1826 (0.6)</td></tr><tr><td>Use of anxiolytics in the preceding year<sup>c</sup></td><td>20 398 (4.3)</td><td>22 043 (6.2)</td></tr><tr><td>Use of antidepressants in the preceding year<sup>c</sup></td><td>21 238 (4.4)</td><td>23 060 (6.5)</td></tr></tbody></table>

Abbreviations: Cu-IUD, copper-intrauterine device; IQR, interquartile range; LNG-IUS, levonorgestrel-intrauterine system; SD, standard deviation.

ªValues are given as number (percentage) unless otherwise indicated.

ᵇIn the 10 years before insertion.

ᶜAt least two dispensations in the previous year.

characteristics and medical history of the women who received a Cu-IUD/IUS in 2019 are shown in Table 1. The mean age of the women was 32.5 ± 7.3 years for Cu-IUDs and 36.4 ± 7.7 years for LNG-IUS.

In the Cu-IUD group, 56 612 (11.9%) women were affiliated to the Universal Health Insurance coverage (vs 36 282 [10.2%] in the LNG-IUS group), and 71 911 (15.1%) belonged to the most deprived social group (vs 58 141 [16.4%] in the LNG-IUS group). A larger proportion of LNG-IUSs than of Cu-IUDs was prescribed by gynecologists (55.0% vs 45.6%), whereas prescriptions by midwives were more frequent in the Cu-IUD group (195 282 [21.2%] vs 21 778 [11.8%]). The proportion of prescriptions by general practitioners was similar for the two groups.

A large proportion of the women who had a Cu-IUD or LNG-IUS in 2019 had a history of device dispensation 5–6 years previously: 232 969 (48.8%) in the Cu-IUD group and 206 891 (58.2%) in the LNG-IUS group. More women in the LNG-IUS group than in the Cu-IUD group had a history of arterial disease. The proportion of women with a history of thromboembolic disease was similar in the two groups. The use of anxiolytics and antidepressants in the preceding year was more frequent in the LNG-IUS group than in the Cu-IUD group.

The multivariate model included the following variables after the stepwise selection: age (in four age groups); gynecological history; previous dispensation of an IUD (5–6 years before); Universal Health Insurance cover; deprivation index; number of deliveries in the last 10 years; type of physician; history of breast/ovarian cancer, venous disease, or arterial disease in the last
10 years; and dispensation of anxiolytics and antidepressant in the preceding year.

Dispensing of LNG-IUS rather than a Cu-IUD was associated with being aged older than 35 years compared with being aged 25-35 years (OR<sub>35-44</sub> 1.85, 95% CI 1.83-1.87, *p* < 0.001; OR<sub>≥45</sub> 3.66, 95% CI 3.59-3.73, *p* < 0.001), having a prescription from a gynecologist rather than from a general practitioner (OR 1.10, 95% CI 1.09-1.11, *p* < 0.001), and having a gynecological history (OR 2.28, 95% CI 2.20-2.36, *p* < 0.001), after full adjustment (see Table 2).

By contrast, having a history of pregnancy in the preceding year (OR 0.65, 95% CI 0.64-0.66, *p* < 0.001) and having prescription from a midwife rather than from a general practitioner (OR 0.65, 95% CI 0.64-0.66, *p* < 0.001) was statistically associated with choosing a Cu-IUD rather than a LNG-IUS.

Among the LNG-IUS group, 217 515 (61.2%) women received a LNG-IUS 52 mg, 109 018 (30.7%) received a LNG-IUS 19.5 mg, and 28 709 (8.1%) received a LNG-IUS 13.5 mg (Table 3). The women receiving a LNG-IUS 13.5 mg were the youngest (mean age 31.3 ± 8.5 years). Those receiving a LNG-IUS 52 mg were the oldest (mean age 38.4 ± 6.8 years) and the most likely to be affiliated to the Universal Health Insurance. The LNG-IUS 19.5 mg was more often prescribed by gynecologists than devices with the two other doses. More than half of the LNG-IUS users had a history of using a copper or hormonal IUD 5-6 years previously. Women who used the dose of 52 mg were more likely to have a gynecological history than those using the other doses.

Details of the continuation rates are presented in Table 4. One year after dispensation, 412 982 (86.4%) women were considered to still be using an IUD and 304 636 (85.7%) a LNG-IUS (84.3% for 52 mg, 83.9% for 19.5 mg, and 86.9% for 13.5 mg). Among the women who were no longer using either device, 63 892 (13.4%) in the Cu-IUD group and 48 974 (13.8%) in the LNG-IUS group switched for another form of contraception (mostly oral contraception). Switch rates were highest for the LNG-IUS 19.5 mg group (15.5%).

