Longer though lighter menstrual and intermenstural bleeding with copper as compared to inert intrauterine devices

The effect of low-dose 3-keto-desogestrel added to a copper-releasing intrauterine contraceptive device on menstrual blood loss: a double-blind, dose-finding, placebo-controlled study

OBJECTIVE

We sought to establish the lowest dose of 3-keto-desogestrel, when added to a copper-releasing intrauterine contraceptive device, that is needed to reduce menstrual blood loss to a very low level and to treat (essential) menorrhagia successfully.

STUDY DESIGN

A double-blind group comparative study was designed in which 203 healthy women with or without menorrhagia were enrolled and randomized to four different Multiload Cu250 intrauterine contraceptive devices, releasing 0 (control), 1.5, 3, or 6 microg of 3-keto-desogestrel daily. Menstrual blood loss, hemoglobin, and serum ferritin levels were determined before and during treatment.

RESULTS

All 3-keto-desogestrel-copper intrauterine contraceptive devices reduced menstrual blood loss significantly, causing a reduction of up to 30 to 40 mL after 12 months of use. All women with essential menorrhagia were considered to have been successfully treated after 6 months of use. Serum ferritin levels rose with all three 3-keto-desogestrel-loaded devices.

CONCLUSION

A Multiload Cu250 intrauterine contraceptive device releasing 1.5 microg of 3-keto-desogestrel daily is able to reduce menstrual blood loss to a very low level and to replete body iron stores in women with or without menorrhagia. Higher doses have no superior effect.

Factor XI deficiency in women

Factor XI (FXI) deficiency is an uncommon autosomally transmitted coagulopathy found predominantly in Jewish kindreds. It is associated with variable bleeding tendency that usually manifests after trauma, surgery, or other challenges to hemostasis. Therefore, women with FXI deficiency are at risk of excessive bleeding during their menstrual periods, childbirth, and after surgery. Increased awareness and close collaboration among hematologists, obstetricians, and gynecologists and availability of management guidelines is essential to minimize these risks. This review provides data from current research in FXI deficiency and pregnancy care, menstrual problems, and the role of screening for this disorder in women referred with menorrhagia.

Dysfunctional uterine bleeding

Dysfunctional uterine bleeding (DUB) is a frequent gynecological problem during adolescence and the most frequent cause of urgent admission to the hospital over this period of life. In about 95% of cases it is caused by the late maturation of the hypothalamic-pituitary-ovarian axis (HPO), leading to anovulatory cycles. These adolescents lack the E2 positive feedback on LH. Thus, the continuous production of estrogen with endometrial stimulation is the basic cause of dysfunctional uterine bleeding. The initial step in the evaluation of DUB includes detailed clinical history, followed by complete physical examination. Laboratory tests should include coagulation profile, complete blood count with platelet evaluation, and sometimes a serum pregnancy test. The treatment of DUB is related to the severity of symptomatology with the objective of stopping bleeding and preventing recurrences. Modern hormonal and other medical therapies enable physicians to treat DUB effectively, regardless of the cause. Surgical treatment, such as dilatation and curettage, is rarely indicated in the adolescent patient. The importance of continued follow-up in DUB cases should be underlined, until stabilization of ovulatory menstrual cycles.

The influence of the Gyne-T 380S IUD on menstrual blood loss and iron status

The influence of the Gyne-T 380S intrauterine contraceptive device (IUD) on menstrual blood loss (MBL) and iron status (hemoglobin, hematocrit, red cell count and indices, and serum ferritin) was evaluated. MBL was determined objectively by the alkaline hematin method in 18 women (mean age 37.1 +/- 1.6 yr, range 22-46 yr) before and 3, 6 and 12 months after insertion of a Gyne-T 380S IUD. MBL prior to IUD insertion was 59 +/- 8 ml and increased to 91 +/- 11 ml (p < 0.01) 3 months after insertion. MBL then remained largely unchanged during the remainder of the observation period (6 months, 94 +/- 12 ml; 12 months, 92 +/- 13 ml). The percentage increase in MBL at the respective measurement points ranged between 54 and 59% which is comparable with previous reports regarding the increase in MBL associated with the use of a copper IUD. There were no significant changes recorded in iron status parameters during the 12-month observation period following IUD insertion. Based on the results of the present study, women from developed countries apparently tolerate an increased MBL of approximately 55% without developing iron deficiency anemia. Iron stores were unchanged indicating an adequate adaptive increase in intestinal iron absorption.

