Morphologic studies on IUD-induced metrorrhagia. II. Surface changes of the endometrium and microscopic localization of bleeding sites

Uterine histopathologic changes after Cu-Fix intrauterine device insertion

A study of uterine histopathologic changes after the insertion of the Cu-Fix intrauterine device (IUD) was carried out at the Obstetrics and Gynecology Department, Faculty of Medicine, Chulalongkorn University. Ten patients, who had cold conization for a suspicious Papanicolaou smear, were fitted with the Cu-Fix IUD. All patients were diagnosed as having carcinoma-in-situ of the cervix and were scheduled for hysterectomy at 6 weeks postconization. Preoperative ultrasonography showed the IUD anchoring at the uterine fundus, which corresponded with posthysterectomized findings. At the anchoring site of the nylon knot, which serves as a small retention body in the fundus, slight mononuclear cells infiltration in the myometrium was found in only one patient. However, in the endometrium, there was infiltration of mononuclear cells as well as a few plasma cells during the proliferative phase of the cycle. Evidence of local foreign body reaction was found in all patients. No patient had symptoms or signs of pelvic infection.

Endometrial cancer in relation to intra-uterine device use

Data from a population-based case-control study were used to evaluate the risk of endometrial cancer among women who have used an intra-uterine device (IUD). Incident cases were identified between 1985 and 1991 among women aged 45-74 years who were residents of one of 3 counties in Washington State. Controls were selected by random digit dialing, and both groups of subjects received an in-person detailed interview. In this study population, women who had ever used an IUD were estimated to have a risk of endometrial cancer that was 0.61 times that of other women (95% CI 0.41-0.89). The reduction in cancer risk was not found to be dependent on duration of IUD use. There was a suggestion that women who had used intra-uterine contraception relatively late in reproductive life experienced a greater reduction in risk than those whose use was more distant or at a younger age. The relative risk among the small number of women who were currently using an IUD was 0.49 (95% CI 0.12-2.80). These results apply to the use of inert and copper IUDs as there was no use of progestin-releasing IUDs among women in the study population. The data from this and several other studies of the question support the hypothesis that use of an IUD has a favorable effect on the subsequent risk of endometrial cancer. The reason(s) for such a reduced risk is unclear.

Uterine cavity and the location of IUDs following administration of meclofenamic acid to menorrhagic women. A pilot study

The relationship between the uterus and the IUD was studied selectively with hysterosalpingograms in 18 menorrhagic women previously treated with Meclofenamic acid (M Ac.), a well known anti-inflammatory drug. Major anomalies (embedding, perforation, rotation) were found in 28.6% of those patients who responded positively to M Ac. In contrast, major anomalies were found in 63.6% of those patients who responded negatively to the drug. It is proposed that the negative response to M Ac. might be due to severe macroscopic disturbances of the uterine wall-IUD relationship. The degree of response to M Ac. might contribute to the decision to remove the IUD from menorrhagic women. In addition, 84.7% anomalies (deformities, embedding, perforation) in the uterine-IUD relationship were found in 13 women with a T-shape IUD device. The fact that those anomalies are related to the tip of the horizontal arm justifies future studies using shortened arms to diminish hypermenorrhea induced by T-shape devices or attempts to use IUDs which do not have the conventional plastic frame, as in the Cu-Fix IUD which has been mentioned as particularly useful to prevent bleeding side effects and pain induced by conventional IUDs. The Cu-Fix IUD consists of 6 sleeves made of pure (99.99%) copper, each sleeve with a length of 5 mm and an outer diameter of approximately 2.2 mm, threaded on surgical 00 monofilament polypropylene (ProleneR, Ethicon). The total area of exposed copper is approximately 390 mm2. The sleeves are prevented from sliding off the suture by 2 smaller copper tubules crushed on the thread in both ends of the IUD structure. This thread-type, copper-bearing device has been designed to overcome the most common IUD-related problems, bleeding and pain.

Endometrial morphological changes in IUD users: a review

The introduction of an intrauterine device into the uterine cavity induces a foreign body reaction in the surrounding endometrium which is characterized by the infiltration of polymorphonuclear leucocytes and macrophages into the endometrial stroma and subsequently through the surface epithelium. Leucocyte migration is greater with copper IUDs than with inert IUDs. Ulceration of the surface epithelium, haemorrhage of erythrocytes and microthrombosis of stomach capillaries occur in the functional endometrium in contact with inert and copper IUDs. In endometrium adjacent to, but not in contact with, the IUD gaps appear in the endothelial lining of small blood vessels without a haemostatic response. The most striking response in endometrium exposed to progesterone-releasing IUDs is the occurrence of dilated, thin-walled vesicles, associated with a thinning of the surface epithelium and a decidual reaction in the stroma. A uniform suppression of the endometrium in progesterone IUD users is always found after six months of treatment, whereas the insertion of IUDs releasing 20-30 micrograms levonorgestrel induce a profound uniform suppression of the functional endometrium throughout the uterus after only four weeks.

