The safety of intrauterine devices among young women: a systematic review

Long-Acting but Reversible: Opportunities to Address Provider Bias in Contraceptive Care

Jasmine is an 18-year-old Black female bringing her infant to the pediatrician for a newborn weight check. She asks her pediatrician's opinion about hormonal contraceptive injections, sharing that they were strongly recommended after she gave birth. The recommending health care provider told her, "We don't want you to end up back here any time soon." Rosita, a 16-year-old Latina female, visits her pediatrician for a well check. She reports a history of vaginal sex with 2 male partners and agrees to have a hormonal subcutaneous implant placed to avoid pregnancy. After 4 months of bothersome spotting, Rosita returns to have the implant removed. Rosita's provider strongly counsels against removal. Jasmine and Rosita are members of populations that have been systematically marginalized throughout American history. Their stories are derived from real cases and reveal how structural racism impacts modern contraceptive care. Specifically, their cases are examples of statistical discrimination, wherein the tendency to disproportionately recommend long-acting reversible contraception to historically marginalized communities does not follow the central tenants of sexual and reproductive justice, including acknowledging historical harms in health care and honoring bodily autonomy for all people. By sharing Jasmine and Rosita's stories, we use a reproductive justice lens to (1) examine the historical roots of disproportional prescription of long-acting reversible contraception to historically marginalized individuals, (2) discuss provider bias related to sexual and reproductive health care, and (3) illustrate how trauma-informed care with a recognition of historical trauma and the use of individuation can facilitate positive and equitable health outcomes.

Immediate and delayed placement of the intrauterine device after abortion: a systematic review and meta-analysis

This article aims to report the comprehensive and up-to-date analysis and evidence of the insertion rate, expulsion rate, removal rate, and utilization rate of immediate placement of intrauterine devices (IUDs) versus delayed placement after artificial abortion. PubMed, Embase, Cochrane, Web of Science, CNKI, and Wanfang databases were comprehensively searched up to January 12, 2024 for studies that compared immediate versus delayed insertion of IUDs after abortion. The evaluation metrics included the number of IUD insertion after surgical or medical abortions, the frequency of expulsion and removal at 6 months or 1 year, the number of continued usage, pain intensity scores, the number of infections, the duration of bleeding, and instances of uterine perforation during or after IUD insertion. Ten randomized controlled articles were eligible, comprising 11 research projects, of which 3 projects involved the placement of an IUD after surgical abortion, and 8 projects involved the placement of an IUD after medical abortion. This included 2025 patients (977 in the immediate insertion group and 1,048 in the delayed insertion group). We summarized all the extracted evidence. The meta-analysis results indicated that for post-surgical abortions, the immediate insertion group exhibited a higher IUD placement rate than the delayed insertion group. After medical abortions, the immediate insertion group showed higher rates of IUD placement, utilization, and expulsion at 6 months or 1 year. The two groups showed no statistically significant differences in the removal rate, post-insertion infection rate, pain scores during insertion, and days of bleeding during the follow-up period. Compared to delayed placement, immediate insertion of IUDs can not only increase the usage rate at 6 months or 1 year but also enhance the placement rate.

Clinical Assessment of 3 Intrauterine Devices in Adolescent Girls: A Randomized Clinical Trial

STUDY OBJECTIVE

To assess clinical performance, bleeding pattern, dysmenorrhea, and satisfaction up to 1 year after placement of 3 types of intrauterine devices (IUDs) (TCu380A, levonorgestrel 52 mg, and levonorgestrel 19.5 mg) in adolescents METHODS: The study was a randomized trial with 318 adolescents allocated to the 3 IUDs. We assessed reasons for removal, continuation, menstrual patterns, dysmenorrhea, and satisfaction.

RESULTS

Participants aged (mean ± SD) 17.9 ± 1.4 years, with 80.8% being nulligravidae. After 1 year, 265 (83.3%) continued using the IUD; however, the continuation rate of TCu380A (75.4 ± 4.2) was lower than that of both the levonorgestrel 52-mg (88.6 ± 3.1) and 19.5-mg IUDs (86.8 ± 3.3), and bleeding/pain and expulsion were the main reasons for removal of the TCu380A IUD. The duration of menstruation was longer among the TCu380A IUD users (6.0 ± 2.0 days) than those using the levonorgestrel 52 mg (2.5 ± 3.9) and 19.5 mg (3.2 ± 3.2) devices, P < .001. Amenorrhea was reported by 49.5% and 37.8% users of the levonorgestrel 52-mg and 19.5-mg devices, respectively, P < .001. Dysmenorrhea was reported in 68.5% of all participants at the baseline; this was 67.9% of the TCu380A group and 33.3% and 36.0% of the levonorgestrel 52-mg and 19.5-mg IUD groups, respectively, P < .001. Satisfaction ranged from 80.7% in the TCu380A group to 97.8% in the levonorgestrel 52-mg group (P = .03).

CONCLUSION

The 3 IUDs are suitable for adolescents, with high contraceptive efficacies and rates of continuation within 1 year of use and high degrees of satisfaction. Users of the hormonal IUDs reported lower expulsion rates, more favorable menstrual patterns, and less dysmenorrhea compared with the TCu380A IUD.

Uptake, discontinuation, and continuation rate of long-acting contraceptive methods when offered at no cost in Campinas, Brazil

OBJECTIVES

This study aimed to compare the uptake, reasons for discontinuation, continuation, and satisfaction of long-acting contraceptive methods (LARC) when offered at no cost in Campinas, Brazil.

STUDY DESIGN

This was a prospective cohort study conducted at University of Campinas, Campinas, São Paulo, Brazil, including women aged 18 to 48 years, who adopted one of three methods. Participants underwent telephone follow-up every 3 months for up to 24 months after insertion. Satisfaction was assessed at the end of 2 years of use through the Likert scale.

RESULTS

We invited 1222 women, and among the 971 women who volunteered to participate in follow-up, 414 (42.6%) chose the levonorgestrel 52-mg intrauterine device (IUD), 358 (36.9%) chose the etonogestrel (ENG) implant, and 199 (20.5%) chose the TCu380A IUD. Discontinuation due to bothersome bleeding was higher among users of the ENG implant (10/358; 2.4%) and the TCu380A IUD (32/199; 8.9%), and expulsion was higher for the TCu380A IUD (30/199; 15.1%). Women continued at 24 months were 340/414 (82.1%), 270/358 (75.4%), and 119/199 (59.8%) among users of the levonorgestrel 52-mg IUD, ENG implant, and TCu380A IUD, respectively. The users of the levonorgestrel 52-mg IUD (301/339, 88.8%), the ENG-implant (222/270, 82.2%), and the TCu380A IUD (105/119, 88.2%) were satisfied or very satisfied by 24 months of follow-up.

CONCLUSIONS

The three LARC methods had great uptake, high continuation, and discontinuation due to bothersome bleeding was higher among users of the ENG implant and the TCu380A IUD, and expulsion was higher for the TCu380A IUD compared to the 52-mg levonorgestrel IUD. Most of the participants reported being very satisfied.

IMPLICATIONS

When the LARC methods were offered at no cost in a Brazilian public clinic the uptake, satisfaction and continuation were high by 24 months after device placement, and high level of satisfaction was reported by most of the participants.

Performance of a handheld point of care ultrasonography to assess IUD position compared to conventional transvaginal ultrasonography

OBJECTIVE

To compare the performance of the abdominal handheld point-of-care ultrasonography (POCUS) Butterfly-iQ to gold standard transvaginal ultrasonography (US) in identifying the position of intrauterine devices (IUDs) in the hands of a medical doctor specialised in ultrasonography.

METHODS

In this diagnostic accuracy study, a single operator conducted abdominal POCUS followed by conventional transvaginal US. Seventy patients utilising copper or hormonal IUDs were assessed between June 2021 and October 2022. IUDs were categorised as entirely within the uterine cavity or malpositioned. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for detecting malpositioned IUDs, with conventional US results serving as the reference standard. Concordance rate and Kappa coefficient were computed to assess the agreement between the two ultrasound modalities.