The multivariate model concerning the continued use 1 year after insertion for all devices included the following variables after the stepwise selection: age (in four age groups); type of device; gynecological history; arterial history; history of breast cancer; Universal Health Insurance cover; deprivation index; history of prior use of IUDs 5-6 years before; deliveries in the last 10 years; history of pregnancy in the preceding year; type of physician; and dispensation of anxiolytics or antidepressants in the preceding year. Having a dispensation of a Cu-IUD in 2019 rather than a LNG-IUS (OR 1.20, 95% CI 1.19-1.22, *p* < 0.001), being aged older than 35 years rather than 25-35 years (OR<sub>35-44</sub> 1.30, 95% CI 1.28-1.32, *p* < 0.001; OR<sub>≥45</sub> 1.87, 95% CI 1.81-1.93, *p* < 0.001), having previous use of an IUD (OR 1.47, 95% CI, 1.44-1.49, *p* < 0.001), and having a device prescription from a gynecologist rather than a general practitioner (OR 1.29, 95% CO 1.27-1.31, *p* < 0.001) are significantly associated with a higher continuation rate 1 year later. ORs are described in Table 5.

4 | DISCUSSION

The dispensing of IUDs under real-life conditions in France over an entire year and in the whole French population were described. Two types of user profiles emerged from the study results depending on the type of device: women aged over 35 years with a gynecological history or a gynecological prescription were more likely to be prescribed a LNG-IUS rather than a Cu-IUD; and women with a prescription from a midwife or a pregnancy in the preceding year were more likely to be prescribed a Cu-IUD. High continuation rates 1 year after dispensation were found for both IUDs: six out of seven women are still using the IUD 1 year after dispensation. After adjustment, having a dispensing of a Cu-IUD rather than a LNG-IUS was associated with a higher chance of still using the device 1 year later.

In the present study, women who received a LNG-IUS were older than those receiving a Cu-IUD, and were less likely to be affiliated to the Universal Health Insurance. On the contrary, women with a LNG-IUS were more likely to live in the most deprived areas, but there was only a very slight difference between the groups, and living in a deprived area is not necessarily a relevant notion to define the socioeconomic position of people.

Previous national French surveys have shown that IUDs/IUSs have appeared to replace the pill as the contraceptive method of choice, mostly in older women and women with a higher socioeconomic status.⁴ These surveys did not distinguish between types of IUDs. Lower levels of financial constraint are known to be associated with increased use of IUDs, including for younger women.¹⁴,¹⁵ In France, dispensation of IUDs/IUSs is reimbursed at a rate of at least 65% by the National Health Insurance. However, access to health professionals for a placement of a device may depend on several factors (heterogeneous medical demography, more expensive consultations for the gynecologist than the general practitioner because of an extra fee charge). The financial incentive for general practitioners to insert an IUD could be a lever to promote dispensation of Cu-IUD/LNG-IUS and to decrease unequal access to long-acting reversible contraception as observed in the United Kingdom.¹⁶ Promoting consultations about contraception with midwives outside the perinatal period could be another option.¹⁷ Lastly, training other health professionals, such as nurses, on the insertion of IUDs is a possibility that should be considered.¹⁸

In the present study, women who had a pregnancy history in the year before dispensation of a device were more likely to get a Cu-IUD rather than a LNG-IUS. A recent Brazilian monocentric study has only showed that users of Cu-IUDs were less likely to be nulliparous compared to users of LNG-IUSs, but it was not focused on the postpartum period.¹⁹