The long-term effects of copper surface area on menstrual blood loss and iron status in women fitted with an IUD

The long-term effects of copper surface area on menstrual blood loss (MBL) and iron status (hemoglobin, hematocrit, red cell count and indices, and serum ferritin) were evaluated in 25 healthy women who were observed for a period of 3 years following insertion of an intrauterine device. MBL was determined objectively by the alkaline hematin method. The women (mean age 37.2 +/- 1.6 yr, range 27-46 yr) were fitted with a Multiload intrauterine device (IUD) with a copper surface area of either 250 mm2 (MLCu-250, n = 13) or 375 mm2 (MLCu-375, n = 12). MBL prior to IUD insertion was 55 +/- 8 ml for women subsequently fitted with a MLCu-250 and 59 +/- 9 ml for women fitted with a MLCu-375. An increase in MBL was recorded at all measurement points following IUD insertion (MLCu-250/MLCu-375: 3 months: 55/49%; 6 months: 58/49%; 12 months: 64/41%; 24 months: 55/49%; 36 months: 47/39%, NS). There were no significant differences in iron status parameters before IUD insertion between groups nor were there any significant changes recorded in any of these parameters after IUD insertion. Our findings that the increase in copper surface area from 250 mm2 to 375 mm2 had no effect on MBL were thus substantiated by the hematological findings. Based on the results of the present study, women from developed countries apparently tolerate an increased MBL of approximately 45% without developing anemia. Iron stores were unchanged indicating an adequate adaptive increase in intestinal iron absorption.

The influence of copper surface area on menstrual blood loss and iron status in women fitted with an IUD

The influence of copper surface area on menstrual blood loss (MBL) was evaluated in 34 healthy women (mean age 36.4 +/- 1.4 yr, range 27-46 yr), who were fitted with a Multiload intrauterine device (IUD) with either 250 mm2 (MLCu-250) or 375 mm2 (MLCu-375) copper wire. MBL prior to IUD insertion was 54.4 +/- 10.3 ml for women subsequently fitted with a MLCu-250 and 56.9 +/- 6.9 ml for women fitted with a MLCu-375. An increase (p less than 0.01) in MBL was recorded 3 months after IUD insertion for both the women fitted with a MLCu-250 (86.4 +/- 10.3 ml) and a MLCu-375 (81.1 +/- 8.3 ml). This increase in MBL remained unchanged throughout the study period of one year. At no point were there any significant differences in MBL or increase in MBL between women fitted with a MLCu-250 or MLCu-375. There were no significant differences in serum ferritin, blood hemoglobin, hematocrit or erythrocyte indices before IUD insertion in the women grouped according to type of IUD, nor were any significant changes recorded in any of these parameters after IUD insertion. Thus, our findings that the increase in copper surface area from 250 mm2 to 375 mm2 had no effect on MBL were also substantiated by the hematological findings.

Consequences of uterine blood loss caused by various intrauterine contraceptive devices in South American women. World Health Organization Special Programme of Research, Development and Research Training in Human Reproduction