RESULTS

Among the 70 patients, 46 (65.7%) used copper IUDs, and 24 (34.3%) used hormonal IUDs. Conventional transvaginal US showed IUDs entirely within the uterine cavity in 56 (80%) patients and 14 (20%) IUDs were malpositioned. Of the 14 malpositioned IUDs seen by conventional US, POCUS identified 13 demonstrating a sensitivity of 92.9% (66.1-99.8). Of the 56 IUDs entirely within the uterine cavity shown by conventional US, only two cases were considered malpositioned by POCUS demonstrating a specificity of 96.4% (87.7-99.6). The concordance rate was 95.7%, and the Kappa value was 0.87 in differentiating between IUDs entirely within the uterine cavity and those that were malpositioned.

CONCLUSION

Abdominal POCUS using Butterfly-iQ, when administered by an imaging specialist, exhibited excellent performance in confirming IUDs entirely within the uterine cavity.

Continuation rates of hormonal intrauterine devices in adolescents and young adults when placed for contraceptive and non-contraceptive indications

OBJECTIVE

This study aimed to estimate and compare continuation rates of hormonal intrauterine devices (IUDs) when placed for contraceptive or menstrual management indications in adolescents and young adults.

STUDY DESIGN

We conducted a secondary analysis of a prospectively collected database of all hormonal IUD insertions from January 1, 2017 through December 31, 2020, with at least 1-year follow-up, across four Adolescent Medicine practices. IUD insertions without known indication were excluded.

RESULTS

A total of 936 IUD insertions were attempted, 45% for contraception only, 18% for menstrual management only, and 37% for both indications. Insertion was successful in 868 (93%) attempts, and success did not differ by indication (p = 0.74). The mean age at insertion was 18.9 years (SD = 2.4 years), with no difference by indication. Of the completed insertions, 650 (75%) had at least one follow-up during the data analysis period. Excluding those without follow-up, the overall continuation rates were 77% at 1 year, 66% at 2 years, and 54% at 3 years. While continuation rates did not differ by indication at 1 year, at 3 years, continuation was highest among those who sought the device for menstrual management only (contraception = 53%, menstrual = 57%, both = 53%, p < 0.01) Malposition was rare (4.0%), as was device expulsion (2.5%), and these did not differ by indication.

CONCLUSION

IUD continuation rates were high among adolescents and young adults and did not significantly differ when placed for contraceptive or non-contraceptive indication in the first year of use.

IMPLICATIONS

Adolescents and young adults may seek the hormonal IUD for contraception and/or menstrual management. Our study found that IUD continuation rates were high at 1 year regardless of the indication for utilization.

Outcomes of Intrauterine Device Insertion by Certified Midwives and Obstetric Nurse Practitioners

OBJECTIVES

to evaluate the outcomes of Interval Copper Intrauterine Device (IUD) insertion performed by certified midwives and obstetric nurse practitioners at a Peri-Hospital Birth Center.

METHODS

a cross-sectional study was conducted involving 75 women who underwent IUD insertion between January 2018 and February 2020. Data collection was carried out using medical records and telephone interviews.

RESULTS

no instances of uterine perforation were observed. Expulsion rates of the devices were 1.3% within 30 to 45 days of use and 5.3% within the first year of use. The follow-up removal rate was 4.0%. The average pain score reported was 4.2 (SD = 3.3). Among those who continued using the device, 93.1% expressed satisfaction.

CONCLUSIONS

the findings demonstrate that IUD insertion by certified midwives and obstetric nurse practitioners is a safe procedure, yielding outcomes comparable to those reported in the existing literature.

Adolescent Long-Acting Reversible Contraceptive Use, Same-Day Insertions, and Pregnancies Following a Quality Initiative

OBJECTIVE

To compare long-acting reversible contraceptive (LARC) use, pregnancy rate, and same-day LARC insertion among adolescents before and after a Kaiser Permanente Northern California quality initiative.

METHODS

A 2016 Kaiser Permanente Northern California initiative aimed to increase adolescent LARC access. Interventions included patient education resources, electronic protocols, and insertion training for pediatric, family medicine, and gynecology providers. This study examined a retrospective cohort of adolescents aged 15-18 years who used contraception before (2014-2015, n = 30,094) and after (2017-2018, n = 28,710) implementation. Contraceptive types included LARC (intrauterine device or implant), injectable, and contraceptive pill, patch, or ring. We reviewed a random sample of LARC users (n = 726) to identify same-day insertions. Multivariable analysis examined the effects of year of provision, age, race, ethnicity, LARC type, and counseling clinic.

RESULTS

Preintervention, 12.1% of adolescents used LARC, 13.6% used injectable, and 74.3% used pill, patch, or ring. Postintervention, the proportions were 23.0%, 11.6%, and 65.4%, respectively, with the odds of LARC provision of 2.57 (95% confidence interval (CI) 2.44-2.72). The pregnancy rate decreased from 2.2% to 1.4% (p < .0001). Higher rates of pregnancy were observed with injectable contraception and in Black and Hispanic adolescents. Same-day LARC insertion rate was 25.1% without significant variation post intervention (OR 1.44, 95% confidence interval 0.93-2.23). Contraceptive counseling in gynecology clinics increased the odds of same-day provision, while non-Hispanic Black race lowered odds.

DISCUSSION

A multifaceted quality intervention was associated with a 90% increase in LARC use and a 36% decrease in teenage pregnancy rate. Future directions may include promoting same-day insertions, targeting interventions in pediatric clinics, and focusing on racial equity.

Five-year Contraceptive Use of 52-mg Levonorgestrel Releasing Intrauterine System in Young Women, Menstrual Patterns, and New Contraceptive Choice

OBJECTIVE

 To evaluate the continuation rates of the 52-mg levonorgestrel-releasing intrauterine system (LNG-IUS) during the first 5 years of use, reasons for its discontinuation, bleeding patterns, and new contraceptive choice after the 5th year, in adolescents and young women.

METHODS

 The present study was a 5-year prospective cohort conducted in a Family Planning Service of a tertiary hospital in Brazil. We selected 100 healthy women between 15 and 24 years old who used 52-mg LNG-IUS for contraception. The clinical follow-up of these women took place from June 2017 to December 2022. The study evaluated the continuation rates of the method, reasons for its discontinuation, bleeding patterns, and new contraceptive choice after the 5th year. Continuous data were reported as mean ± standard deviation (SD) and range (minimum-maximum). Categorical variables were described as percentages.

RESULTS

 The continuation rates of LNG-IUS were 89.1% (82/92), 82.9% (72/87), 75.3% (64/85), 70.5% (60/85), and 64.2% (54/84) in the 1st, 2nd, 3rd, 4th, and 5th years of use, respectively. The main reason for discontinuation was acne (11/30). Amenorrhea rates were 50, 54.1, 39, 35.7, and 51.8% at 12, 24, 36, 48, and 60 months, respectively. All patients who completed the study and needed contraception after the 5th year opted for long-acting contraceptive methods (LARC).

CONCLUSION

 The LNG-IUS showed high continuation rates in adolescents and young women in the first 5 years of use. Most patients who completed the study chose a LARC method after the 5th year.

Unilateral hydroureteronephrosis after introduction of a levonorgestrel-releasing intrauterine system: a case report and literature review

Insertion of a LNG-Intra-uterine System (LNG-IUS) has many gynecological indications. The approved indications worldwide are contraception, treatment of abnormal uterine bleeding depending on not organic disease, and endometrial protection in case of an estrogenic therapy. Instead adenomyosis, fibroids, and fertility-sparing management of endometrial hyperplasia or early endometrial cancer in patients with desire of pregnancy are off label indications. Hydroureteronephrosis is an uncommon complication during LNG-IUS insertion. There are few cases described in the literature. The first diagnostic approach for this complication is an abdominal-pelvic ultrasound scan to identify the abnormal position of the device. Diagnostic management includes computed tomography (CT) or magnetic resonance imaging (MRI), which are necessary to confirm hydroureteronephrosis and to assess the exact location of the LNG-IUS in the abdomen. A minimally invasive approach is the standard of care with the removal of the device, while the therapeutic management of the hydroureteronephrosis depends on ureteral and kidney involvement. We report the history of a dislocated LNG-IUS in the left paracervical space with subsequent ipsilateral hydroureteronephrosis. In our case we removed the device through hysteroscopy and later inserted a J-J stent. Follow-up at three months revealed the persistence of left hydroureteronephrosis, so we performed ureter reimplantation. We also performed a review of the literature to analyze common diagnostic and therapeutic pathways for this rare complication.

