1
|
Madar J, Gaucher M, Barbaroux A, Delotte J, Boudy CA. [Risks of urogenital infections and expulsion associated with the combination of an IUD and a menstrual cup]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024:S2468-7189(24)00259-9. [PMID: 39004187 DOI: 10.1016/j.gofs.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 07/04/2024] [Accepted: 07/04/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVES The increase in intrauterine devices (IUDs) contraception, and the growing use of reusables menstrual hygiene products such as the menstrual cup, necessitates an assessment of the implications of their co-use. The objectives are to assess whether women with IUDs who use menstrual cups have an increased risk of IUD expulsion and/or a change in the risk of upper and lower urogenital tract infections compared to women who use other menstrual hygiene products. METHOD An observational, prospective, multicenter study was conducted in France between 2020 and 2023. Participants were recruited by health professionals and data were collected by telephone questionnaire at the time of IUD insertion and at one year. The primary endpoints were the occurrence of IUD expulsion and the occurrence of urogenital tract infections in menstrual cup users compared to non-users. RESULTS One hundred and three women out of 119 included were analyzed, 25 of them were regular menstrual cup users and five experienced IUD expulsion. Among regular users, 12% experienced IUD expulsion compared to 2.6% among non-users, with no statistically significant difference (Chi2=3.65; P=0.056). Regarding urogenital tract infections, nine women (36%) of the regular menstrual cup users had urogenital infections, compared with 27 (34.6%) of the non-users or not regular users, with no statistically significant difference. CONCLUSION The tendency of menstrual cup users to expel their IUDs is a reason for caution, although it is not sufficient to contraindicate co-use. Physicians should therefore systematically screen such co-use and inform patients of the risks and monitoring instructions.
Collapse
Affiliation(s)
- Johanna Madar
- Université Côte d'Azur (UCA), Rétines, Healthy, département d'Enseignement et de Recherche en Médecine Générale (DERMG), 28, avenue de Valombrose, 06107 Nice cedex 2, France.
| | - Méghane Gaucher
- Université Côte d'Azur (UCA), Rétines, Healthy, département d'Enseignement et de Recherche en Médecine Générale (DERMG), 28, avenue de Valombrose, 06107 Nice cedex 2, France
| | - Adriaan Barbaroux
- Université Côte d'Azur (UCA), Rétines, LAPCOS, Healthy, département d'Enseignement et de Recherche en Médecine Générale (DERMG), 28, avenue de Valombrose, 06107 Nice cedex 2, France
| | - Jérôme Delotte
- Service de gynécologie-obstétrique et médecine de la reproduction, hôpital de l'Archet 2, 151, route de Ginestière, 06202 Nice cedex 3, France
| | - Carol-Anne Boudy
- Université Côte d'Azur (UCA), Rétines, Healthy, département d'Enseignement et de Recherche en Médecine Générale (DERMG), 28, avenue de Valombrose, 06107 Nice cedex 2, France
| |
Collapse
|
2
|
Brown JE, Creinin MD, Wu H, Hubacher D, Schreiber CA, Kaneshiro B, Nanda K, Blithe DL. Menstrual cup use and intrauterine device expulsion in a copper intrauterine device randomized trial. Contraception 2024; 134:110415. [PMID: 38431257 PMCID: PMC11081833 DOI: 10.1016/j.contraception.2024.110415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE To evaluate menstrual cup use and intrauterine device (IUD) expulsion. STUDY DESIGN We performed a secondary analysis of a 3-year contraceptive efficacy trial comparing two copper 380 mm2 IUDs. Investigators randomized participants approximately 1:4 to the TCu380A or NTCu380-Mini IUD. Approximately 12 months after enrollment began, we advised participants against menstrual cup use due to observed IUD expulsions in cup users. We evaluated IUD expulsion (including spontaneous partial and complete expulsion and accidental self-removal) at 12 and 36 months. We used multivariable logistic regression to evaluate IUD expulsion by age, baseline menstrual volume, body mass index, IUD type, menstrual cup use, parity, and uterine length. RESULTS This analysis included 1046 participants (203 TCu380A and 843 NTCu380-Mini), with 879 (84.0%) nulliparas. Through 12 and 36 months, expulsion occurred in 74 (7.1%, 95% CI 5.5-8.6%) and 