In the present study, the LNG-IUS appeared to be prescribed according to French professional recommendations. The National College of French Gynecologists and Obstetricians recommends the use of LNG-IUS in absolute/relative hyperestrogenic environments, endometriosis, adenomyosis, and endometrial hyperplasia.¹⁰ Phase II and III studies showed the 13.5 and 19.5 mg LNG-IUSs to result in lower systemic exposure to LNG with a similar impact on the
<table><caption>TABLE 2 Associations between receiving a levonorgestrel-intrauterine system (LNG-IUS) rather than a copper-intrauterine device (Cu-IUD) in 2019 and sociodemographic and medical characteristics<sup>a</sup></caption><thead><tr><th colspan="7">Receiving an LNG-IUS rather than a Cu-IUD</th></tr><tr><th></th><th>Crude OR</th><th>p value</th><th>Adjusted OR for age in 4 age groups</th><th>p value</th><th>Multi-adjusted OR</th><th>p value</th></tr></thead><tbody><tr><td>Age groups (y)</td><td></td><td>&lt;0.001</td><td>-</td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>13-24</td><td>0.89 (0.88-0.91)</td><td></td><td></td><td></td><td>0.85 (0.84-0.87)</td><td></td></tr><tr><td>25-34</td><td>1.00 (Ref)</td><td></td><td></td><td></td><td>1.00 (Ref)</td><td></td></tr><tr><td>35-44</td><td>2.18 (2.15-2.20)</td><td></td><td></td><td></td><td>1.85 (1.83-1.87)</td><td></td></tr><tr><td>≥45</td><td>4.49 (4.41-4.60)</td><td></td><td>-</td><td></td><td>3.66 (3.59-3.73)</td><td></td></tr><tr><td>Universal Health Insurance</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>0.83 (0.81-0.84)</td><td></td><td>0.97 (0.95-0.98)</td><td></td><td>0.94 (0.92-0.95)</td><td></td></tr><tr><td>Social deprivation</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>1 (least deprived)</td><td>1.00 (Ref)</td><td></td><td>1.00 (Ref)</td><td></td><td>1.00 (Ref)</td><td></td></tr><tr><td>2</td><td>1.07 (1.05-1.08)</td><td></td><td>1.10 (1.08-1.11)</td><td></td><td>1.12 (1.10-1.13)</td><td></td></tr><tr><td>3</td><td>1.11 (1.10-1.13)</td><td></td><td>1.16 (1.14-1.17)</td><td></td><td>1.18 (1.16-1.20)</td><td></td></tr><tr><td>4</td><td>1.19 (1.17-1.21)</td><td></td><td>1.24 (1.22-1.25)</td><td></td><td>1.28 (1.26-1.30)</td><td></td></tr><tr><td>5 (most deprived)</td><td>1.19 (1.17-1.20)</td><td></td><td>1.25 (1.23-1.27)</td><td></td><td>1.29 (1.27-1.31)</td><td></td></tr><tr><td>Type of physician</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>General practitioner</td><td>1.00 (Ref)</td><td></td><td>1.00 (Ref)</td><td></td><td>1.00 (Ref)</td><td></td></tr><tr><td>Gynecologist</td><td>1.20 (1.19-1.21)</td><td></td><td>1.08 (1.06-1.09)</td><td></td><td>1.10 (1.09-1.11)</td><td></td></tr><tr><td>Midwife</td><td>0.54 (0.53-0.55)</td><td></td><td>0.61 (0.60-0.62)</td><td></td><td>0.65 (0.64-0.66)</td><td></td></tr><tr><td>Prior prescription of device</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>0.009</td></tr><tr><td>Yes</td><td>1.42 (1.41-1.44)</td><td></td><td>1.07 (1.06-1.08)</td><td></td><td>1.01 (1.00-1.02)</td><td></td></tr><tr><td>History of arterial disease<sup>b</sup></td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>1.73 (1.68-1.77)</td><td></td><td>1.24 (1.21-1.28)</td><td></td><td>1.17 (1.14-1.20)</td><td></td></tr><tr><td>History of venous disease (thrombosis, pulmonary embolism)</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>1.34 (1.24-1.45)</td><td></td><td>1.30 (1.20-1.41)</td><td></td><td>1.19 (1.10-1.29)</td><td></td></tr><tr><td>Gynecologic history<sup>c</sup></td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>2.70 (2.61-2.80)</td><td></td><td>2.31 (2.23-2.40)</td><td></td><td>2.31 (2.22-2.39)</td><td></td></tr><tr><td>Breast cancer history</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>0.07 (0.06-0.08)</td><td></td><td>0.49 (0.03-0.04)</td><td></td><td>0.03 (0.03-0.04)</td><td></td></tr><tr><td>Ovary cancer history</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>0.002</td></tr><tr><td>Yes</td><td>0.46 (0.30-0.69)</td><td></td><td>0.49 (0.32-0.74)</td><td></td><td>0.48 (0.31-0.74)</td><td></td></tr><tr><td>History of delivery in the last 10 years</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>0.75 (0.74-0.76)</td><td></td><td>0.91 (0.90-0.92)</td><td></td><td>1.11 (1.10-1.12)</td><td></td></tr><tr><td>History of pregnancy in the last year</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>0.47 (0.47-0.48)</td><td></td><td>0.64 (0.63-0.65)</td><td></td><td>0.65 (0.64-0.66)</td><td></td></tr><tr><td>Use of anxiolytics in the preceding year</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>1.49 (1.46-1.52)</td><td></td><td>1.23 (1.21-1.26)</td><td></td><td>1.11 (1.08-1.14)</td><td></td></tr><tr><td>Use of antidepressants in the preceding year</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>1.50 (1.47-1.53)</td><td></td><td>1.21 (1.18-1.23)</td><td></td><td>1.07 (1.05-1.10)</td><td></td></tr></tbody></table>

Abbreviations: CI, confidence interval; Cu-IUD, copper-intrauterine device; LNG-IUS, levonorgestrel-intrauterine system; OR, odds ratio.

<sup>a</sup>Values in parentheses are 95% CI.

<sup>b</sup>High blood pressure, dyslipidemia, myocardial infarction, stroke.

