The intrauterine device: dispelling the myths.

The worldwide popularity and usage of intrauterine devices (IUDs) plummeted in the 1970s, when grim reports of septic abortions and pelvic inflammatory disease were published. Although the Dalkon Shield ultimately was determined to be the culprit for these problems, the reputation of all IUDs was damaged, and their popularity spiraled downward. The stigma continues, despite the proven safety and efficacy of newer IUDs, particularly the ParaGard T 380A and the Progestasert, which are now the only two IUDs approved for use in the United States. This article will review how the IUD works and will focus on dispelling the misconceptions surrounding its use. Rigid patient-selection guidelines and strict aseptic insertion techniques can provide safe, long-term, cost-effective, and highly efficacious contraception for monogamous women. Practitioners who follow these guidelines should not fear prescribing IUDs as a contraceptive device in the appropriate female population.

PIP: Reports of Dalkon Shield-related pelvic inflammatory disease during the 1970s severely damaged public acceptance of all IUDs. This stigma persists, despite the proven safety and efficacy of newer IUDs, especially the ParaGard T 380A and the Progestasert--the only two IUDs approved for use in the US. The ParaGard may be advantageous for older women in whom hormonal contraception is contraindicated, while the Progestasert is a good choice for women who experienced heavy bleeding with copper IUDs. This article was prepared to improve the understanding of nurse practitioners in the US of the mechanism of action of the IUD and to correct misinformation about its side effects. A special section outlines insertion techniques for the ParaGard T 380A. Given rigid patient selection guidelines and strict aseptic insertion techniques, the IUD represents a safe, long-term, cost-effective, and highly efficacious contraceptive method for monogamous women. Current theory holds that the IUD can be inserted at any time during the menstrual cycle, as long as pregnancy can be reliably excluded.

Reproduction, risk and reality: family planning and reproductive health in northern Vietnam.

In collaboration with the National Committee for Population and Family Planning, a study was conducted in 1994 in two Vietnamese communes to provide community level information on women's reproductive health and behaviors. A survey of 504 rural and 523 urban women collected five-year histories of reproduction, contraception, abortion and symptoms of Reproductive Tract Infections (RTI). This analysis focuses on the relationships between women's individual characteristics, use of family planning and abortion, and reported RTI symptoms. The findings reveal that IUDs do not raise women's likelihood of experiencing RTI symptoms in either commune. A recent abortion, however, strongly increases women's likelihood of having RTI symptoms in the rural commune, while low-socioeconomic status is associated with RTI symptoms in the urban commune.

PIP: The reproductive health of Vietnamese women was assessed in a 1994 survey of 504 rural and 523 urban women from two communes (Hai Hung and Ha Bac Provinces). The survey, conducted in collaboration with the National Committee for Population and Family Planning, collected 5-year histories of reproduction, contraceptive use, abortion, and reproductive tract infection (RTI) symptoms. Of particular interest were possible RTI risks associated with IUD use and induced abortion, both of which are widespread in Viet Nam. At the time of the survey, 24.9% of urban and 16.5% of rural respondents were using the IUD and 51.2% of urban and 35.1% of rural women had undergone at least one pregnancy termination. 22.8% of urban and 31.5% of rural women reported menstrual problems. 13.2% of urban and 22.8% of rural respondents reported three or more symptoms suggestive of RTI. The most common RTI symptom was heavy white discharge, reported by 38.2% of urban and 46.4% of rural women. Multivariate analysis identified abortion in the last 6 months (rural women) and few household assets as the only significant predictors of RTI symptoms. IUD use did not increase RTI symptoms in either study group. Behaviors that place women at risk of sexually transmitted RTIs were not investigated. These findings indicate a need to improve the quality of abortion care in Viet Nam.

Factors influencing continuation of IUD use in south India: evidence from a multivariate analysis.