Increased menstrual blood loss (MBL) associated with intrauterine device (IUD) use may precipitate or aggravate iron deficiency anaemia, adversely affecting the health of women particularly those from developing countries. Studies were conducted to define the association of MBL and iron status in South American women; to determine the level of MBL induced by IUD use which would result in iron depletion, the length of time for this depletion to occur and, comparing various IUDS, to determine if any currently tested IUDs are suited to long-term use in South American women. A total of 395 women received one of 5 types of IUDs in Santiago, Chile, and Juiz de Fora, Brazil: Lippes Loop, Multiload-250 and Multiload-375 were used in both centres; in Santiago some subjects received the Copper-7 or ProgestasertR devices and in Juiz de Fora, the TCu 200 and the T-Chloroquin IUDs were also tested. MBL and haemoglobin (HGB) were measured for 3 menstrual cycles before insertion, and following insertion, at one, two, four, six, nine, twelve, eighteen and twenty-four months in the majority of cases. Serum ferritin was measured before insertion and at intervals of six months. Mean values of MBL prior to IUD insertion in both centres varied from 21-30 ml. As with previous publications, the use of the Lippes Loop was associated with the greatest increase in MBL which was sustained throughout the 24 months of observation. Women who had one of the two types of Multiload devices inserted also had increased MBL and reduced ferritin for at least 12 months of use. TCu 200 and Copper-7 IUD users had an initial increase in MBL of 1 to 17 ml in the first six months of observation returning to normal levels beyond six months. Serum ferritin levels were lower for one year and then returned to admission values. ProgestasertR users confirmed previous reports of a reduction of 40-50% in MBL and an increase in serum ferritin. Few significant changes in haemoglobin (HGB) concentrations were found. Serum ferritin levels on admission ranged from 7.1 to 16.4 ng/ml in Santiago and from 15.8 to 23.2 ng/ml in Juiz de Fora. Many women were in a marginal state of iron balance as evidenced by lower serum ferritin values. Changes in serum ferritin were very closely related to those in MBL.(ABSTRACT TRUNCATED AT 400 WORDS)

Quantitative studies on menstrual blood loss in IUD users

Despite the introduction of new intrauterine devices (IUDs), the most important complication involving their use continues to be excessive menstrual bleeding. IUD use in developing countries with women who are already depleted in body iron stores may prove to be deleterious to their health. Mean amounts of menstrual blood loss (MBL) for women not using contraception in the western world is about 32 ml. This mean is increased to 52-72 ml with use of the Lippes loop and other non-medicated devices up to 24 months after insertion. For the Copper-7 and Copper-T-200 devices this mean increase is to 37-40 ml in the first month, decreasing to 30-38 ml at 12 months after IUD insertion. In the users of the Multiload-250 IUD at one month post-insertion the MBL is from 56 to 63 ml and from 36 to 39 ml at 24 months of use. The mean Multiload-375 device users at one month after insertion lose a mean of 45-73 ml at 24 months, 35-50 ml. With the progestogen-releasing IUD mean MBL is 27-36 ml at 1 month and 9-13 ml at 12 months post-insertion. Intermenstrual blood loss is significant only in the first month of use for all IUDs. Discontinuation rates for pain and bleeding with non-medicated IUDs are from 11.0-19.6 per 100 women per year, and for the copper IUDs 4.4 to 6.8 per 100 women in the first year of use. The main problem with prolonged menstrual bleeding is depletion of the body iron stores; this is highly significant with non-medicated devices, less important with copper devices and conversely, iron stores are increased in users of progestogen-releasing devices. This is based on serum ferritin measured up to 24 months after insertion. The ferritin values correlated well with the volumes of MBL. It is suggested, especially for women with low body iron stores, that there is an order of preference for IUDs to be used. This should be: firstly, the progestogen-releasing devices; secondly, the Copper-T and Copper-7 IUDs; thirdly the larger surface copper devices (Cu-T-220C, Multiload 250 and 375, Cu-T-380). Non-medicated devices are not to be recommended for these women.

Two years of intrauterine contraception with levonorgestrel and with copper: a randomized comparison of the TCu 380Ag and levonorgestrel 20 mcg/day devices