Multiple Adverse Outcomes of Intrauterine Devices in One Patient: A Case Report

Intrauterine devices (IUDs) are commonly used, effective forms of long-acting removable contraceptives that may be inserted by primary care providers. Adverse outcomes with copper IUDs specifically have been extensively documented; however, there is little guidance on whether to offer an IUD to a patient who has already experienced adverse outcomes related to IUDs. In this case report, our patient experienced three complications with three different copper IUDs, including a spontaneous expulsion, a fragmented device, and a retained device in addition to two unintended pregnancies. In our view, a different form of contraception should be offered for a patient that has already experienced multiple adverse outcomes related to IUDs.

Migrated intrauterine device: Case series report

INTRODUCTION AND IMPORTANCE

Implantation of an intrauterine device (IUD) is a common method of contraception in Saudi Arabia. Although rare, IUD migration and colon perforation have been reported. The current report presented three cases of IUD migration into the colon and recto-uterine pouch.

METHODS AND OUTCOMES

The study included a series of three cases of migrated IUDs. The first case was a 25-year-old female, Gravida 2, Para 2 + 0, at 28 week-gestation, who presented with abdominal pain with a history of IUD placement that had not been removed or imaged before. The patient submitted to the caesarian section (CS), where IUD was found in the sigmoid colon. Elective laparoscopic removal of IUD with resection and primary repair of sigmoid colon was done later. The second case was a 37-year-old female, Gravida 1, Para 1 + 0, non-pregnant hypothyroidism, and a history of IUD placement. The patient got pregnant and gave birth through CS. She was then presented with abdominal pain and requested the removal of the IUD. On colonoscopy, IUD was seen in the pouch of Douglas with no evidence of a fistulous tract. IUD was removed through laparoscopy. The third case was a 47-year-old female, Gravida 14, Para 14 + 0, with a history of previous CS presented with a missing IUD that had been inserted 20 years ago after she had five pregnancies and subsequent deliveries. On colonoscopy, IUD was embedded on the wall of the transverse colon, and through abdominal surgery, IUD was removed by cutting through the colon and primary repair was done. CLINICAL DISCUSSION: the presentation of IUD migration cases was foundto vary according to the site of migration and type of IUD.however the cases are usually present with abdominal pain. An abdominal pelvic imaging with CT in these patients are essential in diagnosis. Retrival of migrating IUDs may be done through colonoscopy, laparoscopy, and in some cases with adhesion laparotomy is the solution.

CONCLUSION

Abdominal and pelvic CT scan are very important in the diagnosis and the localization of IUD. Elective colonoscopy and laparoscopy are successful management approaches for these cases.

Expulsion and continuation rates of the 52 mg levonorgestrel intrauterine system in adolescents and adult women

OBJECTIVE

To compare the continuation rates, expulsion, and other reasons for discontinuation of the hormonal intrauterine device with 52 mg of levonorgestrel (52 mg LNG-IUD) in adolescents and adult women.

METHODS

We conducted a retrospective cohort study that included 393 women in whom we placed a 52 mg LNG-IUD and followed up to 5 years. We created two retrospective cohorts, one with 131 adolescents (aged between 12 and 19 years) and the other with 262 women aged ≥20 years. Each adolescent was paired with two adult women who had the same parity and who had a 52 mg LNG-IUD inserted on the same day. We used the Mann-Whitney test to compare numerical variables in both groups, the Kaplan-Meier method, and the log-rank test to compare the continuation, expulsion and other reasons for IUD discontinuation of the two groups.

RESULTS

Age of the adolescents and adult women were mean ± SD 18.1 (±1.1) and 31 (±6.8) years, respectively (p = 0.015). Continuation rates by the fifth year of use were 55.6/100 women-years (W-Y) and 70.3/100 W-Y among adolescents and adult women (p = 0.106); and expulsion rates were 8.4/100 and 6.0/100 W-Y, respectively (p = 0.463). Adolescents had a lower continuation rate during 3 to 5 years of follow-up (p = 0.011) and a high rate of removals due to bleeding/pain (18.5 ± 5.7/100 W-Y vs 6.4/100 ± 2.1 W-Y, p = 0.039).

CONCLUSION

Adolescents who used the 52 mg LNG-IUD showed a lower continuation rate 3-5 years after device placement than adult women. The expulsion rates were similar in both groups.

Long-Term Retained Lippes Loop Intrauterine Device Causes Vesicouterine Fistula

This case report discusses a 77-year-old female patient who presented to an outpatient clinic with urinary symptoms and recurrent UTIs. Imaging revealed a foreign body, which was later confirmed as a retained intrauterine device (IUD) that had caused a vesicouterine fistula (VUF). The patient had a medical history of cervical cancer treated with radiation therapy, during which her IUD's string could not be located, leading to the decision to proceed with radiation therapy without removing the IUD. The patient opted to manage her condition medically rather than undergo surgical removal due to concerns about worsening the vesicouterine fistula. This case highlights the potential risks and complications of retained IUDs, and the importance of careful consideration and communication among clinical teams and patients when managing these situations.

Pain and ease of insertion of three different intrauterine devices in Brazilian adolescents: A participant-blinded randomized trial

OBJECTIVES

To compare pain and ease of insertion of the copper 380 mm², levonorgestrel 52 mg, and levonorgestrel 19.5-mg intrauterine devices (IUDs) in Brazilian adolescents.

STUDY DESIGN

We conducted a participant-blinded randomized trial at two clinics in Brazil. We enrolled 318 adolescents<19 years old in a 1:1:1 ratio from November 2021 to February 2022. We informed the adolescents about the IUD type inserted after they evaluated the pain associated with the IUD insertion using a Visual Analogue Scale and immediately after that the healthcare provider who placed the IUD evaluated the ease of the procedure.

RESULTS

The VAS pain level was significantly higher after the levonorgestrel 52-mg IUD placement, median and [interquartile range, IQ] 8.0 [4.0] than the copper 380-mm² IUD 7.0 [4.0], and the levonorgestrel 19.5-mg IUD 7.0 [6.0] (p = 0.001). The placement was easier after the copper 380-mm² IUD (87/106, 82.1%) and the levonorgestrel 19.5-mg IUD (91/106, 85.8%) when compared with the levonorgestrel 52-mg IUD (75/105, 70.7%). After multiple logistic regression analyses, the higher VAS pain scores were associated with the levonorgestrel 52-mg IUD (OR = 2.90), low number of pregnancies (OR -0.48), and with a history of dysmenorrhea (OR = 2.67).

CONCLUSIONS

The placement of the copper 380-mm² IUD and the levonorgestrel 19.5-mg IUD was associated with lower pain according to the adolescent and was easier according to the provider when compared with the levonorgestrel 52-mg IUD. However, the small observed differences may not be clinically relevant.

IMPLICATIONS

We found that the three types of IUDs were generally easy to place; however, mean pain scores were high during insertions. Our findings of high pain scores reinforce the need for interventions to reduce pain for adolescent IUD insertion.

Menstrual cup and risk of IUD expulsion - a systematic review

BACKGROUND

The menstrual cup is a safe, cost-effective, and environmentally friendly menstrual product which is increasing in usage, especially in younger women. The potential risk for concomitant menstrual cup use to increase IUD expulsion has been raised over the last 10 years, however, few studies assess this. This systematic review aims to identify, appraise and synthesize the current specific evidence on menstrual cup use and risk of partial or total IUD expulsion.

METHODS

PubMed, and the Cochrane Library were searched for publications available in English, until February 20th, 2021. Quantitative and qualitative studies, systematic reviews and case series reports were included. Websites of menstrual cup manufacturers LenaCup®, DivaCup®, Lunette®, AllMatters® and Saalt® were searched for warnings relevant to IUD expulsion.

RESULTS

Seven studies were included in this review, comprising 73 partial or total IUD expulsion events in patients with IUD contraception using menstrual cups. The case study reports included two individuals who each experienced two and three expulsions respectively. Of the seven publications, three reported expulsion rates of 3.7%, 17.3% and 18.6%. Time to expulsion ranged from less than one week to two and a half years. These three studies disagree on whether there is a statistically significant association between menstrual cup use and IUD expulsion.

