The contradictive findings between ultrasound, hysteroscopy and cytokines in women with nonhormonal IUDs suffering from menorrhagia: a prospective study

PURPOSE

The objective of this study is to assess the correlation between bleeding irregularities and the accurate placement of the intrauterine device (IUD) device in the uterine cavity, determined through transvaginal ultrasonography and hysteroscopy. In addition, the study aims to examine the cytokine profile in the uterine cavity and serum of patients experiencing bleeding irregularities after the insertion of nonhormonal IUDs.

METHODS

A prospective cohort study was conducted at a single tertiary medical center, wherein patients experiencing intermenstrual bleeding and spotting after the insertion of nonhormonal IUDs were enrolled. The study involved hysteroscopic and sonographic assessments of the uterine cavity and IUD placement, along with the analysis of blood and uterine cavity cytokine profiles.

RESULTS

During the period between July 2019 and February 2020, a total of eight patients who experienced intermenstrual bleeding and spotting after the insertion of nonhormonal IUDs were enrolled the study. One case was excluded since a progestative device was detected by ultrasound. Out of the five cases that underwent a thorough ultrasonographic assessment, three cases (60%) showed an embedded IUD. However, these findings were excluded by the hysteroscopic evaluation.

CONCLUSION

The results suggest that ultrasonographic assessment may lead to an overdiagnosis of IUD mispositioning compared to hysteroscopy. In addition, both ultrasound and hysteroscopy have limitations in diagnosing the cause of bleeding in most cases. The role of local reactive inflammatory cytokines should be further studied.

Bleeding profile and safety of a levonorgestrel 13.5 mg intrauterine device versus Nova T copper 380 mm2 intrauterine device: Results of a 3-year, single-center, randomized phase 4 study

OBJECTIVE

To assess the bleeding profiles of the levonorgestrel 13.5 mg intrauterine device (LNG13.5-IUD) and Nova T copper 380 mm2 IUD (Cu380-IUD).

STUDY DESIGN

Single-center, evaluator-masked, randomized study conducted in women aged 18-45 years starting these methods. Primary outcomes were number of bleeding days, self-reported bleeding intensity, Pictorial Blood Assessment Chart (PBAC) score, and blood biochemical values at baseline, months 3, 6, 12, 24, and 36 per 90-day reference periods except for PBAC (months). Secondary objectives were presence/duration/intensity of dysmenorrhea and tolerability.

RESULTS

We included 106 women aged 32.5 ± 6.7 years: 55 with LNG13.5-IUD and 51 with Cu380-IUD. Data for LNG13.5-IUD versus Cu380-IUD at baseline and month 36 (both respectively) were as follows: (1) median (25th; 75th percentile) number of bleeding days: 12 (9.0; 15.0) versus 12 (9.0; 15.0), p = 0.82, and 4 (0; 13.7) versus 15 (14.2; 20.0), p < 0.001; (2) mean bleeding intensity: 1.7 for both, p = 0.66, and 0.7 and 2.2, p < 0.001. Forty percent versus 0% presented with amenorrhea at month 36; (3) mean PBAC score (95% Confidence interval (CI): 50.7 (16.6; 84.7) versus 130.4 (95.7; 165.0) at month 1, and 7.9 (-26.7; 42.6) versus 126 (90.7; 161.2), p < 0.001; (4) median (25th; 75th percentile) ferritin levels (Ug/L) 33 (19; 53) versus 30 (19; 45), p = 0.70, and 59 (42; 84) versus 21 (8; 39). We did not observe changes or differences between groups in hemoglobin and hematocrit. The duration and intensity of dysmenorrhea were significantly lower with LNG13.5-IUD versus Cu380-IUD. Adverse events were those expected.

CONCLUSIONS

LNG13.5-IUD is associated with a significant reduction in blood loss and dysmenorrhea compared with Cu380-IUD.

IMPLICATIONS

Women eligible for a levonorgestrel 13.5 mg intrauterine device (IUD) or a copper 380 mm2 IUD should be informed of the differences in bleeding profiles-one of the main causes for IUD discontinuation-so they can compare this information against their bleeding expectations.

Real-world outcomes of the levonorgestrel-releasing intrauterine system for heavy menstrual bleeding or dysmenorrhea in Japanese patients: A prospective observational study (J-MIRAI)

OBJECTIVES

We collected real-world data on the safety and clinical outcomes of the levonorgestrel-releasing intrauterine system (LNG-IUS) for heavy menstrual bleeding and dysmenorrhea.

