Non-steroidal anti-inflammatory drugs for heavy bleeding or pain associated with intrauterine-device use.

BACKGROUND: Heavy bleeding and pain are the most common reasons why women discontinue IUDs. Non-steroidal anti-inflammatory drugs, which inhibit prostaglandin synthesis, have been shown to be effective in reducing menstrual bleeding and pain in women without IUDs. OBJECTIVES: This review summarizes all randomized controlled trials studying use of nonsteroidal anti-inflammatory drugs for treatment of bleeding or pain associated with IUD use. Trials of prophylactic use of these drugs around the time of IUD insertion were also included. SEARCH STRATEGY: We performed searches of PubMed, CENTRAL, POPLINE, EMBASE, LILACS, and CINAHL for relevant trials. We also wrote to the authors of all trials identified to seek other published or unpublished trials. SELECTION CRITERIA: We included all randomized controlled trials in any language that tested one or more nonsteroidal anti-inflammatory drugs for treatment or prevention of bleeding or pain associated with IUD insertion or use. DATA COLLECTION AND ANALYSIS: Two authors independently abstracted data from relevant trials, and we entered data into RevMan for analysis. MAIN RESULTS: We found 15 trials from 10 countries; the total number of participants was 2702. Nonsteroidal anti-inflammatory drugs (naproxen, suprofen, mefenamic acid, ibuprofen, indomethacin, flufenamic acid, alclofenac, and diclofenac) were effective in reducing menstrual blood loss associated with IUD use. This held true for women with and without complaints of heavy bleeding. Similarly, these drugs were effective in reducing pain associated with IUD use. In contrast, prophylactic use of nonsteroidal anti-inflammatory drugs had mixed results; studies with ibuprofen found no effect on pain after insertion on IUD discontinuation. No important differences emerged in the one trial comparing the effect of different NSAIDs on bleeding. AUTHORS' CONCLUSIONS: Nonsteroidal anti-inflammatory drugs reduce bleeding and pain associated with IUD use. NSAIDs should be considered first-line therapy; if NSAIDs are ineffective, tranexamic acid may be considered as second-line therapy. Prophylactic ibuprofen administration with the first six menses after insertion appears unwarranted.

Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women.

BACKGROUND: Previous studies of intrauterine devices (IUDs), many of which are no longer in use, suggested that they might cause tubal infertility. The concern that IUDs that contain copper--currently the most commonly used type--may increase the risk of infertility in nulligravid women has limited the use of this highly effective method of birth control. METHODS: We conducted a case-control study of 1895 women recruited between 1997 and 1999. We enrolled 358 women with primary infertility who had tubal occlusion documented by hysterosalpingography, as well as 953 women with primary infertility who did not have tubal occlusion (infertile controls) and 584 primigravid women (pregnant controls). We collected information on the women's past use of contraceptives, including copper IUDs, previous sexual relationships, and history of genital tract infections. Each woman's blood was tested for antibodies to Chlamydia trachomatis. We used stratified analyses and logistic regression to assess the association between the previous use of a copper IUD and tubal occlusion. RESULTS: In analyses involving the women with tubal occlusion and the infertile controls, the odds ratio for tubal occlusion associated with the previous use of a copper IUD was 1.0 (95 percent confidence interval, 0.6 to 1.7). When the primigravid women served as the controls, the corresponding odds ratio was 0.9 (95 percent confidence interval, 0.5 to 1.6). Tubal infertility was not associated with the duration of IUD use, the reason for the removal of the IUD, or the presence or absence of gynecologic problems related to its use. The presence of antibodies to chlamydia was associated with infertility. CONCLUSIONS: The previous use of a copper IUD is not associated with an increased risk of tubal occlusion among nulligravid women whereas infection with C. trachomatis is.

Follow-up visits after IUD insertion. Are more better?

OBJECTIVE: To determine whether frequent follow-up visits for intrauterine device (IUD) users prevents the development of pelvic inflammatory disease (PID). STUDY DESIGN: A prospective, cohort design was used to study 1,713 women who received an IUD in 1992 in Mexico. They were divided into two different follow-up regimens and were asked to return for either two or four revisits in the first year after insertion. The main outcome measures included incidence of PID and asymptomatic/symptomatic lower genital tract infections. Time to detection of lower genital tract infections was measured in a proportional hazards regression model; this analysis achieved 90% power to detect differences between the regimens. RESULTS: The two regimens were nearly identical in terms of PID incidence. The incidence rates for asymptomatic and symptomatic lower genital tract infection were slightly higher in the four-visit regimen; however, the incidence rate ratios were not statistically elevated: 1.41 (0.77-2.56) and 1.23 (0.67-2.27), respectively. In the regression, the variable denoting follow-up regimen was not associated with time to detection of lower genital tract infection. CONCLUSION: More follow-up visits for IUD users provide no benefit in terms of preventing PID or progression toward the disease.

Factors affecting continuation rates of DMPA.