CONCLUSION

There is a possible association between menstrual cup use and increased risk of IUD expulsion and this information should be shared with patients. However evidence is scarce and high-quality randomised controlled trials are needed to address this risk and the impact of factors such as age, menstrual cup removal technique, pelvic anatomy, IUD type, and measures such as cutting the IUD strings short or delaying menstrual cup use for a period post-insertion. This research gap is limiting patients' ability to make informed choices regarding intrauterine contraception and menstrual management and must urgently be addressed in the context of rising IUD and menstrual cup use, particularly among a younger demographic who are seeking highly effective contraception.

[Contraceptive Counseling: The Medical Toolbox Must Include the Full Range of Reversible Contraceptive Methods Also for Adolescent Women]

Contraceptive Counseling: The Medical Toolbox Must Include the Full Range of Reversible Contraceptive Methods Also for Adolescent Women Abstract. When counselling adolescents, empathy and age-appropriate information on medical confidentiality are important. Addressing individual needs and wishes enables the targeted use of the necessary information and resources and is the best guarantee for successful contraception over time. The goal is to make informed decisions and to have a positive experience of successfully protected sexual and reproductive health. The range of suitable contraceptive options is very broad. To make the most of this potential, all methods should be addressed with their advantages and disadvantages, including information on sexually transmitted infections and protection against them. Concerns and questions should be answered comprehensively and openly, and the experiences with sexuality described should be approached without prejudice. Often this is also an opportunity to talk about experienced situations of sexual assault.

Real-world satisfaction and menstrual bleeding pattern with available LNG-IUD among Spanish young women

OBJECTIVE

The aim of this study was to evaluate the satisfaction and menstrual bleeding pattern with levonorgestrel-releasing intrauterine systems (LNG-IUD) in young women.

METHODS

A prospective, multicentre, non-interventional study with 1-year follow-up was conducted in Spain. Participants were women between 18 and 30 years old who freely choose any available LNG-IUD for contraception. Satisfaction with LNG-IUD was measured with a 5-point Likert scale. Type of LNG-IUD, menstrual bleeding pattern and satisfaction with it, easiness of insertion and pain during procedure were collected.

RESULTS

A total of 555 women (37.3% parous, 62.7% nulliparous) (mean age 25.8 ± 3.5) completed the study. After 12 months, 92.4% of women were satisfied or very satisfied with the LNG-IUD, with no differences by parity status, type of IUD or baseline menstrual bleeding pattern. Satisfaction with the LNG-IUD correlated with satisfaction with menstrual bleeding pattern at 12 months. Up to 88.7% of women were satisfied or very satisfied with their menstrual bleeding pattern at 12 months in comparison to 41.5% at baseline (p < 0.001). Adverse events (AE)-related discontinuation rate was low (2.2%).

CONCLUSIONS

Satisfaction with LNG-IUD is very high among young Spanish women, regardless of parity and menstrual bleeding pattern at baseline.

Demographic, Reproductive, and Medical Risk Factors for Intrauterine Device Expulsion

OBJECTIVE

To explore to what extent intrauterine device (IUD) expulsion is associated with demographic and clinical risk factors.

METHODS

The APEX-IUD (Association of Perforation and Expulsion of IntraUterine Devices) study was a U.S. cohort study using electronic health records from three integrated health care systems (Kaiser Permanente Northern California, Southern California, and Washington) and a health care information exchange (Regenstrief Institute). These analyses included individuals aged 50 years or younger with IUD insertions from 2001 to 2018. Intrauterine device expulsion cumulative incidence and incidence rates were estimated. Using Cox regression models, hazard ratios with 95% CIs were estimated before and after adjustment for risk factors of interest (age, race and ethnicity, parity, body mass index [BMI], heavy menstrual bleeding, and dysmenorrhea) and potential confounders.

RESULTS

In total, 228,834 individuals with IUD insertion and no delivery in the previous 52 weeks were identified (184,733 [80.7%] with levonorgestrel-releasing intrauterine system). Diagnosis of heavy menstrual bleeding-particularly a diagnosis in both recent and past periods-was the strongest risk factor for IUD expulsion. Categories with the highest risk of IUD expulsion within each risk factor included individuals diagnosed with overweight, obesity, and morbid obesity; those in younger age groups, especially among those aged 24 years or younger; and in those with parity of four or more. Non-Hispanic White individuals had the lowest incidence and risk, and after adjustment, Asian or Pacific Islander individuals had the highest risk. Dysmenorrhea was not independently associated with expulsion risk when adjusting for heavy menstrual bleeding.

CONCLUSION

Most risk factors for expulsion identified in this study appear consistent with known physiologic factors that affect uterine anatomy and physiology (age, BMI, heavy menstrual bleeding, parity). The increased risk of IUD expulsion among individuals of color warrants further investigation. Intrauterine devices are an effective long-term contraceptive; expulsion is uncommon, but patients should be counseled accordingly.

FUNDING SOURCE

Bayer AG.

CLINICAL TRIAL REGISTRATION

EU PAS register, EUPAS33461.

Placement of long-acting reversible contraception for minors who are mothers should not require parental consent

Decreasing unintended teenage pregnancy, especially repeat teenage pregnancy, is an important public health goal. Unfortunately, legal barriers in the USA impede this goal as all minors are unable to consent for birth control in 24 states, and only 10 of those states allow consent after the minor has given birth according to state statutory law. Placement of long-acting reversible contraception (LARC) is one of the most effective methods of preventing rapid repeat pregnancies. However, restrictions are placed on adolescents who may not have the option of parental consent if the parents are unwilling, or not present, to give consent. A predicament arises when healthcare professionals are willing to place the contraceptive for the patient, but cannot due to the restrictions and guidelines outlined by each state. Even though these adolescents are legally viewed as minors, adolescent mothers should be able to consent to the placement of LARC. Notably, adolescents have the legal ability to give consent for the healthcare of their child starting in the prenatal period. I argue that this ability should be extended to include adolescent consent for their own healthcare. Additionally, the procedure to place LARC is relatively low risk and highly effective, which is an opportune situation to allow minors to consent. Allowing adolescents to consent to LARC after delivery is a simple and effective way to decrease rapid repeat pregnancy rates in the USA.

Systematic review of copper intrauterine contraception continuation in young nulliparous women based on intrauterine device type

OBJECTIVES

No copper intrauterine device (IUD) type is known to better suit young nulliparous women who tend to experience higher rates of IUD discontinuation compared with their older parous counterparts. A systematic review to determine which IUDs have higher continuation rates in young nulliparous women was undertaken.

DESIGN

Systematic review and meta-analyses of available evidence based on IUD type.

DATA SOURCES

AMED, BNI, CINAHL, DARE, EMBASE, EMCARE, HMIC, MEDLINE, PsycINFO, PubMed, TRIP, and the Cochrane Library electronic databases were searched from inception to 11 May 2022; as well as the Bandolier, Medicines and Healthcare products Regulatory Agency, Faculty of Sexual and Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists, Department of Health, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines, WHO and Google Scholar websites.

ELIGIBILITY CRITERIA

All studies on IUDs currently available in the UK or comparable (same design and size) to those available in the UK, involving nulliparous women of any age including those aged under 30.

DATA EXTRACTION AND SYNTHESIS

Independently extracted data were assessed as low risk of bias using the Mixed Methods Appraisal Tool. Random effects meta-analyses of proportions were performed where data, including subgroups, were amenable to quantitative synthesis. Heterogeneity was reported using tau² and I² statistics, and sensitivity analyses were also performed.

RESULTS

Nineteen studies involving 13 045 nulliparous women were included but the heterogeneity of participant ages, parity and IUD types made quantitative synthesis of outcome data in totality inappropriate. The highest continuation rate obtained was 91.02% (95% CI 88.01% to 93.64%) for the smaller TCu 380A at 12 months post insertion.

CONCLUSIONS

Evidence for IUD use in young nulliparous women based on IUD type remains limited. Smaller sized IUD types appear better suited to this group of IUD users, however, more research is needed.

PROSPERO REGISTRATION NUMBER

CRD42019120969.

Utility of the Levonorgestrel-Releasing Intrauterine System in the Treatment of Abnormal Uterine Bleeding and Dysmenorrhea: A Narrative Review

INTRODUCTION

We undertook a literature review of the use of levonorgestrel-releasing intrauterine devices when utilized for heavy menstrual bleeding and/or dysmenorrhea.