STUDY DESIGN

This was a prospective, multicenter, single-cohort, open-label, post-authorization 12-month follow-up study of Japanese patients initiating the LNG-IUS for heavy menstrual bleeding and/or dysmenorrhea. The primary endpoint was the safety profile based on adverse events and adverse drug reactions (ADRs), including expulsions and abnormal bleeding, within 12 months of LNG-IUS insertion. Secondary endpoints included changes from baseline in menstrual blood loss based on bleeding days and dysmenorrhea graded on a visual analog scale (VAS).

RESULTS

Of the 595 patients included, many had underlying conditions such as adenomyosis (39.5%), uterine leiomyoma (30.8%), or endometriosis (12.9%). The incidences of ADRs and serious ADRs were 59.7% and 0.3%, respectively. Frequently reported ADRs were metrorrhagia (48.9%), procedural pain (14.1%), and ovarian cyst (6.2%). The cumulative incidence of expulsions at 12 months was 8.7%. Risk factors for expulsion were obesity (body mass index ≥25 kg/m²), adenomyosis, and uterine cavity length ≥8 cm. The median [interquartile range] VAS score for dysmenorrhea improved from 46.5 [13.0-68.0] at insertion to 1.0 [0.0-13.0] at 12 months, and improvements were also observed in chronic pelvic pain and painful defecation.

CONCLUSIONS

The LNG-IUS safely and effectively reduced dysmenorrhea, chronic pelvic pain, and painful defecation. Risk factors for expulsion suggest that patients with underlying organic disease should be monitored carefully when using the LNG-IUS.

IMPLICATIONS

The LNG-IUS is an effective treatment for secondary dysmenorrhea with organic disease, and for the reduction of chronic pelvic pain; however, physicians should be aware of the increased risk of expulsion in patients with organic conditions.

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.

Dislocated intrauterine devices: clinical presentations, diagnosis and management

OBJECTIVE

Intrauterine devices (IUDs) are globally one of the most popular methods of contraception. Uterine perforation is one of the most significant complications of IUD use and commonly occurs at the time of IUD insertion rather than presenting as delayed migration. This paper reports a series of 13 cases of displaced IUDs requiring retrieval by laparoscopy or laparotomy. All the IUDs were copper bearing and most perforations occurred immediately after IUD insertion.

CASES

In two patients with sigmoid colon injury and IUD penetration of the appendix, laparoscopic management had failed and laparotomy was necessary owing to severe obliteration of the pelvic cavity. In one patient laparotomy was the preferred surgical approach owing to acute bowel perforation. In the remaining patients, the displaced devices were successfully removed by laparoscopy.

CONCLUSION

Uterine perforation and IUD migration to the organs in the abdominopelvic cavity are serious complications of IUD insertion and can be successfully managed by laparoscopy, or by laparotomy in the presence of severe pelvic adhesions or unexpected complications.

Timing of insertion affects expulsion in patients using the levonorgestrel 52 mg intrauterine system for noncontraceptive indications

OBJECTIVE

To evaluate levonorgestrel 52 mg intrauterine system (IUS) expulsion risk by menstrual cycle day of insertion (days 1-8 vs days 9 and beyond) in women using the IUS for noncontraceptive indications.

STUDY DESIGN

We performed a retrospective cohort study of patients with a levonorgestrel IUS inserted for the management of noncontraceptive, gynecologic conditions at Kaiser Permanente-Hawaii between January 2009 and December 2010. We used multivariable logistic regression models to estimate the likelihood of IUS expulsion adjusting for demographic and clinical factors and a Kaplan-Meier curve for survival analysis.

RESULTS

Of 176 patients identified, insertion occurred in 42 patients in cycle days 1 to 8 and 87 patients after day 8. Patient follow-up within the Kaiser system ranged from 1 to 71 months. Thirty-nine (22%) patients experienced expulsion, 16 (38%) and 15 (17%) for the 2 timing groups, respectively. Expulsion was more likely if the IUS placement occurred during the menstrual cycle days 1 to 8 (adjusted odds ratio 3.57 [95% confidence interval 1.13, 11.31]), which was consistent with the Kaplan-Meier analysis (p = 0.008).

CONCLUSION

Levonorgestrel IUS expulsion among women using the IUS for noncontraceptive indications occurred more frequently if insertion occurred during the first eight days of the menstrual cycle.