<sup>c</sup>Endometrial hyperplasia, endometriosis, polyp/myoma, heavy menstrual bleeding.
<table><caption>TABLE 3 Sociodemographic and medical characteristics of the women (n = 355 242) at the time of dispensation of LNG-IUS, by LNG dose, in 2019ª</caption><thead><tr><th></th><th>LNG-IUS 13.5 mg (n = 28 709, 8.1%)</th><th>LNG-IUS 19.5 mg (n = 109 018, 30.7%)</th><th>LNG-IUS 52 mg (n = 217 515, 61.2%)</th></tr></thead><tbody><tr><td>Mean age (y)</td><td>31.3 ±8.5</td><td>33.8 ±7.8</td><td>38.4 ±6.8</td></tr><tr><td>Median age (y) (IQR)</td><td>31 (24-38)</td><td>34 (28-40)</td><td>39 (34-44)</td></tr><tr><td>Age (y)</td><td></td><td></td><td></td></tr><tr><td>13-24</td><td>7639 (26.6)</td><td>16 126 (14.8)</td><td>7776 (3.6)</td></tr><tr><td>25-34</td><td>10 584 (36.9)</td><td>40 024 (36.7)</td><td>52 743 (24.2)</td></tr><tr><td>35-44</td><td>8179 (28.5)</td><td>42 456 (38.9)</td><td>109 113 (50.2)</td></tr><tr><td>≥45</td><td>2307 (8.0)</td><td>10 412 (9.6)</td><td>47 883 (22.0)</td></tr><tr><td>Universal Health Insurance</td><td>2381 (8.3)</td><td>11 117 (10.2)</td><td>22 784 (10.5)</td></tr><tr><td>Missing</td><td>0</td><td>0</td><td>1 (0.0)</td></tr><tr><td>Social deprivation index</td><td></td><td></td><td></td></tr><tr><td>1 (least deprived)</td><td>6955 (24.2)</td><td>20 943 (19.2)</td><td>40 741 (18.7)</td></tr><tr><td>2</td><td>5892 (20.5)</td><td>23 604 (21.7)</td><td>44 495 (20.5)</td></tr><tr><td>3</td><td>5478 (19.1)</td><td>22 650 (20.8)</td><td>42 916 (19.7)</td></tr><tr><td>4</td><td>4456 (15.5)</td><td>20 278 (18.6)</td><td>42 566 (19.6)</td></tr><tr><td>5 (most deprived)</td><td>3562 (12.4)</td><td>16 704 (15.3)</td><td>37 875 (17.4)</td></tr><tr><td>Missing</td><td>2366 (8.2)</td><td>4839 (4.4)</td><td>8922 (4.1)</td></tr><tr><td>Physician</td><td></td><td></td><td></td></tr><tr><td>Gynecologist</td><td>14 569 (50.7)</td><td>65 557 (60.1)</td><td>115 156 (52.9)</td></tr><tr><td>General practitioner</td><td>8332 (29.0)</td><td>23 609 (21.7)</td><td>66 309 (30.5)</td></tr><tr><td>Midwife</td><td>4188 (14.6)</td><td>13 902 (12.7)</td><td>23 784 (10.9)</td></tr><tr><td>Other</td><td>1328 (4.6)</td><td>5289 (4.8)</td><td>10 894 (5.0)</td></tr><tr><td>Missing</td><td>292 (1.0)</td><td>661 (0.6)</td><td>1372 (0.6)</td></tr><tr><td>History of insertion of Cu-IUD or LNG-IUS in the previous 6 years</td><td>17 753 (61.8)</td><td>57 686 (52.9)</td><td>145 621 (66.9)</td></tr><tr><td>Pregnancy in the year before insertion</td><td>4514 (15.7)</td><td>30 066 (27.6)</td><td>43 260 (19.9)</td></tr><tr><td>Abortion/medical termination in the preceding year</td><td>1331 (4.6)</td><td>5639 (5.2)</td><td>5885 (2.7)</td></tr><tr><td>Delivery in the preceding year</td><td></td><td>24 427 (22.4)</td><td>37 375 (17.2)</td></tr><tr><td>History of arterial disease<sup>b</sup></td><td></td><td></td><td></td></tr><tr><td>High blood pressure</td><td>707 (2.5)</td><td>3362 (3.1)</td><td>10 362 (4.8)</td></tr><tr><td>Dyslipidemia</td><td>171 (0.6)</td><td>852 (0.8)</td><td>2529 (1.2)</td></tr><tr><td>Myocardial infarction</td><td>10 (0)</td><td>92 (0.1)</td><td>334 (0.2)</td></tr><tr><td>Stroke</td><td>116 (0.4)</td><td>445 (0.4)</td><td>1100 (0.5)</td></tr><tr><td>History of venous disease<sup>b</sup></td><td></td><td></td><td></td></tr><tr><td>Thrombosis</td><td>83 (0.3)</td><td>298 (0.3)</td><td>588 (0.3)</td></tr><tr><td>Pulmonary embolism</td><td>65 (0.2)</td><td>210 (0.2)</td><td>436 (0.2)</td></tr><tr><td>Gynecological history<sup>b</sup></td><td></td><td></td><td></td></tr><tr><td>Heavy menstrual bleeding</td><td>167 (0.6)</td><td>791 (0.7)</td><td>2293 (1.1)</td></tr><tr><td>Endometrial hyperplasia</td><td>76 (0.3)</td><td>329 (0.3)</td><td>1068 (0.5)</td></tr><tr><td>Endometriosis</td><td>332 (1.2)</td><td>1178 (1.1)</td><td>3475 (1.6)</td></tr><tr><td>Polyp/myoma</td><td>170 (0.6)</td><td>688 (0.6)</td><td>2233 (1.0)</td></tr><tr><td>Breast cancer<sup>b</sup></td><td>20 (0.1)</td><td>56 (0.1)</td><td>131 (0.1)</td></tr><tr><td>Endometrial cancer<sup>b</sup></td><td>0</td><td>2 (0)</td><td>3 (0)</td></tr><tr><td>Ovarian cancer<sup>b</sup></td><td>0</td><td>15 (0)</td><td>21 (0)</td></tr></tbody></table>