METHODS

A narrative review of articles in the Scopus and Medline databases was conducted.

RESULTS

A number of options exist for the management of both abnormal uterine bleeding (AUB) and dysmenorrhea, and evidence is accumulating that the insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) represents a useful option for their long-term treatment. The idea of using a progestogen released in utero was initially conceived to achieve long-term contraception, but it was quickly found that these systems could be utilized for a number of therapeutic applications. The first device to be made commercially available, Progestasert, was withdrawn from the market because, in the event of contraceptive failure, it caused a disproportionate percentage of extrauterine pregnancies. On the other hand, the LNG-IUS continues to be successfully utilized in its various variants, releasing 20, 13, or 8 μg/day. These devices have a respective duration of action of 7 (possibly 8), 5, and 3 years, and there exist versions of frameless systems affixed to the myometrium of the uterine fundus. In the present review, following a brief description of the major causes of AUB and dysmenorrhea, the molecular bases for the use of the LNG-IUS are summarized. This is followed by a compendium of its use in AUB and dysmenorrhea, concluding that the insertion of the system improves the quality of life, reduces menstrual blood loss better than other medical therapies, and decreases the extent of dysmenorrhea and pelvic pain. In addition, there is no evidence of a significant difference in these outcomes when the use of the LNG-IUS was compared with improvements offered by endometrial ablation or hysterectomy. Possibly, the most important mechanism of action of the system consists of its ability to induce amenorrhea, which effectively eliminates heavy bleeding and dysmenorrhea. However, no method is ideal for every woman, and, in the case of the LNG-IUS, younger age and severe dysmenorrhea seem to be associated with a higher risk of discontinuation.

CONCLUSION

The higher-dose LNG-IUS is a useful tool for HMB and dysmenorrhea in women of all ages. The low cost and ease of use make the LNG-IUS an attractive option, especially when contraception is also desired.

[Evolution of contraceptive practices in France: An overview from 2014 to 2019]

OBJECTIVES

To study the use of reimbursed contraceptive methods in France between 2014 and 2019, with an analysis of the profile of users by age group and an analysis by type of prescriber.

METHODS

We conducted a national descriptive study using data from the Assurance Maladie Open Data database on the use of contraceptive methods reimbursed in France from January 1, 2014, to December 31, 2019. We analyzed the number of users by year, by age group (<20years, 20-60years), and by prescriber (liberal general practitioner, liberal gynecologist, hospital practitioner, liberal midwife).

RESULTS

In 2019, 50.1% (5,345,122) of women of childbearing age used a reimbursed contraceptive method. Hormonal oral contraception was the leading contraceptive method used (42.3%), followed by the intrauterine device (6.2%) and the implant (1.6%). Use of combined estrogen-progestogen oral contraception had been declining since 2015 (-8.1 points), to the benefit of the micro progestin pill (+9.1 points) and the copper intrauterine device (+1.4 points). Among women under 20, the hormonal implant was the second most popular contraceptive method (1.2%), followed by the copper intrauterine device (0.8%) and the hormonal intrauterine system (0.2%). Among women over 20years of age of childbearing age, the copper IUD was the second most-reimbursed contraceptive method (2.4%), followed by the hormonal intrauterine system (1.6%) and the hormonal implant (1.2%). There are disparities in prescribing practices: in 2019, 51% of prescribers were general practitioners and 97% of them prescribed hormonal oral contraception.

CONCLUSION

The contraceptive supply in France is diversifying, although oral contraception remains predominant. Disparities exist between age groups of users and there is great heterogeneity in practices among contraceptive prescribers.

Ectopic Intrauterine Device Revealed by Ureteral Colic in a 37-Week Pregnant Woman: Case Report

Copper T intrauterine devices (IUDs) are a popular long-acting reversible contraceptive method. The most common reasons for contraceptive failure are expulsion and extrauterine migration. We report a case of a 28-year-old female, G13P3, 37 weeks pregnant, who presented to the hospital for left abdominal flank pain. The patient was admitted for treatment of left ureteral colic. The woman went into labour, and Caesarean Section was performed due to foetal distress. During the surgery, an inspection of the peritoneal cavity revealed a copper IUD embedded in the granulous tissue located in the left lateral abdominal region, which was extracted. No uterine scar tissue could be identified macroscopically. The migration of an IUD in the abdominal cavity is a rare finding, and coexistence with third-trimester pregnancy is an infrequent but serious event due to potential visceral complications. Higher gravidity can be associated with an increased risk of IUD migration in women with a non-scarred uterus.

Caregiver Knowledge of and Attitudes Toward the Levonorgestrel-Containing Intrauterine Device for the Treatment of Heavy Menstrual Bleeding in Adolescents and Young Adults

STUDY OBJECTIVE

We evaluated caretaker knowledge of and attitudes toward the levonorgestrel-containing intrauterine device (L-IUD) as a treatment option for adolescents and young adults with heavy menstrual bleeding.

DESIGN

A survey assessed demographic characteristics, menstrual history, perception of the L-IUD, and knowledge of the indications, risks, and benefits of the L-IUD.

SETTING

Participant recruitment occurred in the offices of a pediatric gynecologist, pediatric hematologist, and adolescent medicine physician in a hospital-based practice in New York.

PARTICIPANTS

English-speaking caretakers of patients with a chief concern of heavy menstrual bleeding (<21 years old) were invited to participate.

INTERVENTIONS

Electronic and paper surveys were administered prior to seeing the physician.

MAIN OUTCOME MEASURES

The primary outcome was participant willingness to allow their daughter to use the L-IUD for heavy menstrual bleeding. Additional outcomes were explored by calculating a mean knowledge score and conducting a descriptive analysis of the perception questions.

RESULTS

Forty surveys were included. Seventy percent of participants said they would allow their daughter to use birth control pills for heavy menstrual bleeding, whereas only 10% said the same of the L-IUD. The mean knowledge score was 73.3% (±15.7). Sixty-five percent of participants expressed the need for additional information on the L-IUD.

CONCLUSION

Caretaker acceptance of the L-IUD as treatment for their daughter with heavy menstrual bleeding is limited. Although baseline knowledge was high, many indicated needing additional information. Because heavy menstrual bleeding can negatively impact quality of life, potential caretaker bias must be addressed to ensure full access to this highly effective treatment option.

Use of the Levonorgestrel Intrauterine System to Treat Heavy Menstrual Bleeding in Adolescents and Young Adults with Inherited Bleeding Disorders and Ehlers-Danlos Syndrome

STUDY OBJECTIVE

To report on the rate of amenorrhea among adolescents and young adults with a bleeding diathesis after insertion of the 52-mg levonorgestrel intrauterine system (LNG-IUS) DESIGN: Retrospective chart review SETTING: Tertiary care, multidisciplinary Gynecology-Hematology clinic or Adolescent Gynecology clinic PARTICIPANTS: The cohort included 35 females aged 12-25 years presenting from January 2010 to January 2020 with heavy menstrual bleeding, 23 with an inherited blood disorder, and 12 with Ehlers-Danlos syndrome INTERVENTIONS: The 52-mg LNG-IUS MAIN OUTCOME MEASURES: Primary outcome was bleeding profile after LNG-IUS insertion. Secondary outcomes included rates of amenorrhea, intrauterine device (IUD) expulsion, IUD discontinuation, and unplanned pregnancy.

RESULTS

Mean age at menarche was 11.6 years, with mean age at insertion of 16.9 (range 11-23). Most participants were white (n = 26, 74.3%). Von Willebrand disease was present in 16 patients (45.7%) and Ehlers-Danlos syndrome in 12 (34.3%). Most (91.4%) had tried at least 1 hormonal regimen prior to LNG-IUS. Most participants (81.8%) reported improvement in bleeding, with 60.6% reporting spotting or amenorrhea. LNG-IUS expulsion occurred in 3 participants (9.1%) within the first 21 days, despite hemostatic agents at time of insertion. Mean continuation was 5.08 years (95% CI, 4.24-5.92), with 79% likelihood that participants kept their IUD in place for at least 2.5 years, and some up to 6 years.