A prospective study was conducted with 430 new depot medroxyprogesterone acetate (DMPA) acceptors to estimate continuation rates and investigate factors associated with length of use. Data were collected on services received and sociodemographic characteristics of participants. Women were enrolled over the course of 1 year and were followed for up to 13 months. Failure to return to the same clinic within 104 days of the last injection was the outcome of interest. The 3-, 6-, 9-, and 12-month continuation rates were 68%, 67%, 55%, and 51%, respectively. In the bivariate analysis, women who were told to return to the clinic for side effects were more likely to continue using DMPA than those who were not given such advice (p <0.05). Likewise, women who received information on DMPA efficacy, side effects, and amenorrhea were more likely to continue using DMPA compared to those who did not receive such information (p <0.05). A proportional hazards regression model was constructed to estimate the simultaneous effect of various factors on length of use. In results consistent with the bivariate analysis, women who were told to return to the clinic were 2.7 times more likely to continue using DMPA compared to women who did not receive that advice. Likewise, women who were told about the possibility of amenorrhea were 2.5 times more likely to continue using DMPA compared to those who did not receive that information. The regression model also identified new factors such as number of children, attitude toward menstruation, lactating at admission, and spousal input on method choice. The findings suggest that providers play an important role in ensuring the highest possible continuation rates for DMPA.

Should the recommended number of IUD revisits be reduced?

This study uses data from clinical trials of intrauterine devices to examine the effect of reducing the recommended number of IUD follow-up visits. Over 11,000 follow-up forms were analyzed to estimate the number of health problems that would have escaped detection if women with no or mild symptoms had not made recommended revisits. Less than one percent of woman-visits with no or only mild symptoms had an underlying health risk that could have gone undetected if the follow-up visits that were made in the clinic trial setting had not been made. The results from this analysis suggest that a reduction in the number of recommended follow-up visits is safe, when measured according to selected conditions. Additional research is necessary to determine whether any revisits should be recommended in the absence of signs or symptoms.

PIP: International Program in Population and Family Planning, Pathfinder International, and other organizations providing support to family planning organizations in developing countries, generally recommend that women who use intrauterine devices (IUDs) go for an initial revisit at four to six weeks postinsertion, a second revisit at one year, and subsequent revisits at yearly intervals. However, ministries of health and family planning organizations in developing countries generally recommend more frequent revisits. This study examined the effect of reducing the recommended number of IUD follow-up visits using data from clinical trials of the TCu380A and other widely used IUDs conducted by Family Health International (FHI) during 1986-89. The clinical studies were conducted in 13 clinics in 9 countries (Cameroon, Egypt, El Salvador, Mexico, Pakistan, Peru, Philippines, Sri Lanka, and Venezuela) among sexually active and healthy women aged 18-40. Over 11,000 follow-up forms were analyzed to estimate the number of health problems that would escape detection if women with no or mild symptoms had not made recommended visits. Less than 1% of woman-visits with no or only mild symptoms had an underlying health risk that could have gone undetected if the follow-up visits that were made in the clinic trial setting had not been made. Results suggest that a reduction in the number of recommended follow-up visits is safe, when measured according to selected conditions. Clinic policy and practice in family planning probably could move toward encouraging fewer recommended follow-up visits, while simultaneously encouraging those who feel they need assistance to seek medical attention. Additional research is, however, needed to determine whether any revisits should be recommended in the absence of sign and symptoms.

Estimating infant mortality rates prospectively in Honduras.

In order to determine the validity of infant mortality estimates based on retrospective reporting, the Honduran Ministry of Health carried out a follow-up survey of women interviewed in a 1987 national survey. Women were interviewed approximately 14 months after the baseline survey and were asked about the outcomes of their pregnancies and the survival status of their young children. The overall infant mortality rate calculated from the follow-up survey was lower than that obtained from the baseline survey, due to the particularly low rate among the group of women who were pregnant at the time of the baseline survey. Possible explanations for this low rate are discussed.

PIP: Indirect and direct methods may be used to estimate infant mortality rate (IMR). Respondents surveyed retrospectively about births, deaths, and corresponding dates often, however, omit or misreport vital events. Prospective studies virtually eliminate the potential for these types of errors. To test the validity of IMR estimates based upon retrospective reporting, this paper compares the former with estimates drawn from baseline survey data obtained 14 months prior. Baseline data came form 10,159 women ages 15-44, interviewed in 1987, by the Ministry of Health of Honduras. 1048 women were pregnant at baseline, and IMR was estimated to be 48/1000. The follow-up survey questioning pregnancy outcome and survival status of respondents' young children achieved a 74% response rate, and yielded an estimated IMR of 26/1000 for newborns. IMR estimated from follow-up data is probably unrealistically low given mortality trends and socioeconomic conditions in HOnduras. 3 sources of error potentially contributing to low IMR for the cohort of newborns are considered: pregnancy denial, unreported, and underreporting of pregnancies. Future studies should be conducted with more than 1048 pregnant women, baseline survey should be improved to better detect pregnancies, and regional and community studies should be considered in an effort to reduce study cost and boost response rates at follow-up.