Selection and performance of the levonorgestrel-releasing intrauterine system.

BACKGROUND: The levonorgestrel-releasing intrauterine system (LNg IUS) is a hormonal contraceptive that is used in the uterine cavity. To determine whether the reasons for choosing LNg IUS vs. copperreleasing intrauterine devices (Cu IUDs) differ and whether their performances are comparable, we carried out a retrospective study in Finland during the first years of LNg IUS use. METHODS: Gynecological and contraceptive histories of 626 LNg IUS and 626 Cu IUD users and the performance of the device were reviewed from patient records. RESULTS: Women who accepted the LNg IUS were more likely than Cu IUD acceptors to have a history of menstrual bleeding of 6 days or more (44.4% vs. 28.4%), heavy bleeding (44.8% vs. 8.4%) and moderate or severe dysmenorrhea (15.9% vs. 7.5%). In both groups, 70% of the women had used Cu IUDs earlier. However, the LNg IUS acceptors had had more side effects during previous use of CU IUDs (58.2% vs. 28.8%). They also reported more side effects that resulted in discontinuation of a previous Cu IUD (39.4% vs. 10.1%). However, the 12-month life-table continuation rates of 80.6 (SE 1.9)% vs. 83.4 (SE 1.8)% were alike. Cu IUD users discontinued the current method more often because of problems of bleeding and unwanted pregnancy. Among those women who had previously discontinued a hormonal method because of hormonal side effects, there were no differences in the continuation rates of the two groups. CONCLUSIONS: LNg IUS can be successfully used by women who cannot use a CU IUD or who have experienced hormonal side effects with oral contraceptives.

Intracervical anchoring: a new approach to intrauterine contraception.

The intracervical device described in this paper consists of copper wire around a small plastic frame that is anchored to the inner wall of the cervix, at about 1.5 cm from the external os. The device represents a radical departure from conventional intrauterine contraception and 'frameless' IUDs, which are anchored to the uterine fundus. The device was evaluated in a preliminary study of 11 women. During the 3-month evaluation period, there were no expulsions or removals for any reason. The device was well tolerated. Expanded clinical trials are planned.

Flow velocity waveforms in uterine and umbilical arteries during submaximal bicycle exercise in normal pregnancy.

Eight healthy women who were not conditioned athletes, at 35-38 weeks' gestation, performed a submaximal bicycle exercise test three times for 4 minutes each with stepwise increases (73 +/- 27, 114 +/- 29, and 161 +/- 16 W) of the work load. The target heart rate at the end of the last load was 170 beats per minute. The systolic-diastolic ratios (S/Ds) of flow velocity waveforms were measured with pulsed color Doppler ultrasound in the uterine and umbilical arteries immediately after each work load and during recovery. The heart rates at the end of each load (133 +/- 3, 156 +/- 3, and 173 +/- 7 beats per minute) corresponded to an average of 70, 83, and 92% of the calculated maximum heart rate. With the subject in the sitting position on the ergometer before exercise, the S/D in the uterine artery was 1.49 +/- 0.09, increasing gradually and significantly during the exercise to the maximum of 2.04 +/- 0.06 at 1 minute of recovery. Heart rate and S/D in the uterine artery correlated significantly (r = 0.58, P less than .01). Although the mean arterial pressure increased significantly during exercise from 92 +/- 6 to 109 +/- 10 mmHg, the significant decrease of the ratio of the mean arterial blood pressure and S/D suggests that the flow in the main uterine artery may decrease during intense exercise. No changes occurred in the S/D of the umbilical artery flow velocity, but the fetal heart rate increased significantly.

Iron deficiency in women using modern copper intrauterine devices.

To evaluate the risk of iron deficiency and anemia connected with the use of modern copper intrauterine devices, serum ferritin, transferrin, iron, hemoglobin and hematocrit levels, red cell counts, and morphology, as well as red cell indexes were determined in 40 women and in 19 controls. Follow-up was for one year. Mean hemoglobin, hematocrit, serum iron, and serum ferritin levels decreased and serum transferrin levels increased significantly in the study population. About 20% of intrauterine device users but none of the controls showed signs of iron deficiency, and 10% had clinical anemia at 12 months of use. No differences were found between the three different copper intrauterine devices tested (Nova T, Multiload and Fincoid). Because the risk of anemia did not correlate with subjective evaluation of the amount of bleeding, it is recommended that hemoglobin levels should be determined for all intrauterine device users before its insertion and at six and 12 months of use. In those with decreased hemoglobin levels, serum ferritin should be measured and iron replacement instituted or the device removed.

Intrauterine contraceptive device localization by clinical evaluation and real-time ultrasonography.

A total of 43 Intrauterine Contraceptive Device (IUD) wearers were examined clinically and ultrasonically in order to ascertain the intrauterine position of IUDs (copper devices of five different types). The time elapsed from the insertion was 2-26 months. The mean age of the women was 28 years; 95% of them were parous. The intrauterine location of the IUD was assessed clinically by means of threads cut to a standard length. In the ultrasound examination, the distance of the uppermost point of the stem of the device from the fundal wall was measured within an accuracy of 1 mm. The clinical assessment of the IUD location was found to agree surprisingly closely with the results of the ultrasound examination. The clinical assessment deviated significantly from the ultrasonography findings in about 10% of the cases.

Microbiology of vaginitis associated with the intrauterine contraceptive device.

A malodorous, homogeneous, grey, thin and non-purulent discharge, which resembles non-specific vaginitis occurs in 20% of women with an intrauterine contraceptive device (IUCD); four times more common than in non-users. The aim of this investigation was to study the bacteriological aetiology of this IUCD-associated vaginal discharge, and to assess whether the infection was ascendent. No specific microbiological aetiology was found, but the normal, Lactobacillus-dominated microbial vaginal flora was replaced by Gardnerella vaginalis and certain anaerobic species in IUCD-users with the discharge. Clue cells, pepper-salt phenomenon and curved rods and/or fusiform-shaped rods demonstrated by microscopy, were typical of symptomatic patients. The endometrium and the IUCD were infected with these species in the symptomatic group more often than in IUCD-users who had no symptoms or in the control women who did not use the IUCD.

Randomized comparison of multiload standard and short devices.

A randomized study was conducted to compare the clinical performance of the ML Cu 25-standard and the ML Cu 250-short devices. 375 insertions were performed postmenstrually to mainly parous women 16-43 years of age. Over 90% of the women in both IUD groups had uterine sound lengths from 7-9 cm. The rates are based on the total of 4273 woman months of use. The lost-to-follow-up rates at 12 months were 6.7 and 4.6% for standard and short ML series, respectively. The ML Cu 250-standard had a lower pregnancy rate and a lower removal rate for bleeding and/or pain, but a higher expulsion rate that the short model. However, these differences were not statistically significant. The shortening of the vertical arm of the Multiload device has no remarkable effect on its clinical performance.

Positional factors of the uterus play a contributing part in IUD failure.

This study is based on a uniform material of 3 500 copper IUD insertions at the Family Planning Unit of Turku Health Center, including 72 cases resulting in pregnancy. Among the pregnant subjects there were significantly more women with a retroverted flexed or mid-positioned uterus than in the control material. Repeat IUD pregnancies were rather common. These observations should be taken into account in practice, especially regarding great care with the insertion technique and a close follow-up of these women. The predisposing factors and the outcome of accidental pregnancies are discussed.