This paper studies the correlates of IUD continuation, particularly in relation to quality of service provided in Karnataka, South India, by using a discrete-time logit model. Provision of follow-up services had a moderate influence on continuation, and medical check-up at insertion influenced the experience of side effects. But these effects were trivial in comparison with the overriding influence of motivational variables and of reported side effects. The IUD is retained for a limited duration in rural India where it is used mainly as a spacing device by lowly motivated young women who discontinue the method at the slightest feeling of discomfort or abnormality. If the IUD were recommended to older women for limiting childbearing by emphasizing its reversibility, it would enhance the method's popularity and improve the levels of contraceptive use among younger women.

PIP: In northern Karnataka, South India, the IUD is the most popular reversible contraceptive method but has a low continuation rate. The determinants of this pattern, with special emphasis on the role of programmatic factors, were investigated through an analysis of data from several small-scale follow-up studies of family planning acceptors conducted by the Population Research Center. A total of 713 IUD acceptors (461 rural and 252 urban) were interviewed in these studies. The mean age of IUD acceptors was 25 years; they averaged 2.3 children. 75% of rural and 58% of urban respondents had selected the IUD for spacing reasons. 45% reported IUD-related side effects such as irregular bleeding. Only 35% of respondents had their original IUD in situ at the time of follow-up and 57% had requested removal, primarily because of side effects. A multinomial logit model identified the level of motivation to use the method and the experience of real or perceived side effects as the most significant determinants of IUD continuation; unexpectedly, the quality of services provided before and after insertion was not as influential. Medical check-ups at insertion moderately reduced the experience of side effects. Women who selected the IUD for child spacing had significantly higher discontinuation rates at 3 months and were more likely to complain about side effects than those who chose the method for other reasons. A policy shift toward recommending the IUD to older, high-parity women for limiting purposes should be considered. Such a strategy might encourage contraceptive use among women who do not want more children but are concerned about child mortality and thus reluctant to undergo sterilization.

Menstrual problems and side effects associated with long-term TCu 380A IUD use in perimenopausal women.

The study assessing menstrual problems and side effects associated with long-term TCu 380A intrauterine device (IUD) use in perimenopausal women is reported. Fifty perimenopausal TCu 380A IUD acceptors who had IUD inserted after age 40 and used IUD at least 36 months were recruited. The mean age of acceptors at time of insertion was 44.2 years with an average parity of two live births. The mean body weight at insertion was 62.13 kg. Most of the bleeding patterns were regular cycles. Intermenstrual bleeding and pelvic pain were side effects most often reported. No pregnancies, pelvic inflammatory disease, or IUD expulsions occurred during the follow-up period. This study suggests that the use of TCu 380A IUD in perimenopausal women is safe and effective.

PIP: Menstrual problems and side effects associated with long-term Copper T 380A use in perimenopausal women were investigated in a follow-up study of 50 Thai women who had the IUD inserted after 40 years of age (average, 44.2 years) and used the device for at least 36 months. All study participants had their IUD inserted at the family planning clinic of the Faculty of Medicine, Chulalongkorn University, in Bangkok, Thailand, and were followed at 6-month intervals. Their average parity was 2 live births. The numbers of women with irregular menstrual cycles at 12, 24, and 36 months after IUD insertion were 7 (14%), 11 (22%), and 15 (30%), respectively. Intermenstrual bleeding and pelvic pain--the most common side effects--were experienced by 15 (30%) and 9 (18%) women, respectively, during 36 months of follow up. No pregnancies, pelvic inflammatory disease, or IUD expulsions occurred and there were no significant changes in body weight or blood pressure. These findings suggest that TCu 380A use is both safe and effective up to menopause.

Progestin receptor isoforms and prostaglandin dehydrogenase in the endometrium of women using a levonorgestrel-releasing intrauterine system.