IMPLICATIONS

In women planning to use the levonorgestrel IUS to treat gynecologic conditions such as abnormal uterine bleeding, dysmenorrhea, and endometrial hyperplasia, providers should consider waiting until after cycle day 8 to perform insertion.

Long-acting reversible contraception side effect management

PURPOSE OF REVIEW

Long-acting reversible contraception (LARC) is increasingly used by adolescents and young adults (AYAs). Subsequent to LARC insertion, AYAs are presenting to their primary care providers with LARC concerns. This article seeks to equip primary care clinicians with the tools necessary to assess and manage common LARC-associated side effects.

RECENT FINDINGS

Side effects are common with progestin-only LARC, and can precipitate early discontinuation of an otherwise effective, low-maintenance form of contraception. Abnormal uterine bleeding, pelvic pain, acne, and weight change are often cited as progestin-only LARC side effects, yet the causes are poorly understood despite extensive research. While most side effects improve with time, therapeutic interventions are available for patients with undesirable side effects that prefer medical management. Research emphasizes the importance of proper patient counseling and clinical follow-up.

SUMMARY

Counseling remains essential in the management of LARC-associated side effects. However, options are available to temporarily mitigate such side effects and increase LARC satisfaction. While these therapeutic options are prescribed based on expert opinion, such regimens remain inadequately studied in AYA populations.

Levonorgestrel-Releasing Intrauterine System as a Contraceptive Method in Nulliparous Women: A Systematic Review

The aim of this review was to summarize the available evidence about the use of levonorgestrel-releasing intrauterine system (LNG-IUS) as a contraceptive method in nulliparous women. For this purpose, studies evaluating the efficacy, safety, bleeding pattern, satisfaction and discontinuation of the levonorgestrel-releasing intrauterine system in nulliparous women were analyzed. Only original research articles published in English between 1990–27th March 2020 were considered eligible. Reviews, book chapters, case studies, conference papers, opinions, editorials and letters were excluded. The systematic literature search of PubMed/MEDLINE, Scopus, Embase and Cochrane Library databases identified 816 articles, 23 of which were analyzed. The available evidence indicates that LNG-IUS is an effective and safe contraceptive method for nulliparous women that achieves high levels of satisfaction among patients. Moreover, nulliparous women seem to experience fewer expulsions than parous ones. Bleeding pattern is acceptable for the majority of patients, and bleeding disorders mainly occur in the first months after the insertion. More in-depth, long-term prospective studies are needed in this patient group to determine risk factors for the occurrence of side effects and associated discontinuations, which should not, however, delay the wider use of the method in this group, given the number of advantages.

Menstrual bleeding and spotting with the Levonorgestrel Intrauterine System (52 mg) during the first-year after insertion: a systematic review and meta-analysis

BACKGROUND

Changes in menstrual bleeding concern many users of the 52 mg Levonorgestrel Intrauterine System. Prescribing information for Levonorgestrel Intrauterine System devices describe an overall decrease in bleeding and spotting days over time; however, estimates derived from a variety of existing clinical data are currently unavailable.

OBJECTIVE

The objective of the study was to systematically calculate the mean days of bleeding-only, spotting-only, and bleeding and/or spotting experienced by a population of reproductive-aged Levonorgestrel Intrauterine System users with normal regular menses prior to insertion during the first year of use.

DATA SOURCES

We identified clinical trials, including randomized controlled trials and randomized comparative trials, as well as cohort studies published in English between January 1970 and November 2018 through searching 12 biomedical and scientific literature databases including MEDLINE and ClinicalTrials.gov.

STUDY ELIGIBILITY CRITERIA

We considered studies that reported data on Levonorgestrel Intrauterine System devices releasing 20 μg of levonorgestrel per day, collected daily menstrual bleeding data for at least 90 consecutive days, defined bleeding and spotting per World Health Organization standards and evaluated participants with normal regular menses prior to insertion.

STUDY APPRAISAL AND SYNTHESIS METHODS

We assessed study quality using established guidelines. Two reviewers independently conducted all review stages and rated the quality of evidence for each article; any disagreements were resolved by a third. Where possible, we pooled data using a random-effects model.