CONCLUSION

The 52-mg LNG-IUS is an effective treatment option for adolescents and young adults with heavy menstrual bleeding and a bleeding diathesis, with high rates of amenorrhea. Rates of IUD expulsion appeared higher during the first 30 days, but long-term continuation remained high.

Quality of Life and Health Status of Jordanian Women Users of Various Contraceptive Methods and Associated Factors: Implications for Contraceptive Policies

AIM

The study aimed at investigating the differences in health status of women users and non-users of contraceptive methods and assess differences in contraception quality of life (CQoL) according to method used.

METHODS

Across sectional study with 372 women between the ages of 18 and 49 years old were recruited. Participants completed the health status and the CQoL questionnaire, which was validated using factor analysis combining three factor loading measures with a good Cronbach's alpha reliability coefficient.

RESULTS

Results showed that there were no significant differences in health status between users and non-users. There was a significant difference in QoL according to the method used at the p <0.05 level for the three conditions F (2193) = 6.0 and p = 0.003. Post hoc analysis indicated that the total CQoL was significantly higher in IUD users (M = 55.7, SD = 9.6) than users of natural methods (M = 50, SD = 9.0, p < 0.01). In addition, the total CQoL was significantly higher among women from the southern region (M = 56.7, SD = 9.0) than from the northern and mid-regions (M = 49.5, SD = 0.07 and M = 52, SD = 10, respectively, p < 0.01).

CONCLUSION

The physiological changes of women's QoL was affected by the use of the IUD method with significantly lower QoL scores than those who used oral contraceptives and non-hormonal methods. In addition, there was no significant difference in health status between users and non-users of contraceptive methods.

IMPLICATIONS

The study has implications for contraceptive counselling on quality of life of women users of IUD and women from the south region and provides opportunities for the advancement of the reproductive health services in Jordan.

Pelvic inflammatory disease in the adolescent and young adult: An update

Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is typically polymicrobial with classic core involvement of Neisseria gonorrhoeae and/or Chlamydia trachomatis, though other endogenous flora from the vagino-cervical areas can be involved as well. It is often a sexually transmitted disease but other etiologic routes are also noted. A variety of risk factors have been identified including adolescence, young adulthood, adolescent cervical ectropion, multiple sexual partners, immature immune system, history of previous PID, risky contraceptive practices and others. An early diagnosis and prompt treatment are necessary to reduce risks of PID complications such as chronic pelvic pain, ectopic pregnancy and infertility. Current management principles of PID are also reviewed. It is important for clinicians to screen sexually active females for common sexually transmitted infections such as Chlamydia trachomatis and provide safer sex education to their adolescent and young adult patients. Clinicians should provide comprehensive management to persons with PID and utilize established guidelines such as those from the US Centers for Disease Control and Prevention (CDC).

Contraception in Adolescents

Adolescents are at risk for unwanted pregnancy when they become sexually active, and contraception is an important part of mitigating this risk. Use of contraceptive methods, and long-acting reversible contraceptive methods such as implants and intrauterine devices in particular, has increased among adolescents. Although sexual activity has declined and contraceptive use has increased among adolescents in the United States in recent years, the unintended pregnancy rate remains high. All of the currently available contraceptive methods are safe and effective for adolescents to use; however, adolescents may have specific concerns about side effect profiles and unscheduled bleeding that should be addressed during contraceptive counseling. Healthcare providers should prioritize adolescents' needs and preferences when approaching contraceptive counseling, and also consider the unique access and confidentiality issues that adolescents face when accessing contraception.

Attendance of an Initial Follow-up Visit after Long-Acting Reversible Contraception Insertion and Method Continuation Among Adolescents and Young Adults: A Retrospective Study

STUDY OBJECTIVE

To assess attendance of an initial follow-up visit after long-acting reversible contraception (LARC) insertion and whether follow-up was associated with a higher likelihood of method continuation in adolescents and young adults (AYAs).

DESIGN

Retrospective chart review including patients receiving LARC (etonogestrel 68 mg implant, levonorgestrel 52 mg intrauterine device, or copper intrauterine device) between January 1, 2014, and August 1, 2017.

SETTING

An urban adolescent center providing primary care and reproductive health services.

PARTICIPANTS

A total of 331 patients 13-28 years of age.

INTERVENTIONS

Attendance of a follow-up visit 4-8 weeks after LARC insertion.

MAIN OUTCOME MEASURES

Follow-up was defined as visits addressing LARC method or routine physical examinations in the adolescent center or affiliated school-based health clinics. Continuation and discontinuation were defined as documented presence or removal, respectively, of device at various time points. Descriptive analyses, χ² test, Fisher exact test, t test, and survival analysis were used.

RESULTS

Approximately one-third (29.3%) of the patients attended a follow-up visit. Follow-up was associated with a higher likelihood of LARC removal in the first year (hazard ratio [HR] = 2.10, 95% confidence interval [CI] 1.33-3.32). At 500 days post-insertion and beyond, there was no difference in LARC continuation between AYAs who followed-up and those who did not (HR = 1.07, 95% CI 0.67-1.71).

CONCLUSION

Few AYAs attended an initial follow-up visit after LARC placement. These visits were associated with an increased likelihood of LARC removal in the first year; however, this association was not observed long term. More information is needed to determine how to approach follow-up this population.

Current evidence of contraceptive uptake, pregnancy and continuation rates in young women: a systematic review and Meta-analysis

OBJECTIVE

Half of all pregnancies worldwide are unintended, and the rate is even higher in women aged ≤25 years. We sought to identify which method of contraception was the most effective option to prevent unintended pregnancy in young women and adolescents.

METHODS

Systematic searches, without language restrictions, were carried out of the PubMed, Embase, Lilacs and Cochrane databases from inception to July 2020. Abstracts and full-text articles of observational studies and randomised controlled trials comparing the use of multiple methods of long-acting reversible contraception (LARC) and short-acting reversible contraception (SARC) in young women and adolescents were screened and reviewed. Risk ratios (RRs) and mean differences with their 95% confidence interval (CI) were derived using a random-effects meta-analytical model. Meta-analyses provided pooled estimates for adverse events, continuation rates and efficacy of LARC methods in young women and adolescents. Nine of the 25 included studies compared LARC with SARC, and 16 compared LARC methods only.

RESULTS

At 12 months, young women had better adherence with LARC compared with SARC (n = 1606; RR 1.60; 95% CI 1.21, 2.12; I ² = 88%), which suggests a better unintended pregnancy prevention outcome for young women. However, more young women chose SARC (n = 2835; RR 0.37; 95% CI 0.17, 0.80; I ² = 99%). Pregnancy during LARC use was rare.

CONCLUSION

LARC methods are the most efficacious in preventing pregnancy, and women should be informed of this if pregnancy prevention is their priority. The evidence, however, is of low quality.

PROSPERO REGISTRATION NUMBER

CRD42017055452.

Safety, Quality, and Acceptability of Contraceptive Implant Provision by Community Health Extension Workers versus Nurses and Midwives in Two States in Nigeria

Task sharing is a strategy with potential to increase access to effective modern contraceptive methods. This study examines whether community health extension workers (CHEWs) can insert contraceptive implants to the same safety and quality standards as nurse/midwives. We analyze data from 7,691 clients of CHEWs and nurse/midwives who participated in a noninferiority study conducted in Kaduna and Ondo States, Nigeria. Adverse events (AEs) following implant insertions were compared. On the day of insertion AEs were similar among CHEW and nurse/midwife clients—0.5 percent and 0.4 percent, adjusted odds ratio (aOR) 0.92 (95 percent CI 0.38–2.23)—but noninferiority could not be established. At follow‐up 6.6 percent of CHEW clients and 2.1 percent of nurse/midwife clients experienced AEs. There was strong evidence of effect modification by State. In the final adjusted model, odds of AEs for CHEW clients in Kaduna was 3.34 (95 percent CI 1.53–7.33) compared to nurse/midwife clients, and 0.72 (95 percent CI 0.19–2.72]) in Ondo. Noninferiority could not be established in either State. Implant expulsions were higher among CHEW clients (142/2987) compared to nurse/midwives (40/3517). Results show the feasibility of training CHEWs to deliver implants in remote rural settings but attention must be given to provider selection, training, supervision, and follow‐up to ensure safety and quality of provision.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Intraperitoneal migration of an intrauterine device (IUD): A case report

Introduction

The IUD is one of the most widely used reversible, long-term contraceptive methods in the world. About 80% of IUDs are found in the peritoneal cavity after uterine perforation.