This study has examined endometrial tissue in 14 normal women prior to insertion of a levonorgestrel-releasing intrauterine system (LNG-IUS) and thereafter longitudinally for up to 12 months post-insertion. The specific endpoints examined by immunohistochemistry were progesterone receptor (PR) subtypes A + B, oestrogen receptor (ER) and prostaglandin dehydrogenase (PGDH). Two antiprogesterone receptor antibodies, one specific to PR(B) subtype and the other to PR subtype A + B, were employed to examine the localization of both PR isoforms. The activity of PGDH, a progesterone dependent enzyme, was also measured. ER and PR(A+B) and PR subtype B were significantly down-regulated in glands and stroma in the presence of continuous intrauterine LNG delivery. There was an apparent increase in PR(A) immunoreactivity in endometrial glands between 6 and 12 months post-insertion. Consistent with down-regulation of both isoforms of PR was reduced glandular PGDH immunostaining following LNG-IUS insertion, and PGDH activity (as measured by metabolism of excess substrate in vitro). Furthermore, PGDH activity, known to be localized in the glands, significantly increased (P < 0.05) at 12 months post-insertion, coinciding with the observed increase in glandular PR(A+B) immunoreactivity at this time. Since the LNG-IUS suppresses the PR(B) so strongly, PR(A) is likely to be the subtype that mediates long term LNG action in the endometrium. PR(B) is the more suppressed of the two subtypes, and only PR(A) rises along with PGDH activity. Alterations to normal endometrial morphology and function, e.g. perturbation of normal sex steroid receptor expression, following exposure to high concentrations of local LNG, may play a role in the aetiology of bleeding disorders associated with the LNG-IUS. Further elucidation of local uterine mediators involved in the mechanism of bleeding problems is required.

PIP: The effects of a levonorgestrel-releasing intrauterine system (LNG-IUS) on endometrial tissue were investigated in 14 UK women who were followed for 12 months after its insertion. Of particular interest was the etiology of menstrual aberration associated with progestogen-only contraception. In the presence of continuous intrauterine LNG delivery, estrogen receptor and progesterone receptor (PR) subtype A + B and subtype B were significantly downregulated in the endometrial glands and stroma. There was no apparent increase in PR subtype A immunoreactivity in endometrial glands 6-12 months after LNG-IUS insertion. Also observed was reduced glandular prostaglandin dehydrogenase (PGDH) staining and activity. PGDH activity significantly increased at 12 months post-insertion coinciding with the increase in glandular PR subtype A + B. Since the LNG-IUS suppresses the PR subtype B so strongly and only PR subtype A rises along with PGDH activity, PR A is likely the subtype that mediates long-term LNG action in the endometrium. Perturbation of normal sex steroid receptor expression after exposure to high concentrations of local LNG may play a role in the bleeding disorders associated with use of the LNG-IUS. Examination of more local mechanisms in endometrium exposed to an LNG-IUS should help elucidate some of the potential mechanisms regulating endometrial bleeding.

Primary carcinoma of fallopian tube after prolonged retention of Lippes loop.

PIP: Although a small number of uterine malignancies have been reported in long-term IUD users, a cause-effect relationship is difficult to establish. This article presents a case of primary carcinoma of the fallopian tubes with a coexisting Lippes loop. The 50-year-old patient presented to Seth Sukhlal Karnani Memorial Hospital (Calcutta, India) 5 years after menopause with complaints of occasional vaginal bleeding for the past 2 months. A Lippes loop had been inserted 20 years earlier, with no follow-up after the first year of use. Total hysterectomy was performed. Gross cut-section revealed the Lippes loop inside the uterine cavity. The distal parts of both fallopian tubes showed multiple small cystic spaces filled with fluid, with features of papillary adenocarcinoma arising from mucosa infiltrating the wall and projecting into the lumen. The distorted tubes also showed features of hydrosalpinx follicularis. Although the ovaries were adherent to the tubes, they were not malignant. The atrophic endometritis present in this case suggests that carcinoma was preceded by salpingitis, in turn possibly initiated by prolonged IUD retention.^ieng

Continuation rates of long-acting methods of contraception. A comparative study of Norplant implants and intrauterine devices.