RESULTS

Among 3403 potentially relevant studies, we included 7 in our meta-analysis. We calculated the mean days of bleeding-only, spotting-only, and bleeding and/or spotting for the first four 90 day intervals after Levonorgestrel Intrauterine System insertion. Combined menstrual bleeding and/or spotting days gradually decreased throughout the first year, from 35.6 days (95% confidence interval, 32.2-39.1) during the first 90 day interval to 19.1 (95% confidence interval, 16.6-21.5), 14.2 (95% confidence interval, 11.7-16.8), and 11.7 days (95% confidence interval, 9.7-13.7) in the second, third, and fourth intervals. Measures for bleeding-only and spotting-only days similarly decreased throughout the first year, with the greatest decreases occurring between the first and second intervals.

CONCLUSION

Our study provides 90 day reference period measures that characterize menstrual patterns for Levonorgestrel Intrauterine System users with normal regular menses prior to insertion during the first year of use. Our findings provide broader generalizability and more detail than patterns described in the prescribing information. These findings quantify an overall decrease in menstrual bleeding days with longer duration of use, with the greatest decrease occurring between months 3 and 6. Accurately establishing expectations with the Levonorgestrel Intrauterine System may improve informed selection and decrease discontinuation.

Differences in continuation rates and early removal between contraceptive and therapeutic use of the levonorgestrel-releasing intrauterine system 52 mg

Objective: To investigate differences in continuation rates between contraceptive and therapeutic use of the levonorgestrel-releasing intrauterine system 52 mg (LNG-IUS) and factors associated with early removal.Methods: Study design: Retrospective consecutive cohort design.Cohort: Women with the insertion of the LNG-IUS for contraceptive or therapeutic use from 1 January 2006 through 1 January 2009 at the Zuyderland Medical Centre, The Netherlands, with a follow-up of 5 years. The continuation period and reasons of early removal were noted. Univariable and multivariable analysis were performed.Results: Follow-up was possible in 2481 women, 1855 (74.8%) in the contraception group, and 626 (25.2%) in the therapy group. Multivariable Cox proportional hazards models showed, that therapeutic use was associated with an increased risk of early removal of the LNG-IUS (HR 1.23; 95% CI 1.08-1.41), as was having one child (HR 1.20; 95% CI 1.04-1.38), and a decreased risk with advancing age (HR 0.96; 95% CI 0.95-0.97). In both groups, an unacceptable bleeding pattern and adverse events were the main reasons of early removal, resulting in very low continuation rates over the years.Conclusion: Therapeutic use, having one child and a younger age are independent risk factors of early removal of the LNG-IUS, in contrast with previous LNG-IUS use which is associated with a lower risk. In both the contraception group and the therapy group, the main reasons for LNG-IUS discontinuation are continuation with a new LNG-IUS, and no more need for an LNG-IUS (for contraception or therapy). An unacceptable bleeding pattern or adverse events are associated with the lowest continuation rates in both groups.

International Perspectives: IUDs and Adolescents

Unplanned or unwanted pregnancy among adolescents is a worldwide public health issue. In many countries unmarried young women are denied contraceptive services. Long-acting reversible contraceptive methods such as the intrauterine devices (IUDs) have been shown to be more effective than short-acting such as the pill, and safe also for adolescents. The popularity has varied a lot with time and between populations. Health care providers, health system, and user factors all influence IUD use. A good sexuality education through school provides a foundation, and health care providers give specific individual counseling. International and country-specific guidelines have been published during the past decade indicating the advantage of IUDs. New smaller size devices make placement easier for nulliparous adolescents. Still the uptake has remained rather low in most regions, cost being one barrier. Several municipalities have started to provide long-acting reversible contraceptive methods for adolescents free of charge, and this has led to a significant increase in IUD use, accompanied by a reduction in abortion rates. Adolescent-friendly services should offer low-cost or free contraception, including male and female condoms, emergency contraception, and a full range of modern methods, including long-acting reversible methods, according to adolescents' preferences and needs.

Pain Perception during Levonorgestrel-releasing Intrauterine Device Insertion in Nulliparous Women: A Systematic Review

STUDY OBJECTIVE

Intrauterine devices (IUDs) still remain underused in adolescents. Pain during insertion might prevent adolescents to opt for a levonorgestrel-releasing IUD. This study aimed to conduct a systematic review, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, and critically appraise published data with respect to the efficacy of various substances (analgesics or not) in preventing pain during levonorgestrel-releasing IUD insertion in nulliparous women as a proxy for adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A comprehensive computerized systematic literature search of all English language studies between 2006 and 2016 was performed in PubMed, EMBASE, Scopus, Evidence Based Medicine Reviews (Cochrane Database and Cochrane Central Register of Controlled Trials), and Google Scholar. Relevant article reference lists were manually searched.