Case report

A 27-year-old female patient presented with chronic pelvic pain with minimal metrorrhagia for 8 months on IUD. On examination, there was no IUD thread. Pelvic ultrasound showed a hypoechoic, heterogeneous, poorly limited formation measuring 3 × 2.68 cm. Abdominal-pelvic CT scan showed hyperdense supravesical material surrounded by a hypo-dense, well-limited collection measuring 26 × 25 mm. Laparoscopy showed an anterior peritoneal collection above the bladder containing the IUD, a uterus, adnexa, and a bladder without abnormality. The IUD was removed after incision of the collection and aspiration of the pus.

Discussion

The IUD is one of the most widely used long-term reversible contraceptive methods in the world. But like any foreign body, it can present complications, notably migration after uterine perforation, which remains rare, and even rarer peritoneal localization. The clinical diagnosis is not always obvious, and additional examinations are necessary to locate the device, including endovaginal ultrasound, a CT scan or magnetic resonance imaging.

WHO recommends surgical removal of the migrated IUD by minimally invasive methods, including hysteroscopy, cystoscopy, colonoscopy, or laparoscopy, depending on the location of the IUD.

Conclusion

IUDs are effective contraceptive measures, and the majority of patients with uterine perforation by IUD migration are asymptomatic. Diagnosis is based on a thorough gynecologic analysis and appropriate radiologic imaging.

•

The IUD is one of the most widely used long-term reversible contraceptive methods in the world.

•

Perforation with migration is rare but is one of the most serious complications.

•

Clinical diagnosis is not always evident and needs additional examinations to locate the device (Ultrasound, CT scan, MRI).

•

Who recommends surgical removal of migrated DIU as soon as possible, using minimally invasive methods, including hysteroscopy, laparoscopy, depending on the location of the DIU.

[Long-acting reversible contraception methods in women under 26 years of age]

OBJECTIVES

Long-acting reversible contraception (LARC) methods have proven their high safety and efficacy for pregnancy prevention and they are specially indicated in young and vulnerable population, but their use encounter barriers both between providers and users due to lack of information or to the economic cost. The aim of this study was to assess the use of two LARC methods, intrauterine device (IUD) and implant, in minors under 26 years old after giving an adequate contraceptive advice and subsidizing them in vulnerability situations. To analyze the population that chooses them, the side effects, the reasons for abandoning and the permanence time.

MATERIAL AND METHODS

Retrospective descriptive study of IUD and implants inserted to minors under 26 years old from January 2016 to December 2019 at the Municipal Health Center of Usera belonging to Madrid Salud. Data is collected from n=266 women who started using IUD or implant. 87 copper IUD, 37 medicated IUD and 142 implants have been placed.

RESULTS

Increased prescription of both methods, with significant implant use in the last year of the study. There has been vulnerability in 91.7% of women. The average age of IUD users is about 21.4 years, almost 2 years older than that of the implant and they have more children. The side effects frequency has been similar with both methods, being abnormal bleeding as the most frequent side effect. 31% of copper IUD, 32% of medicated IUD and 12% of implants have been removed early. The average permanence time was 19.3 months (SD=13.3), 89.1% remained at the end of the first year, 81.2% at two years and 77.4% at three years.

CONCLUSIONS

An adequate contraceptive advice and free access are essential keys for increasing the LARC methods use in this particularly vulnerable population. Few and minor side effects and high continuity rate have been found, especially for the implant.

Intrauterine Devices and Sexually Transmitted Infection among Older Adolescents and Young Adults in a Cluster Randomized Trial

STUDY OBJECTIVE

Provider misconceptions regarding intrauterine device (IUD) safety for adolescents and young women can unnecessarily limit contraceptive options offered; we sought to evaluate rates of Neisseria gonorrhoeae or Chlamydia trachomatis (GC/CT) diagnoses among young women who adopted IUDs.

DESIGN

Secondary analysis of a cluster-randomized provider educational trial.

SETTING

Forty US-based reproductive health centers.

PARTICIPANTS

We followed 1350 participants for 12 months aged 18-25 years who sought contraceptive care.

INTERVENTIONS

The parent study assessed the effect of provider training on evidence-based contraceptive counseling.

MAIN OUTCOME MEASURES

We assessed incidence of GC/CT diagnoses according to IUD use and sexually transmitted infection risk factors using Cox regression modeling and generalized estimating equations.

RESULTS

Two hundred four participants had GC/CT history at baseline; 103 received a new GC/CT diagnosis over the 12-month follow-up period. IUDs were initiated by 194 participants. Incidence of GC/CT diagnosis was 10.0 per 100 person-years during IUD use vs 8.0 otherwise. In adjusted models, IUD use (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 0.71-2.40), adolescent age (aHR, 1.28; 95% CI, 0.72-2.27), history of GC/CT (aHR, 1.23; 95% CI, 0.75-2.00), and intervention status (aHR, 1.12; 95% CI, 0.74-1.71) were not associated with GC/CT diagnosis; however, new GC/CT diagnosis rates were significantly higher among individuals who reported multiple partners at baseline (aHR, 2.0; 95% CI, 1.34-2.98).

CONCLUSION

In this young study population with GC/CT history, this use of IUDs was safe and did not lead to increased GC/CT diagnoses. However, results highlighted the importance of dual sexually transmitted infection and pregnancy protection for participants with multiple partners.

Rates of Intrauterine Device Expulsion Among Adolescents and Young Women

STUDY OBJECTIVE

The objective of our study was to determine the rate of intrauterine device (IUD) expulsion and risk factors for expulsion among adolescents and young adults.

DESIGN

Retrospective chart review.

SETTING

IUD insertions were performed at a single children's hospital.

PARTICIPANTS

Eligible adolescent and young adult patients who underwent IUD insertion between August 2009 and March 2019.

INTERVENTIONS

IUD insertion.

MAIN OUTCOME MEASURES

Primary outcome was the incidence of IUD expulsion in adolescents and young women. Secondary outcomes were risk factors for IUD expulsion including heavy menstrual bleeding, abnormal uterine bleeding (AUB), anemia, or a bleeding disorder diagnosis.

RESULTS

Six hundred forty-two eligible patients underwent IUD insertion. The incidence of first IUD expulsion in this population was 58/642 (9.03%). Among those who chose to have a second IUD placed (n = 29), 8/29 (27.6%) had a second expulsion. Patients who expelled their IUD were more likely to have a history of AUB, heavy menstrual bleeding, anemia, or a bleeding disorder. When controlled for body mass index and age at insertion, history of AUB and anemia remained significant risks for IUD expulsion.

CONCLUSION

This study similarly showed a higher risk of primary and secondary IUD expulsion in adolescents and young women. A history of AUB, anemia, bleeding disorder, and elevated body mass index are associated with higher risk for IUD expulsion. This population should be counseled that these conditions might place them at higher risk for expulsion.

Ex-vivo forces associated with intrauterine device placement and perforation: a biomechanical evaluation of hysterectomy specimens

Background

This biomechanical analysis of hysterectomy specimens assesses the forces associated with intrauterine device placement. These include compressive forces required to cause uterine perforation with two commonly available commercial intrauterine device placement instruments and a metal uterine sound.

Methods

We obtained hysterectomy specimens at a single academic center. All specimens resulted from excision for benign conditions in premenopausal women by any operative method. Within one hour of excision, we stabilized uterine specimens in an apparatus specifically designed for this analysis. A single, experienced clinician performed all experimental maneuvers and measured forces with a Wagner FDIX-25 force gauge. The investigator applied traction on a tenaculum to approximate force used during an intrauterine device placement. The maximum compressive force to the uterine fundus was determined by using manufacturers’ placement instruments for two commercially available products and a metal sound.

Results

Sixteen individuals provided hysterectomy specimens. No complete perforations occurred while using loaded intrauterine devices; in a single observation the LNG IUS entered the myometrium. The plastic intrauterine device placement rod bowed in all attempts and did not perforate the uterine serosa at the fundus. A metal uterine sound created a complete perforation in all specimens (p < .001). The lowest mean maximum force generated occurred with the levonorgestrel intrauterine system placement instrument 12.3 N (SD ± 3.8 N), followed by the copper T380A intrauterine device placement instrument 14.1 N (SD ± 4.0 N), and highest for the metal sound 17.9 N (SD ± 7.6 N) (p < 0.01).