133 (12.7%, 95% CI 10.7-14.7%) participants, respectively. Overall, 250 (23.9%) reported menstrual cup use. More menstrual cup users than non-users experienced expulsion through 12 months (32/203 [15.8%] vs. 42/843 [5.0%]) and 36 months (58/250 [23.2%] vs. 75/796 [9.4%]). Through 36 months, NTCu380-Mini menstrual cup users had higher expulsion odds, while TCu380A cup users did not. Menstrual cup users more frequently experienced accidental self-removal than non-users in participants using the TCu380A (3/53 [5.7%] vs. 0/150 [0.0%]) and the NTCu380-Mini (20/197 [10.2%] vs. 7/646 [1.1%]). In multivariable regression, we found increased odds of expulsion through 36 months in participants using menstrual cups with the NTCu380-Mini (aOR 3.13, 95% CI 1.16-8.46) and <25 years (aOR 1.59, 95% CI 1.07-2.34). CONCLUSIONS We found higher odds of IUD expulsion with menstrual cup and concurrent NTCu380-Mini IUD use over 36 months of use, but not with concurrent TCu380A IUD use. Menstrual cup users experienced higher likelihood of accidental self-removal regardless of IUD type. IMPLICATIONS Menstrual cup and NTCu380-Mini use may increase IUD expulsion risk and may increase accidental self-removal risk with TCu380A and NTCu380-Mini use. Clinicians should advise patients of these risks and consider warning patients using an IUD shaped like the NTCu380-Mini (Nova-T frames) of expulsion risk with menstrual cup use.
Collapse
Affiliation(s)
- Jill E Brown
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Sacramento, CA, USA
| | - Hongsheng Wu
- Biostatistical Science, Premier Research, Morrisville, NC, USA
| | - David Hubacher
- Contraceptive Technology Innovation Initiative, FHI 360, Durham, NC, USA
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Penn Medicine University City, Philadelphia, PA, USA
| | - Bliss Kaneshiro
- Department of Obstetrics and Gynecology, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Kavita Nanda
- Contraceptive Technology Innovation Initiative, FHI 360, Durham, NC, USA
| | - Diana L Blithe
- Contraceptive Development Program, Division of Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| |
Collapse
|
3
|
Liberty A, Samuelson Bannow B, Matteson K, Edelman A, Colwill A. Menstrual Technology Innovations and the Implications for Heavy Menstrual Bleeding. Obstet Gynecol 2023; 141:666-673. [PMID: 36791417 PMCID: PMC10026971 DOI: 10.1097/aog.0000000000005126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/20/2022] [Accepted: 01/05/2023] [Indexed: 02/17/2023]
Abstract
Menstruation is a personal and cultural experience with financial and health implications. Menstruation historically has been managed with disposable commodities, including tampons and pads. New technologies, including underwear and menstrual cups and discs, have emerged to address diverse menstrual needs such as prioritization of sustainability, discretion, and inclusivity. New technologies are not routinely integrated into history taking or validated questionnaires, which currently rely on traditional tampon and pad use for identifying individuals with heavy menstrual bleeding. Review of menstrual technologies and accessories provides insight to empower gynecologists and other clinicians to take comprehensive menstrual histories, including strategies for identification of heavy menstrual bleeding and troubleshooting menstrual disturbances, within the context of new menstrual technologies.
Collapse
Affiliation(s)
- Abigail Liberty
- Division of Family Planning, Department of Obstetrics and Gynecology, and the Division of Hematology/Medical Oncology, Department of Medicine, Oregon Health and Science University, Portland, Oregon; and the Department of Obstetrics and Gynecology, UMass Memorial Medical Center, Worcester, Massachusetts
| | | | | | | | | |
Collapse
|
4
|
FSRH Guideline (March 2023) Intrauterine contraception. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:1-142. [PMID: 37188461 DOI: 10.1136/bmjsrh-2023-iuc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
|
5
|
Bowman N, Thwaites A. Menstrual cup and risk of IUD expulsion - a systematic review. Contracept Reprod Med 2023; 8:15. [PMID: 36670496 PMCID: PMC9863186 DOI: 10.1186/s40834-022-00203-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/19/2022] [Indexed: 01/22/2023] Open
Abstract
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.