RESULTS

The computerized database search revealed 31 citations of relevance, 9 of which with a total of 355 treated women and 345 controls fulfilled the inclusion/exclusion criteria. In women treated with misoprostol (n = 150) vs placebo (n = 145), the median visual analogue scale (VAS) score ± SD were 5.7 ± 2.1 vs 5.1 ± 2.2, respectively. In the previously mentioned population, there was a nonsignificant change in VAS score (odds ratio, 1.44; 95% confidence interval, 0.86-2.40). In women treated with lidocaine (n = 140) vs placebo (n = 136), the median VAS score ± SD were 4.6 ± 2.1 vs 5.8 ± 2, respectively. In the aforementioned population, there was a significant decrease in VAS score (odds ratio, 0.12; 95% confidence interval, 0.02-0.91).

CONCLUSION

In nulliparous women, lidocaine treatment seems to be a reasonable choice. However, further studies are required to examine the different routes and modes of administration as well as optimal quantities.

Factors associated with low-lying intrauterine devices: a cross-sectional ultrasound study in a cohort of African-American women

OBJECTIVE

The object of this study is to examine factors and symptoms associated with low-lying IUDs as defined by ultrasound.

STUDY DESIGN

This is a cross-sectional sub-study of participants in the Study of Environment, Life-style, and Fibroids (SELF). SELF participants had screening ultrasounds for fibroids at study enrollment; those with an IUD in place are included in this sub-study. Low-lying IUDs were identified and localized. Logistic regression was used to identify factors and symptoms associated with low-lying IUDs.

RESULTS

Among 168 women with IUDs at ultrasound, 28 (17%) had a low-lying IUD. Having a low-lying IUD was associated with low education level (≤high school: aOR 3.1 95% CI 1.14-8.55) and with increased BMI (p=.002). Women with a low-lying IUD were more likely to report a "big problem" with dysmenorrhea (the highest option of the Likert scale) as compared to women with a normally-positioned IUD (OR 3.2 95% CI 1.07-9.54).

CONCLUSION

Our study found that women with a low-lying IUD are more likely to be of lower education and higher BMI, and to report more dysmenorrhea.

IMPLICATIONS

Women who are obese may benefit from additional counseling and closer follow-up after IUD placement. Future research is warranted to investigate IUD placement and possible IUD migration among women who are obese.

LNG-IUS 12: a 19.5 levonorgestrel-releasing intrauterine system for prevention of pregnancy for up to five years

INTRODUCTION

Globally, intrauterine devices (IUDs) are the second most commonly used form of reversible contraception because of their high efficacy, safety, convenience and cost effectiveness. The levonorgestrel releasing intrauterine system with daily average release of 20 mcg (LNG-IUS 20) is the popular choice because of its favorable bleeding patterns and many noncontraceptive benefits. A three year (LNG-IUS 8) became available three years ago. More recently, the LNG-IUS 12 was added. This new IUD shares a smaller frame, narrow inserter and lower rate of amenorrhea with the LNG-IUS 8, but it offers the five years of contraceptive protection of the LNG-IUS 20. Areas covered: This article provides information on the contraceptive efficacy, safety and tolerability of this new IUS based on approximately 60,000 cycles of use. Where available, the impacts of subject age, parity and body mass index (BMI) on study outcomes are reported. Expert opinion: This new LNG-IUS 12 with mid-dose hormone levels, smaller frame and longer effective life fills a niche that may better meet the needs of women who might appreciate the narrow insertion tube and/or the lower rates of amenorrhea. Cost will ultimately help determine success.

Uterine Length in Adolescents with Developmental Disability: Are Ultrasound Examinations Necessary before Insertion of the Levonorgestrel Intrauterine System?

STUDY OBJECTIVE

(1) To determine if there are any differences in uterine length between adolescents with developmental disability (DD) compared with their normally developing (ND) peers that might necessitate ultrasonography before insertion of levonorgestrel intrauterine system (LNG-IUS) in patients with DD; and (2) to characterize the LNG-IUS insertion procedure in adolescents with disabilities.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

This was a retrospective cohort study of 223 female adolescents with or without DDs. Seventy-five adolescents had DD; 33 underwent intrauterine system insertion in the operating room and 42 did not. A comparative cohort of 148 ND adolescents who had pelvic ultrasound examinations for abnormal uterine bleeding were included. The study period was between January 2006 and July 2013 at the Hospital for Sick Children, Toronto, Canada. Cases were identified from surgical databases and medical records.