(Continues)
<table><caption>TABLE 3 (Continued)</caption><thead><tr><th></th><th>LNG-IUS 13.5 mg (n = 28 709, 8.1%)</th><th>LNG-IUS 19.5 mg (n = 109 018, 30.7%)</th><th>LNG-IUS 52 mg (n = 217 515, 61.2%)</th></tr></thead><tbody><tr><td>No. of deliveries<sup>b</sup></td><td></td><td></td><td></td></tr><tr><td>0</td><td>17 167 (59.8)</td><td>43 660 (40.0)</td><td>95 269 (43.8)</td></tr><tr><td>1</td><td>6403 (22.3)</td><td>31 699 (29.1)</td><td>63 031 (29.0)</td></tr><tr><td>2</td><td>4478 (15.6)</td><td>28 391 (26.1)</td><td>49 318 (22.6)</td></tr><tr><td>3</td><td>596 (2.1)</td><td>4720 (4.3)</td><td>8684 (4.0)</td></tr><tr><td>≥4</td><td>65 (0.2)</td><td>548 (0.5)</td><td>1213 (0.6)</td></tr><tr><td>Use of anxiolytics in the preceding year<sup>c</sup></td><td>1626 (5.7)</td><td>6085 (5.5)</td><td>14 332 (6.6)</td></tr><tr><td>Use of antidepressants in the preceding year<sup>c</sup></td><td>1700 (5.9)</td><td>6235 (5.7)</td><td>15 125 (7.0)</td></tr></tbody></table>

Abbreviations: Cu-IUD, copper-intrauterine device; IQR, interquartile range; LNG-IUS, levonorgestrel-intrauterine system; SD, standard deviation.

<sup>a</sup>Values are given as number (percentage) unless otherwise indicated.

<sup>b</sup>In the 10 years before insertion.

<sup>c</sup>At least two dispensations in the previous year.

<table><caption>TABLE 4 Continued use of Cu-IUD and LNG-IUS (by dose) 1 year after insertion: contraceptive switch, indicators of pregnancy and removal acts (n = 832 947)<sup>a</sup></caption><thead><tr><th></th><th>Cu-IUD<br>(n = 477 705)</th><th>LNG-IUS<br>All (n = 355 242)</th><th>13.5 mg<br>(n = 28 709)</th><th>19.5 mg<br>(n = 109 018)</th><th>52 mg<br>(n = 217 515)</th></tr></thead><tbody><tr><td>Continued use 1 year after<br>dispensation<sup>b</sup></td><td>412 982 (86.4)</td><td>304 636 (85.7)</td><td>24 195 (84.3)</td><td>91 427 (83.9)</td><td>189 014 (86.9)</td></tr><tr><td>Contraceptive switch</td><td>63 892 (13.4)</td><td>48 974 (13.8)</td><td>4341 (15.1)</td><td>16 951 (15.5)</td><td>27 681 (12.7)</td></tr><tr><td>Oral contraception</td><td>53 223 (11.1)</td><td>41 655 (11.7)</td><td>3587 (12.8)</td><td>14 152 (13.3)</td><td>22 901 (10.7)</td></tr><tr><td>Implant</td><td>3281 (0.7)</td><td>3957 (0.9)</td><td>293 (1.0)</td><td>982 (0.9)</td><td>1782 (0.8)</td></tr><tr><td>Sterilization</td><td>1115 (0.1)</td><td>656 (0.2)</td><td>43 (0.1)</td><td>179 (0.2)</td><td>434 (0.2)</td></tr><tr><td>LNG-IUS</td><td>10 636 (2.3)</td><td>NA</td><td>NA</td><td>NA</td><td>NA</td></tr><tr><td>Cu-IUD</td><td>NA</td><td>7241 (2.1)</td><td>625 (2.2)</td><td>2507 (2.4)</td><td>4109 (1.9)</td></tr><tr><td>Pregnancy indicator<sup>c</sup></td><td>7062 (1.5)</td><td>5157 (1.4)</td><td>535 (1.9)</td><td>1964 (1.8)</td><td>2658 (1.2)</td></tr><tr><td>Abortion</td><td>6287 (1.3)</td><td>3321 (0.9)</td><td>322 (1.1)</td><td>1266 (1.2)</td><td>1733 (0.8)</td></tr></tbody></table>

Abbreviations: Cu-IUD, copper-intrauterine device; LNG-IUS, levonorgestrel-intrauterine system.

<sup>a</sup>Values are given as number (percentage).

<sup>b</sup>No other contraceptive delivered, no pregnancy indicator, and no removal act code in the year after dispensation of the device.

<sup>c</sup>Second trimester ultrasound ≥180 days or abortion ≥60 days after dispensation of the device.

endometrium and cervical function as the 52 mg device.²⁰ However, evidence of efficacy for conditions other than contraception has been established for the 52 mg LNG-IUS only, and only the 52 mg LNG-IUS is recommended in France for heavy menstrual bleeding and endometriosis.