The effects of intrauterine contraceptive devices on the ultrastructure of the endometrium in relation to bleeding complications

The effects of inert (Lippes Loop D and Dalkon Shields) and medicated (copper 7, copper T, and Progestasert) intrauterine contraceptive devices (IUDs) on the ultrastructure of the endometrium were studied in intact human uteri. The most striking morphologic changes induced by the inert and copper-bearing devices were erosion of the surface epithelium and extensive microthrombosis in stromal capillaries of the endometrium in contact with the device. These abnormalities were associated with extravascular thrombi, erythrocytes, and fibrin deposition in the adjacent stroma. Capillary microthrombosis and leukocyte infiltration into the uterine cavity were most extensive around the active part of the copper-bearing devices. With the Progestasert erosion of surface epithelium was rarely seen, but the intact epithelial lining had fewer ciliated cells with flattened and shortened cilia. Large dilated venules were a common finding below the surface epithelium adjacent to the active part of the Progestasert; capillary microthrombosis was found only below the inert arms of the Progestasert. The vascular response of the endometrium to IUDs appears, therefore, to be directly related to the type and proximity of the device. The morphologic changes induced in both surface epithelium and the microvasculature of the endometrium are the likely explanation of the uterine bleeding problems associated with IUDs but are probably intrinsic to the mode of action of the IUD in interfering with implantation.

Changes of plasminogen activator in human uterine tissue induced by intrauterine contraceptive devices

Potassium thiocyanate-extractable uterine plasminogen activator activity was determined to be highest in the endometrium surrounding intrauterine devices (IUDs). Such activity was significantly higher than that encountered in control endometrium or in the endometrium remote to IUDs. As in control cases, extracted endometrial activity fluctuated during the intermenstrual ovarian cycle. It was highest in the pre- or periovulation part of the cycle, and it rose again prior to menstruation. These peaks of activity seem to correspond to times in the cycle when metrorrhagia and abnormal menstruation are usually encountered. Possible implications of the myometrial and endometrial patterns of plasminogen activator in control and IUD-exposed uterine tissue are discussed.

Effects of a progesterone-releasing intrauterine contraceptive device on endometrial blood vessels: a morphometric study

The concentration of microscopically detectable blood vessels was significantly lower in endometrium exposed to progesterone-releasing intrauterine contraceptive devices (IUDs) than in control endometrium (mean vessel density 2.39 and 3.92, respectively). The percentage of vessels with defects was significantly higher in IUD samples (35.0%) than in control samples (13.4%). There was no significant difference in hemostatic response to vessel injury between the IUD and control samples. Although they were more defective than in controls, the blood vessels of progesterone IUD-exposed endometrium were far fewer in number, which may account for significantly less uterine blood loss in the users of these devices. In addition, the progesterone IUDs do not appear to inhibit hemostasis in the endometrium so that blood loss from injured vessels may be minimized.

Ultrastructural alterations in human endometrium caused by intrauterine contraceptive devices

Biopsies of endometrium from women using intrauterine contraceptive devices (IUDs) were examined by electron microscopy to elucidate the possible cause of IUD-associated uterine hemorrhage. The findings reveal the presence of degenerated, shrunken cells in the endometrial glands of IUD users. These cells, termed pyknotic or apoptotic, are more prevalent in tissue from women with complaints of excessive bleeding than in cases without such complaints. The pyknotic cells often show discontinuities of the plasma membrane at their luminal pole, from which cell contents stream into the lumen. Sometimes erythrocytes are also observed in the lumen. A second alteration in the ultrastructure of the endometrium is an abnormal increase in microfilaments in the epithelial cells. These two changes, a large number of pyknotic cells on the one hand and increase in microfilaments on the other, are correlated with excessive bleeding but they do not explain in simple terms of outflow of erythrocytes. Probably some inflammatory mechanism is involved. The increased number of microfilaments might be helping the movement of fluid from healthy to pyknotic cells.

Morphologic studies on IUD-induced metrorrhagia. I. Endometrial changes and clinical correlations

Morphologic studies on human hysterectomy specimens indicate the IUD elicits a vascular reaction which is most pronounced in the endometrium adjacent to the device. This reaction includes increased vascularity, congestion and increased permeability, and degeneration with defect formation. In addition, there is poor hemostatic responsiveness to vascular permeability and damage. The reaction leads to interstitial hemorrhage which undoubtedly causes metrorrhagia. A likely cause for initial vascular damage is mechanical stress transmitted by the IUD through the endometrium to its vascular network. Vascular reaction and poor hemostatic responsiveness may be perpetuated during each cycle by the products released from endothelial cell degeneration and necrosis. Bleeding is one of the most frequent complications leading to discontinuation of an otherwise effective form of long-term contraception and family spacing. Therefore, its solution could be of crucial importance to world-wide population control. Our findings suggest that better understanding of the mechanism of IUD-induced metrorrhagia should result from closer study of the endometrium adjacent to that which is compressed by the IUD.