MAIN OUTCOME MEASURES

Mean uterine length on pelvic ultrasound, demographic characteristics (age, age at menarche, time from menarche to ultrasound, weight), and descriptive statistics on intrauterine system insertion.

RESULTS

There was a statistically significant difference (P = .03) in uterine length between adolescents with and without DD (6.7 vs 7.1 cm). However, this was not a clinically significant difference because insertion of the LNG-IUS in patients with DD was successful in patients with uteri more than 5 cm long. There was no difference (P = .97) in uterine length of adolescents with DD whether they had LNG-IUS insertion or not (6.7 cm). Adolescents with DD were younger than adolescents without DD at time of ultrasound examination (P = .01). However, among patients with DD, those who underwent intrauterine system insertion were older (P = .001). Incidence of uterine anomaly in patients with DD is low (2.7%) and was the same as in ND adolescents. Rates of complications and expulsions were low and there were no failures of LNG-IUS insertion in adolescents with DD.

CONCLUSION

Routine pelvic ultrasound examinations are not necessary before insertion of the LNG-IUS for menstrual suppression in adolescents with DD. Renal abnormalities, obstructive symptoms, and very small stature might necessitate imaging. Insertion using anesthesia is often straightforward and successful with minimal complications.

New developments in intrauterine device use: focus on the US

Many more women in the US today rely upon intrauterine devices (IUDs) than in the past. This increased utilization may have substantially contributed to the decline in the percentage of unintended pregnancies in the US. Evidence-based practices have increased the number of women who are medically eligible for IUDs and have enabled more rapid access to the methods. Many women enjoy freedom to use IUDs without cost, but for many the impact of the Affordable Care Act has yet to be realized. Currently, there are three hormonal IUDs and one copper IUD available in the US. Each IUD is extremely effective, convenient, and safe. The newer IUDs have been tested in populations not usually included in clinical trials and provide reassuring answers to older concerns about IUD use in these women, including information about expulsion, infection, and discontinuation. On the other hand, larger surveillance studies have provided new estimates about the risks of complications such as perforation, especially in postpartum and breastfeeding women. This article summarizes significant features of each IUD and provides a summary of the differences to aid clinicians in the US and other countries in advising women about IUD choices.

Association of baseline bleeding pattern on amenorrhea with levonorgestrel intrauterine system use

OBJECTIVE

This study aims to evaluate the effect of baseline bleeding patterns on rates of amenorrhea reported at 12 months in levonorgestrel (LNG) 52 mg intrauterine system (IUS) users. We also assessed the effect of baseline bleeding patterns at 3 and 6 months postinsertion.

STUDY DESIGN

In this secondary analysis of the Contraceptive CHOICE Project, we included participants who had an LNG-IUS inserted within 1 month of enrollment and continued use for 12 months. Using 12-month telephone survey data, we defined amenorrhea at 12 months of use as no bleeding or spotting during the previous 6 months. We used chi-square and multivariable logistic regression to assess the association of baseline bleeding pattern with amenorrhea while controlling for confounding variables.

RESULTS

Of 1802 continuous 12-month LNG-IUS users, amenorrhea was reported by 4.9%, 14.8% and 15.4% of participants at 3, 6 and 12 months, receptively. Participants with light baseline bleeding or short duration of flow reported higher rates of amenorrhea at 3 and 6 months postinsertion (p<.03), while LNG-IUS users with heavy or prolonged flow were less likely to report amenorrhea at 3 and 6 months (p<.03). In a multivariable analysis, participants with self-reported heavy bleeding at baseline were less likely to report amenorrhea at 12 months than those who reported moderate bleeding (OR_adj, 0.36; 95% CI, 0.16-0.69).

CONCLUSION

Women with heavier menstrual bleeding are less likely than women with moderate flow to report amenorrhea following 12 months of LNG-IUS use.

IMPLICATIONS

Baseline heavy menstrual flow reduces the likelihood of amenorrhea with LNG-IUS use, information that could impact contraceptive counseling. Anticipatory counseling can improve method satisfaction and continuation, an important strategy to continue to reduce unintended pregnancy and abortion rates.