Conclusions

In this ex-vivo model, metal uterine sounds caused complete perforation and intrauterine device placement instruments did not.

This study received Institutional Review Board (IRB0059096) approval.

Copper IUD continuation, unwanted effects and cost consequences at 1 year in users aged under 30 - a secondary analysis of the EURAS-IUD study

OBJECTIVE

To conduct a secondary analysis of continuation, unwanted effects and cost consequences at 1 year in copper intrauterine device (IUD) users aged under 30 in the European Active Surveillance Study for Intrauterine Devices (EURAS-IUD study) based on IUD type.

METHODS

Descriptive and comparative analyses of copper IUD continuation, unwanted effects and estimated cost consequences at 1 year were performed in users aged under 30 based on IUD copper surface area, shape or design, width and arms' flexibility.

RESULTS

5796 copper IUD users were identified to have been aged under 30 at EURAS-IUD study recruitment and data for 5762 users (99.4%) was analysed. Higher IUD continuation, fewer unwanted effects and lower costs were observed with IUDs of the lowest copper content (<300mm²), horse-shoe frame design, widths 18 mm to <30mm and flexible IUD arms. Discontinuation, unwanted effects and costs were greater with frameless IUDs and framed, ≥30mm width IUDs with 380mm² of copper and copper bands on their rigid transverse IUD arms.

CONCLUSIONS

Significant differences in continuation, reported unwanted effects and estimated costs at 1 year between IUD types were observed in users aged under 30. Although further research is needed, clinicians should consider these findings when counselling and choosing IUD types for younger women.

Relationship of parity and prior cesarean delivery to levonorgestrel 52 mg intrauterine system expulsion over 6 years

OBJECTIVE

Assess the relationship between parity and prior route of delivery to levonorgestrel 52 mg intrauterine system (IUS) expulsion during the first 72 months of use.

STUDY DESIGN

We evaluated women enrolled in the ACCESS IUS multicenter, Phase 3, open-label clinical trial of the Liletta levonorgestrel 52 mg IUS. Investigators evaluated IUS presence at 3 and 6 months after placement and then every 6 months and during unscheduled visits. We included women with successful placement and at least one follow-up assessment. We evaluated expulsion rates based on obstetric history; for prior delivery method subanalyses, we excluded 12 participants with missing delivery data. We determined predictors of expulsion using multivariable regression analyses.

RESULTS

Of 1714 women with IUS placement, 1710 had at least one follow-up assessment. The total population included 986 (57.7%) nulliparous women. Sixty-five (3.8%) women experienced expulsion within 72 months, 50 (76.9%) within the first 12 months. Expulsion rates among nulliparous women (22/986 [2.2%]) or parous women with any pregnancy ending with a Cesarean delivery (6/195 [3.1%]) differed from parous women who only experienced vaginal deliveries (37/517 [7.2%]) (p < 0.001). In multivariable regression, obesity (adjusted odds ratio [aOR] 2.2, 95% confidence interval [CI] 1.3-3.7), parity (aOR 2.2, 95% CI 1.2-4.1), and non-white race (aOR 1.8, 95% CI 1.1-3.2) predicted expulsion. Among parous women, obesity (aOR 2.2, 95% CI 1.2-4.2) increased the odds and having ever had a cesarean delivery (aOR 0.4, 95% CI 0.1-0.9) decreased the odds of expulsion.

CONCLUSION

IUS expulsion occurs in less than 4% of users over the first 6 years of use and occurs mostly during the first year. Expulsion is more likely among obese and parous women.

IMPLICATIONS

Levonorgestrel 52 mg intrauterine system expulsion occured more commonly in parous than nulliparous women; the increase in parous women is primarily in women who had vaginal deliveries only. The association between obesity, delivery route, and IUS expulsion needs further elucidation.

Insertion of intrauterine device for doctors and nurses in a low-risk maternity hospital

OBJECTIVE

To characterize the production related to the insertion of Intrauterine Devices by doctors and nurses in a low-risk maternity hospital.

METHOD

Cross-sectional exploratory research, with retrospective collection of secondary data from medical records of women who received the device in a low-risk maternity hospital in Curitiba, Paraná, over 12 months. Data collected between October/2017 to March/2018 that underwent descriptive analysis and Chi-square test.

RESULTS

Of the 828 insertions, there was a significant difference between women who received the IUD at the Obstetric Center (247) and Ambulatory (571) in terms of the expulsion rate (p = 0.00001), with a greater chance of expulsion in the immediate postpartum period (Odds ratio 8.73), there was no significant difference between nurses (481) and doctors (347) (p = 0.07), however, more chance of expulsion when the doctor was (Odds ratio 3.60). The main complications were dysmenorrhea and vaginosis.

CONCLUSION

The insertion of the IUD in the ambulatory by the nurse proved to be as safe as by the doctor.

Intrauterine device use is safe among nulligravidas and adolescent girls

The use of intrauterine devices (IUDs), including the copper-bearing device and the levonorgestrel intrauterine system (LNG-IUS), is safe among nulligravidas and adolescent girls. However, several misconceptions limit their use in clinical practice; health-care providers are hesitant to prescribe IUDs, and several myths associated with their usage in nulligravidas and adolescents exist among both providers and women themselves. The high rates of unplanned pregnancies (which in many settings constitute a public health issue, primarily among adolescent females) can be attributed at least partially to lack of awareness and limited use of highly effective contraceptives such as IUDs. In this review, we discuss the role of non-hormonal and hormonal IUDs as effective contraceptives in nulligravidas and adolescent girls. We present a literature review of data that highlight contraceptive efficacy, side effects (including reasons for discontinuation), and continuation rates with the method. We searched the PubMed/MEDLINE, Cochrane Library, Embase, and Scopus databases for all articles published in English between January 1990 through September 2020. A large body of evidence confirmed the effectiveness of IUD/IUS, independent of age and parity. Studies showed a high expulsion rate among adolescents but not among nulligravidas. Additionally, bleeding patterns among adolescents and nulligravidas were similar to those observed among adults and parous women. The high early removal rates observed in adolescents were attributable to bleeding and/or pain, which indicate that compared with adults, adolescents are less likely to accept IUD-induced side effects. IUD placement is an excellent strategy to avoid the high rates of unplanned pregnancies in adolescents and nulligravidas. IUDs are more effective than short-acting reversible contraceptives with failure rates that are equivalent to those observed with permanent contraception. However, few long-term studies have investigated this category of women to definitively establish the role of IUD/IUS as effective means of contraception.

Levonorgestrel Intrauterine Device Use for Medical Indications in Nulliparous Adolescents and Young Adults

PURPOSE

Intrauterine devices (IUDs) are highly effective at preventing pregnancy. Levonorgestrel (LNG) IUDs also have beneficial effects on menstrual bleeding and abdominal and pelvic pain. Although there are increasing data on use of IUDs for contraception in adolescents and for medical indications in adults, there are extremely limited data on LNG IUD use for medical indications in adolescents. Our objective is to describe the characteristics and experiences of LNG IUD use in nulliparous adolescents and young women using IUDs for medical indications.

METHODS

We conducted a retrospective chart review of all nulliparous patients aged 22 years and younger who underwent LNG IUD insertion at a tertiary care children's hospital between July 1, 2004 and June 30, 2014 primarily for noncontraceptive indications. Descriptive statistical analysis was performed.

RESULTS

We identified 231 LNG IUDs placed in 219 nulliparous women for medical indications during this time period. Mean patient age was 16.8 years (±2.2). Only 41% reported ever being sexually active. IUD continuation rate at 1 year was 86%. The amenorrhea rate at 1 year was 51%. Approximately 80% of women reported improvements in menstrual bleeding and abdominal and pelvic pain. Side effects and complications were low.

CONCLUSIONS

This study provides evidence that LNG IUDs are effective, well-tolerated, and safe menstrual management options in young nulliparous women, including younger adolescents and those who have never been sexually active. This method is an excellent first-line therapy option for adolescents and young women for both contraceptive and noncontraceptive indications, regardless of age, parity, or sexual activity.