Collapse
Affiliation(s)
| | - Annette Thwaites
- grid.83440.3b0000000121901201Institute of Women’s Health, University College London, London, UK
| |
Collapse
|
6
|
Fanse S, Bao Q, Burgess DJ. Long-acting intrauterine systems: Recent advances, current challenges, and future opportunities. Adv Drug Deliv Rev 2022; 191:114581. [PMID: 36270490 PMCID: PMC10302114 DOI: 10.1016/j.addr.2022.114581] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/13/2022] [Accepted: 09/27/2022] [Indexed: 01/24/2023]
Abstract
Levonorgestrel intrauterine systems (LNG-IUSs) are complex drug-device combination products designed to release a hormonal contraceptive drug for up to 7 years. These drug delivery systems offers a great promise as a modern method of long-acting reversible contraceptives (LARCs) to improve women's health. Unfortunately, there are some scientific challenges associated with the development of these products which are among the major reasons contributing to the availability of relatively few IUS products on the market. This review summarizes the formulation considerations (drug and excipient attributes), manufacturing methods, advances in characterization and in vitro drug release testing of IUSs, as well as factors influencing drug release from IUSs. A critical discussion on the major challenges to IUS product development is presented. Specifically, insights on bioequivalence evaluation, in vitro-in vivo correlation (IVIVC) establishment, and regulatory challenges are detailed. Lastly, methodological tools to overcome some of these hurdles to product development are proposed. The knowledge furnished through this review will be helpful towards obtaining better product understanding. Such understanding will facilitate the development of these complex drug products, as well as their regulatory approval process.
Collapse
Affiliation(s)
- Suraj Fanse
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA
| | - Quanying Bao
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA
| | - Diane J Burgess
- University of Connecticut, School of Pharmacy, Storrs, CT 06269, USA.
| |
Collapse
|
7
|
Patel SK, Valicherla GR, Micklo AC, Rohan LC. Drug delivery strategies for management of women's health issues in the upper genital tract. Adv Drug Deliv Rev 2021; 177:113955. [PMID: 34481034 DOI: 10.1016/j.addr.2021.113955] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/23/2021] [Accepted: 08/28/2021] [Indexed: 02/08/2023]
Abstract
The female upper genital tract (UGT) hosts important reproductive organs including the cervix, uterus, fallopian tubes, and ovaries. Several pathologies affect these organ systems such as infections, reproductive issues, structural abnormalities, cancer, and inflammatory diseases that could have significant impact on women's overall health. Effective disease management is constrained by the multifaceted nature of the UGT, complex anatomy and a dynamic physiological environment. Development of drug delivery strategies that can overcome mucosal and safety barriers are needed for effective disease management. This review introduces the anatomy, physiology, and mucosal properties of the UGT and describes drug delivery barriers, advances in drug delivery technologies, and opportunities available for new technologies that target the UGT.
Collapse
|
8
|
Gilliam ML, Jensen JT, Eisenberg DL, Thomas MA, Olariu A, Creinin MD. Relationship of parity and prior cesarean delivery to levonorgestrel 52 mg intrauterine system expulsion over 6 years. Contraception 2021; 103:444-449. [PMID: 33651995 DOI: 10.1016/j.contraception.2021.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- Melissa L Gilliam
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, United States
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, United States
| | - David L Eisenberg
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO, United States
| | - Michael A Thomas
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, OH, United States
| | | | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States.
| |
Collapse
|
9
|
Ruddock-Ward K, Lane S. Is there inadequate awareness amongst patients and medical students of the risks of concurrent menstrual cup and IUD/IUS usage? EUR J CONTRACEP REPR 2020; 25:502-503. [PMID: 32852236 DOI: 10.1080/13625187.2020.1807000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
| | - Suzie Lane
- Brighton and Sussex Medical School, Brighton, UK
| |
Collapse
|