Following adverse widespread publicity in the United Kingdom and the United States, it is commonly believed that discontinuation rates for the contraceptive implants Norplant in the UK are high. We have compared discontinuation rates between new intrauterine device (IUD) users (253 women) and new Norplant implant users (502 women) over 33 months following the introduction of Norplant implants among a population of women attending the same clinic and counseled in the same manner by the same group of providers. Women choosing the IUD were slightly older and were more likely to be changing their contraceptive method because of dissatisfaction with their current method. Nor plant implant users were more likely to have completed their families. Continuation rates for Norplant implants were significantly higher than for IUD at 12, 18, and 24 months after insertion. At 24 months, continuation rates for Norplant implants were 72% compared with rates of 55% for IUD users. Higher continuation rates may be related more to factors associated with the providers than with the users of these two long-acting methods.

PIP: Widespread adverse publicity in both the US and UK about side effects associated with Norplant contraceptive implants is generally assumed to have resulted in high discontinuation rates. The accuracy of this assumption was investigated in a comparative retrospective study of discontinuation rates among new first-time IUD users (n = 253) and new Norplant acceptors (n = 502) attending the same large family planning clinic in Edinburgh, Scotland, and counseled by the same providers in the 33-month period after Norplant introduction (1993-95). The most common reason for Norplant selection was as an alternative to sterilization, while IUD requests tended to be based on dissatisfaction with other methods. IUDs were removed steadily over time, at an average of 3.2/month. Norplant removals increased with time, from a monthly mean of 1.4 in the first 18 months to 7.8 in the subsequent 15 months. Continuation rates at 12, 18, and 24 months were 84%, 80%, and 71.8%, respectively, in the Norplant group compared with 70%, 63%, and 54.6%, respectively, among IUD users. For both methods, the predominant reason for removal was bleeding problems. These findings demonstrate that, contrary to popular assumption, women who have been well counseled manifest high Norplant implant continuation rates.

Can intrauterine device removals for bleeding or pain be predicted at a one-month follow-up visit? A multivariate analysis.

From 4%-14% of intrauterine device (IUD) users have their IUD removed due to bleeding or pelvic pain in the first year of use. Past studies have analyzed whether baseline patient information can help predict such removals, but no previous analysis has examined whether information provided at the recommended 1-month follow-up visit could improve such predictions. Using data from an international multicenter randomized controlled trial, 89 women with removals for bleeding and pain after the 1-month visit were compared with 2536 continuing users. Logistic regression indicated several significant predictors of removal. Women reporting intermenstrual bleeding since last menses were nearly three times more likely to have removals for bleeding or pain (odds ratio [OR] 2.9; 95% confidence interval [CI] 1.4-5.9). Similarly, those complaining of excessive menstrual flow were 3.5 times more likely to have removals within 12 months (95% CI 1.4-9.2). Women reporting these menstrual problems during scheduled revisits may benefit from counseling and treatment with nonsteroidal anti-inflammatory drugs (NSAID).

PIP: In the first year of use, 4-14% of IUD users have the device removed because of pelvic pain or bleeding. Identification of women at risk of removal for these reasons would enable targeted counseling and treatment, thereby reducing the frequency of removal requests. The hypothesis that problems reported at the 1-month follow-up visit can help to predict eventual IUD removal for pain or bleeding was investigated through use of data from a randomized controlled trial of IUD acceptors from 18 centers in 14 countries in Asia, Africa, and Latin America, who were followed for 1 year. The present analysis was restricted to 2536 women who received Copper T-380A or Multiload 250 IUDs. There were 89 removals for pain or bleeding during the study period. When baseline acceptor characteristics were considered, breast-feeding status was the most significant predictor of removal. Women not breast feeding at the time of IUD insertion were 2.8 times (95% confidence interval (CI), 1.5-5.2) as likely as those who were breast feeding to undergo removal for pain or bleeding in the 12 months after insertion. The following variables reported at the 1-month follow-up visit were significant predictors of removal: intermenstrual bleeding since last menses (odds ratio [OR], 1.9; 95% CI, 1.4-5.9), excessive menstrual flow (OR, 3.5; 95% CI, 1.4-9.2), and cessation of breast feeding since IUD insertion (OR, 2.2; 95% CI, 0.9-5.6). Although intermenstrual pelvic pain, spotting, and menstrual flow of more than 1 week's duration increased the risk of removal, they were not statistically significant predictors in this sample. Women who report intermenstrual bleeding or excessive menstrual flow at their 1-month follow-up visit may benefit from counseling and, in some cases, treatment with nonsteroidal anti-inflammatory drugs to reduce their risk of early IUD discontinuation.