IUDs releasing 20 mcg/day of levonorgestrel (LNg20) were in randomized trial together with the Copper T, model TCu 380Ag, in seven centers involving 2244 women. Two-year (25 months) gross cumulative pregnancy rates were 0.2 +/- 0.2 and 0.9 +/- 0.3 for the levonorgestrel and copper releasing devices, respectively (P greater than 0.05). There were no ectopic pregnancies in more than 1600 woman-years of use of each device. Removal rates for bleeding and/or pain or for medical reasons other than menstrual problems did not differ significantly between devices. Oligomenorrhea or amenorrhea prompted 10.7 per hundred (gross rate, 8.4 net rate) women using the LNg 20 IUD to request removal in the two-year period, significantly above the 0.2 per hundred rate among women with the Copper IUD (P less than 0.001). At the end of two years an estimated 59.4 per 100 women were continuing use of the LNg 20 IUD, and 67.5 per 100 (P less than 0.001) with the TCu 380Ag. This difference is almost wholly ascribable to a marked reduction in bleeding episodes and days among women using the LNg 20 device with concomitant removal of device. Hemoglobin rose an average of 0.5 g/dl (P less than 0.001) for this group whereas women using the TCu 380Ag experienced a decline of 0.2 g/dl compared with baseline values (P less than 0.001).

A preliminary study of factors influencing perception of menstrual blood loss volume

Sixty-nine women with a convincing complaint of menorrhagia took part in a double-blind treatment trial. Menstrual blood loss was measured and the subject's own perception was carefully recorded. Only 38% had objective menorrhagia with a measured loss greater than 80 ml although 59% would qualify with an upper limit of normal of 60 ml. Overall the measured loss in the "heaviest" periods (69.6 +/- 7.3 ml; mean +/- SEM) were significantly greater than that of the "lightest" periods (42.7 +/- 4.7 ml; p less than 0.001), but there were many major errors in perception by individuals. Perceived daily blood loss volume on a 4-point rating scale gave the following group means and ranges: spotting, 2.5 ml (0.1 to 15.5); light, 5.7 ml (0.1 to 63.1); moderate, 16.1 ml (0.5 to 108.6); very heavy, 22.0 ml (1.4 to 215.8); very wide individual ranges of assessment are illustrated. As a whole the group was also able to distinguish between a day-to-day volume increase or decrease, but again there were many major errors. Some subjects who experienced a reduction in measured blood loss from one day to the next actually perceived this as a large increase. Menstrual pain and duration of bleeding were not found to influence perception of blood loss volume, whereas younger subjects (26 and under) were significantly more likely than older women (37 and over) to regard a moderate loss as very heavy. There was no significant correlation between the number of pads/tampons used and the measured menstrual loss, and some individuals showed extreme variations between blood loss and pad usage. This study suggests that the only reliable assessment of menstrual blood loss volume and changes in volume in women complaining of menorrhagia is obtained by objective measurement of blood loss by a technique such as alkaline hematin extraction.

Anaemia and menstrual blood loss studies in women using multiload Cu250 and progestasert IUDs

Two to 9 months following insertion of the ML Cu250 (n = 54) and Alza T (n = 30) IUDs, mean menstrual blood losses (MBL) were 46.3 ml and 32.7 ml, respectively (p less than 0.005). Significantly more of the Alza T users had losses below 40 ml and they also perceived their menses to be lighter. Based on a haemoglobin level of 12gm/dL, the upper normal limit of MBL was about 40 ml. These findings are consistent with earlier observations that during the first year, ferritin levels fall in ML Cu250 users whereas they are unaltered in Alza T users.

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.

Predictive value of serum ferritin in anemia development after insertion of T Cu 220 intrauterine device

A one-year follow-up study in 30 healthy women was undertaken to study serum ferritin as well as other hematological parameters prior, six and twelve months after insertion of an intrauterine device, T Cu 220. Women were allocated into one of two groups according to the baseline ferritin serum levels; Group I abnormal ferritin and Group II normal ferritin levels. Other hematological parameters were normal and no iron supplement was given throughout the study. A direct relationship between low ferritin serum values (Group I), and anemia development was found. Seven out of 15 developed anemia, whereas only 2 out of 15 had anemia at twelve months in Group II with normal ferritin values. The overall data suggested that measurement of serum ferritin levels could be a useful tool to anticipate anemia development in women with intrauterine devices.