In the contraceptive CHOICE project, the 1-year continuation rates for LNG-IUS and Cu-IUD were 88% and 84%, respectively.²¹ The continuation rates that were found are comparable with these figures. It was shown that dispensing of Cu-IUDs rather LNG-IUSs is associated with a higher chance of continued use 1 year later, and users of the low-dose LNG-IUS had a lower continuation rate than those who used the 52 mg LNG-IUS. The 12-month continuation rate of the 13.5 mg LNG-IUS was 80.4% in the Phase III European multicenter study.²² As of 2021, the 19.5 mg LNG-IUS continuation rate has not been studied or compared to that of the other available

methods of contraception. The lower continuation rate for the low-dose LNG-IUS than for the 52 mg LNG-IUS could be explained by dissatisfaction related to bleeding disturbances or because low-dose devices concerned younger women, although a previous study found no difference between continuation rates of LNG-IUS 52 mg for younger and older women.²³

The present study has some limitations. One is that placement and removal of Cu-IUDs/IUSs might not be correctly coded within the SNDS database. Additional information was used to measure effective use of IUDs (removal act, other contraceptive dispensation, and pregnancy indicators) but this could have led to errors in measurement and to an overestimation of the continuation rates. Nevertheless, the present results are consistent with previous studies. Moreover, the misclassification bias seems to be non-differential, so the associations between use of Cu-IUDs/LNG-IUSs 1 year after dispensation and
<table><caption>TABLE 5 Associations between use of IUD 1 year after dispensation and sociodemographic and medical characteristics<sup>a</sup></caption><thead><tr><th colspan="7">Continued use of IUD 1 year after dispensation</th></tr><tr><th></th><th>Crude OR</th><th>p value</th><th>Adjusted OR for age in 4 age groups</th><th>p value</th><th>Multi-adjusted OR</th><th>p value</th></tr></thead><tbody><tr><td>Type of device</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>LNG-IUS</td><td>1.00 (Ref)</td><td></td><td>1.00 (Ref))</td><td></td><td>1.00 (Ref)</td><td></td></tr><tr><td>Cu-IUD</td><td>1.04 (1.02-1.05)</td><td></td><td>1.22 (1.20-1.23)</td><td></td><td>1.20 (1.19-1.22)</td><td></td></tr><tr><td>Age groups (y)</td><td></td><td>&lt;0.001</td><td></td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>13-24</td><td>0.74 (0.72-0.75)</td><td></td><td>-</td><td></td><td>0.74 (0.73-0.76)</td><td></td></tr><tr><td>25-34</td><td>1.00 (Ref)</td><td></td><td></td><td></td><td>1.00 (Ref)</td><td></td></tr><tr><td>35-44</td><td>1.44 (1.42-1.46)</td><td></td><td></td><td></td><td>1.30 (1.28-1.32)</td><td></td></tr><tr><td>≥45</td><td>2.28 (2.22-2.65)</td><td></td><td></td><td></td><td>1.87 (1.81-1.93)</td><td></td></tr><tr><td>Universal Health Insurance</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td>0.62 (0.61-0.63)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>0.51 (0.50-0.52)</td><td></td><td>0.55 (0.54-0.56)</td><td></td><td></td><td></td></tr><tr><td>Social deprivation</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>1 (least deprived)</td><td>1.00 (Ref)</td><td></td><td>1.00 (Ref)</td><td></td><td>1.00 (Ref)</td><td></td></tr><tr><td>2</td><td>0.89 (0.87-0.91)</td><td></td><td>0.90 (0.88-0.92)</td><td></td><td>0.92 (0.90-0.94)</td><td></td></tr><tr><td>3</td><td>0.85 (0.83-0.86)</td><td></td><td>0.86 (0.84-0.88)</td><td></td><td>0.89 (0.87-0.91)</td><td></td></tr><tr><td>4</td><td>0.79 (0.77-0.81)</td><td></td><td>0.80 (0.78-0.82)</td><td></td><td>0.84 (0.83-0.86)</td><td></td></tr><tr><td>5 (most deprived)</td><td>0.67 (0.65-0.68)</td><td></td><td>0.68 (0.67-0.69)</td><td></td><td>0.76 (0.75-0.78)</td><td></td></tr><tr><td>Type of physician</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>General practitioner</td><td>1.00 (Ref)</td><td></td><td>1.00 (Ref)</td><td></td><td>1.00 (Ref)</td><td></td></tr><tr><td>Gynecologist</td><td>1.45 (1.43-1.48)</td><td></td><td>1.35 (1.33-1.37)</td><td></td><td>1.29 (1.27-1.31)</td><td></td></tr><tr><td>Midwife</td><td>1.19 [1.17-1.21]</td><td></td><td>1.28 [1.25-1.30]</td><td></td><td>1.25 [1.22-1.27]</td><td></td></tr><tr><td>Gynecological history</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>0.83 (0.79-0.87)</td><td></td><td>0.72 (0.69-0.75)</td><td></td><td>0.79 (0.76-0.83)</td><td></td></tr><tr><td>History of delivery in the last 10 years</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>0.81 (0.79-0.82)</td><td></td><td>0.80 (0.79-0.81)</td><td></td><td>0.84 (0.83-0.86)</td><td></td></tr><tr><td>History of pregnancy in the preceding year</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>0.74 (0.73-0.75)</td><td></td><td>0.84 (0.83-0.85)</td><td></td><td>0.94 (0.92-0.95)</td><td></td></tr><tr><td>History of previous utilization of IUD 5-6 years before</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>1.69 (1.66-1.71)</td><td></td><td>1.45 (1.43-1.47)</td><td></td><td>1.47 (1.44-1.49)</td><td></td></tr><tr><td>History of breast cancer in the last 10 years before</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>7.96 (6.30-10.04)</td><td></td><td>6.07 (4.81-7.67)</td><td></td><td>5.63 (4.46-7.12)</td><td></td></tr><tr><td>History of arterial disease in the last 10 years</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>1.06 (1.02-1.09)</td><td></td><td>0.85 (0.82-0.88)</td><td></td><td>0.93 (0.92-0.95)</td><td></td></tr><tr><td>Use of anxiolytics in the preceding year<sup>b</sup></td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>0.75 (0.73-0.77)</td><td></td><td>0.66 (0.64-0.68)</td><td></td><td>0.73 (0.70-0.75)</td><td></td></tr><tr><td>Use of antidepressants in the preceding year<sup>b</sup></td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td><td></td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>0.88 (0.86-0.91)</td><td></td><td>0.77 (0.75-0.79)</td><td></td><td>0.90 (0.87-0.93)</td><td></td></tr></tbody></table>