Contraception-associated menstrual problems: etiology and management.

PIP: Menstrual cycle irregularities are common during the first few months of use of hormonal contraception and the IUD. Although most contraception-related menstrual problems are not clinically significant, they can lead to erratic method use or even discontinuation. This article presents guidelines for the assessment and management of bleeding problems related to use of combined oral contraceptives (OCs), progestin-only pills, subdermal progestin implants, injections, and IUDs. Much of the patient dissatisfaction that results from these menstrual changes can be averted by careful counseling prior to method selection. Candid dialogue regarding the potential for bleeding disturbances is critical before a method is prescribed in order to avert the interrupted contraceptive practices that place women at risk of unintended pregnancy.^ieng

Low risk of infection from IUD use shown.

PIP: The findings of a large, multicenter US study indicate that women who are screened for infection risks before IUD insertion are at low risk of such complications, regardless of whether prophylactic antibiotics are administered. More than 300 clinicians at 11 clinics in Los Angeles County, California, provided 1867 women with either 500 mcg of azithromycin or placebo capsules before insertion of a Copper T 380A IUD. The risk of sexually transmitted infection was assessed before IUD insertion through both self-reported medical history and screening for chlamydia and gonorrhea. At least 90 days of postinsertion follow-up was accumulated for about 98% of women in both groups. At 90 days, 92.7% of women who received the antibiotic and 93.2% of those who received a placebo still had their IUD in place. Only 1 woman in each group developed salpingitis. The rate of IUD removal for any reason other than spontaneous partial expulsion was 3.8% in the antibiotic group and 3.4% in the placebo group. At 12 months, approximately 80% of women still had their IUDs in place, indicating a high level of satisfaction with the device. Researchers have expressed hope that these findings will help counteract concerns about IUD safety.^ieng

Characterization of calcified deposits on contraceptive intrauterine devices.

The formation of calcified deposits on > 200 contraceptive intrauterine devices (IUD) was quantitated as a function of time in healthy women, pregnant women, and women with a pathologic lesion. The incrustment formation was significantly enhanced when inflammation occurred, but change could not be observed in cases of pregnancy. The incrustments were analyzed by x-ray diffraction, infrared spectroscopy, x-ray microprobe, and ultramicrochemical stone analysis techniques. Major components and their average w/w percent quantities in the incrustments are as follows: calcium carbonate 75%, apatite 5%, and organic matrix 20%. Earlier hypotheses on the chemical processes of deposit formation are discussed, and a new, ionic mechanism of calcification on IUD surfaces is suggested.

PIP: Calcium incrustation on the surface of an IUD significantly increases the likelihood of side effects such as bacterial and fungoid infections. The time-dependence of calcification on IUDs and the chemical composition of calcified deposits were investigated in devices removed from more than 200 healthy women with lower abdominal complaints or a planned or accidental pregnancy. A linear relationship was found between the amount of incrustation on plastic IUDs and the duration of IUD use. Incrustment formation was faster when inflammation occurred, presumably as a result of enhanced excretion of incrustment-forming compounds, but pregnancy had no effect on this rate. Deposit formation on copper IUDs was less uniform and proceeded at a slower rate. The incrustments were characterized by x-ray diffraction, infrared spectroscopy, x-ray microprobe, and ultramicrochemical stone analysis techniques. On average, incrustments were composed of calcium carbonate (75%), organic matrix (20%), and apatite (5%). The rate of incrustation depended not only on the size and quality of the IUD, but also on the individual capability of the uterus to produce calcium ions. The growth of incrustments on IUDs can be monitored by noninvasive ultrasonography.