Menstrual blood loss estimates in women using copper 7 and multiload-250 intrauterine devices

An estimate of the menstrual blood loss (MBL) in 29 women using the Cu-7 and in 33 women using the ML-250 IUDs was carried out. None of the women who took part in the study used hormonal contraceptives or IUDs for six months previous to the study. Before the insertion of the IUD, the MBL of each woman was measured for one or two cycles. Once the IUD was inserted, the MBL was measured at intervals of 1, 3, 6, 9 and 12 months after insertion. After this, the IUD was removed and the MBL measured each month thereafter for 3 months. In the pre-insertion period, the MBL was similar in both groups: 39.3 +/- 5.9 for the group with the Cu-7, and 41.6 +/- 5.5 ml for the one with the ML-250. After the insertion of the Cu-7, either a slight increase or no increase at all of MBL was observed during the 12 months of IUD use. When the IUD was removed, the menstrual blood loss level returned to normal, i.e. to the pre-insertion level.

Haemostasis in menstrual endometrium in the presence of an intrauterine device

The histology and ultrastructure of the haemostatic response in the endometrium have been studied in 12 uteri containing an inert or copper wound intrauterine contraceptive device (IUCD). The uteri were removed during the premenstrual phase or during the first 96 hours of menstruation. The results have been compared to earlier observations in non-IUCD influenced endometrium. In all uteri the tissue shedding proceeded more slowly in the presence of an IUCD and considerably fewer haemostatic plugs were found. The platelets in these plugs were more loosely packed and less degranulated, and the plugs contained less fibrin than in the absence of an IUCD. Haemostatic plugs were still observed at times when no such plugs were seen in uteri without an IUCD. Unoccluded vessel lesions were regularly seen and vessels open to the shedding surface were occasionally encountered. These observations suggest that IUCD-induced menorrhagia is caused by the combination of delayed shedding and a decreased haemostatic reaction in the endometrium.

Intrauterine devices: present and future

Although the mortality associated with the use of intrauterine contraception is low, its morbidity is probably higher than that associated with oral contraception. Much anxiety has been generated and whole programs prejudiced by lack of attention to detail during counseling, the fitting of intrauterine devices and follow-up. This paper draws attention to the shared etiology of many of the important adverse effects of the method, the fact that several become increasingly rare with increasing age of the user, and other factors that can assist in choosing the right device for the right woman. Likely future trends are also predicted.

The response of endometrial blood vessels to intrauterine contraceptive devices: an electron microscopic study

The ultrastructure of the vascular supply of the endometrium in uteri containing inert and copper bearing intrauterine contraceptive devices (IUCDs) has been compared with that in uteri removed at comparable stages of the menstrual cycle for dysfunctional uterine bleeding. In the endometrium from all uteri containing inert and copper IUCDs, stromal capillaries below the devices showed extensive microthrombosis with platelet and fibrin aggregations filling gaps in the endothelial linings of the vessels. Considerable stromal haemorrhage and erosion of surface epithelium was associated with this vascular pathology. In the uteri removed for dysfunctional bleeding, microthrombosis was a rare occurrence. In the stromal vessels of the endometrium not in contact with the devices, the surface epithelium was usually intact and the underlying stromal capillaries often showed breaks in the endothelial lining but without a haemostatic plug. Leucocyte migration into the stroma was more evident in association with the copper IUCDs than the other devices. The ultrastructural changes in the microvasculature of the endometrium associated with IUCDs did not appear to be related to a stage of the menstrual cycle. The extent and type of microvascular changes appeared to be related to the proximity and surface area of the IUCD and to the presence or absence of copper in the device.

Effect of prior pregnancy and combined oral contraceptives on baseline menstrual blood loss and bleeding response to intrauterine devices

No effect of pregnancy was found on baseline menstrual blood loss (MBL) in women within one year of parturition or abortion. The increased bleeding response of women to intrauterine devices (IUDs) was found to be independent of pregnancy status during the year preceding IUD sertion. Women pregnant within a year of insertion had no different MBL than those pregnant more than a year prior to insertion. MBL quantified in subjects within three months of discontinuing combined oral contraceptives (OCs) was significantly lower than in prior non-OC users. Furthermore, MBL was significantly reduced in the former group during the first three menses following IUD insertion. At the sixth and twelfth menses post-insertion, MBL was still lower in prior OC users, but the difference between users and non-users was less and no longer statistically significant.