Abbreviations: CI, confidence interval; Cu-IUD, copper intrauterine device; IUD, intrauterine device; LNG-IUS, levonorgestrel intrauterine system; OR, odds ratio. Unless otherwise stated, *p* <0.001.

(Continues)

<footnote><sup>a</sup>Values in parentheses are 95% CI.</footnote>

<footnote><sup>b</sup>At least two dispensations in the preceding year.</footnote>
medical characteristics could be underestimated. Lastly, diagnoses such as heavy menstrual bleeding are made at the hospital and are not always available within the SNDS database. Indeed, women who consult outside hospitals for this condition may not be recorded and the frequency of diagnosis would therefore be underestimated.

Beside these limitations, this is the first study of a nationwide cohort that precisely reflects the use of Cu-IUDs and the various LNG-IUSs in France. These data will make it possible to study changes in the dispensation of these contraceptive devices since the French pill crisis in 2012. Lastly, these data may be of particular importance as they were collected the year before the COVID-19 pandemic, which had a major impact on reproductive services and the use of contraceptives worldwide.²⁴,²⁵

## AUTHOR CONTRIBUTIONS

NR and MZ conceived and designed the experiments. NR, LD, RSD, AW, and MZ analyzed the data. NR and MZ wrote the paper. LR, RSD, and AW revised the work critically for important intellectual content. NR performed the literature review. BB extracted data from the French hospitalization database. Each author has confirmed compliance with the journal's requirements for authorship.

## ACKNOWLEDGMENTS

We thank Alex Edelman & Associates for their help in correcting and clarifying the manuscript. This research was funded by EPI-PHARE, the French National Health Insurance Fund (CNAMTS), and the French National Agency for Medicines and Health Products Safety (ANSM) in the framework of a PhD funding.

## CONFLICT OF INTEREST

All authors have no conflict of interest to disclose. NR, RDS, and MZ are employees of the French National Agency for Medicines and Health, BB and AW of the French National Health Insurance Fund. LD is employee of the Public Hospitals of Paris (APHP).

## DATA AVAILABILITY STATEMENT

Research data are not shared.

## ORCID

Noémie Roland https://orcid.org/0000-0002-8079-4263

Bérangère Baricault https://orcid.org/0000-0001-5835-7668

Rosemary Dray-Spira https://orcid.org/0000-0001-7646-3667

Alain Weill https://orcid.org/0000-0001-8687-9092

Lise Duranteau https://orcid.org/0000-0001-9434-248X

Mahmoud Zureik https://orcid.org/0000-0002-8393-4217

## REFERENCES

1. United Nations. Contraceptive Use by Method 2019: Data Booklet [Internet]. UN; 2019. [cited 2021 May 20]. Available from: https://www.un-ilibrary.org/content/books/9789210046527

2. Rahib D, Le Guen M, Lydié N. Baromètre santé 2016. Contraception. Quatre ans après la crise de la pilule, les évolutions se poursuivent. Santé Publique France; 2017:8.

3. World Health Organization. Family planning-contraception methods [Internet]. 2020. [cited 2021 May 20] Available from: https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception

4. Moreau C, Bohet A, Hassoun D, Teboul M, Bajos N. Trends and determinants of use of long-acting reversible contraception use among young women in France: results from three national surveys conducted between 2000 and 2010. *Fertility and Sterility*. 2013;100(2):451-458.

5. Tricotel A, Collin C, Zureik M. Impact of the sharp changes in the use of contraception in 2013 on the risk of pulmonary embolism in France. *J Thromb Haemost*. 2015;13(9):1576-1580.

6. Weill A, Dalichampt M, Raguideau F, et al. Low dose oestrogen combined oral contraception and risk of pulmonary embolism, stroke, and myocardial infarction in five million French women: cohort study. *BMJ*. 2016;353:i2002.

7. Tricotel A, Raguideau F, Collin C, Zureik M. Estimate of venous thromboembolism and related-deaths attributable to the use of combined oral contraceptives in France. *PLoS One*. 2014;9(4):e93792.

8. Darroch JE. Trends in contraceptive use. *Contraception*. 2013;87(3):259-263.

9. Haute Autorité de Santé. Contraception chez la femme adulte et l'adolescente en âge de procréer (hors post-partum et post-IVG). [Internet]. 2013 [cited 2021 May 20]. Available from: https://www.has-sante.fr/upload/docs/application/pdf/2015-02/1e_maj_contraceptionfadulte-procreer-060215.pdf

10. Collège National des Gynécologues et Obstétriciens Français. Mises à jour en gynécologie. *J Gynécol Obstét Biol Reprod*. 2005;34(5):513.

11. Bezin J, Duong M, Lassalle R, et al. The national healthcare system claims databases in France, SNIIRAM and EGB: powerful tools for pharmacoepidemiology. *Pharmacoepidemiol Drug Saf*. 2017;26(8):954-962.

12. Penso L, Dray-Spira R, Weill A, Zureik M, Sbidian E. Psoriasis-related treatment exposure and hospitalization or in-hospital mortality due to COVID-19 during the first and second wave of the pandemic: cohort study of 1 326 312 patients in France. *Br J Dermatol*. 2022;186(1):59-68.

13. JORF. Décret n° 2016-1871 du 26 décembre 2016 relatif au traitement de données à caractère personnel dénommé « système national des données de santé » [Internet]. 2016-1871, JORF n°0301 Dec 26. 2016. Available from: https://www.legifrance.gouv.fr/affic hTexte.do?cidTexte=JORFTEXT000033702840&categorieLien=id

14. Postlethwaite D, Trussell J, Zoolakis A, Shabear R, Petitti D. A comparison of contraceptive procurement pre- and post-benefit change. *Contraception*. 2007;76(5):360-365.

15. Secura GM, Allsworth JE, Madden T, Mullersman JL, Peipert JF. The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. *Am J Obstet Gynecol*. 2010;203(2):115.e1-115.e7.

16. French RS, Geary R, Jones K, et al. Where do women and men in Britain obtain contraception? Findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). *BMJ Sex Reprod Health*. 2018;44(1):16-26.

17. Walker SH, Hooks C, Blake D. The views of postnatal women and midwives on midwives providing contraceptive advice and methods: a mixed method concurrent study. *BMC Preg Childbirth [Internet].* 2021;21(1):411.

18. Laporte M, Becerra A, Castro L, Veiga N, Espejo-Arce X, Bahamondes L. Evaluation of clinical performance when intrauterine devices are inserted by different categories of healthcare professional. *Int J Gynaecol Obstet*. 2021 Feb;152(2):196-201.

19. Laporte M, Metelus S, Ali M, Bahamondes L. Major differences in the characteristics of users of the copper intrauterine device or levonorgestrel intrauterine system at a clinic in Campinas, Brazil. *Int J Gynecol Obst. 2022;156(2):240-246.
20. Apter D, Gemzell-Danielsson K, Hauck B, Rosen K, Zurth C. Pharmacokinetics of two low-dose levonorgestrel-releasing intrauterine systems and effects on ovulation rate and cervical function: pooled analyses of phase II and III studies. *Fertil Steril.* 2014;101(6):1656, e1-4-1662.

21. Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. *Obstet Gynecol.* 2011;117(5):1105-1113.

22. Apter D, Briggs P, Tuppurainen M, et al. A 12-month multicenter, randomized study comparing the levonorgestrel intrauterine system with the etonogestrel subdermal implant. *Fertil Steril.* 2016;106(1):151-157.e5.

23. Berenson AB, Tan A, Hirth JM, Wilkinson GS. Complications and continuation of intrauterine device use among commercially insured teenagers. *Obstet Gynecol.* 2013;121(5):951-958.

24. UNFPA. Impact of the COVID-19 Pandemic on Family Planning and Ending Gender-based Violence, Female Genital Mutilation and Child Marriage [Internet]. 2020 [cited 2022 Feb 15]. Available from:

https://www.unfpa.org/sites/default/files/resource-pdf/COVID-19_impact_brief_for_UNFPA_24_April_2020_1.pdf

25. Roland N, Drouin J, Desplas D, et al. Effects of the coronavirus disease 2019 (COVID-19) lockdown on the use of contraceptives and ovulation inductors in France. *Obstetrics & Gynecology.* 2021;137(3):415-417.

**How to cite this article:** Roland N, Baricault B, Dray-Spira R, Weill A, Duranteau L, Zureik M. Profiles of copper intrauterine devices and levonorgestrel intrauterine systems users in France in 2019: A national observational population-based study. *Int J Gynecol Obstet.* 2023;160:594-603. doi: 10.1002/ijgo.14438