[The urological complications of contraception using intrauterine coils]. / Urologicheskie oslozhneniia kontratseptsii vnutrimatochnymi spiraliami.

Being a foreign body, intrauterine coil causes decubitus and inflammation of the adjacent tissues. Long-term carriage of the coil may give rise to endometritis, myometritis, parametritis, salpingo-oophoritis, tubo-ovarian inflammatory infiltrates. These infiltrates invade retroperitoneal pelvic fat and may obstruct pelvic ureters. Ureteral obstruction may bring about ureterohydronephrosis, pyelonephritis and renal calculi. The coil may be also responsible for chronic pyelonephritis. The authors have treated 64 females aged 18-45 years with urological complications due to intrauterine coils which stayed from 6 months to 14 years. 34 of them presented with attack of acute pyelonephritis, 29 with renal colic and acute pyelonephritis, 26 with renal calculi. To arrest renal colic and attack of acute pyelonephritis ureteral catheterization and renal pelvis drain were performed in 31 patients. One patient has undergone ureterolithotomy. 8 patients rejected removal of the coil and had recurrent renal colics and acute pyelonephritis attacks. Removal of the coil arrested pyelonephritis and lithogenesis in the kidney. In one case of coil removal there was injury to the uterine cervix and urinary bladder eventuating in vesicovaginal fistula.

PIP: According to various authors the frequency of inflammatory complications associated with the use of IUDs ranges from 2% to 8%. Gynecological surgery on account of purulent, inflammatory disease of the adnexa uteri associated with IUD use (4-7%), damaging the urinary bladder and the ureters, is not uncommon. At the urological clinic of Stavropol, Russia, a total of 64 women who were in the 18-64 year age range, had urological complications, and had worn IUDs for 6 months to 14 years were observed. 34 of them presented with acute pyelonephritis attacks, 29 of them with renal colic and acute pyelonephritis, and 26 with renal calculi. In 22 women the acute pyelonephritis attacks were treated with antibiotics and uro-antiseptics. 19 of the 29 women who had renal colic and acute pyelonephritis underwent catheterization and drainage of the renal pelvis, and all of them passed fine kidney stones after the removal of their catheters. Urethral catheterization and drainage of the renal pelvis were performed in 31 patients in order to arrest renal colic and acute pyelonephritic attacks. The catheters stayed in for 2-3 days. For all these women removal of the IUD was recommended. 1 patient underwent ureterolithotomy. 8 patients rejected the removal of the IUD and had recurrent renal colics and acute pyelonephritis attacks. Removal of the IUD arrested pyelonephritis and lithogenesis in the kidneys. In 1 case of IUD removal injury to the uterine cervix and urinary bladder occurred, resulting in a vesicovaginal fistula. The report concludes with the case of a 44-year old patient who had worn a plastic IUD for 14 years.

Intrauterine device use and endometrial cancer risk.

BACKGROUND: Because intrauterine devices (IUD) invoke acute and chronic inflammatory responses in the endometrium, it is possible that prolonged insertion of an IUD could induce endometrial cancer. METHODS: We examined the relation between use of an IUD and endometrial cancer risk using data from a multicentre case-control study involving 405 endometrial cancer cases and 297 population controls. RESULTS: A total of 20 (4.9%) cases and 34 (11.4%) controls reported any use of an IUD. After adjustment for potential confounders, IUD use was not associated with an increased risk of endometrial cancer (RR = 0.56 for ever use; 95% CI: 0.3-1.0). Little reduction in risk was observed among women who last used an IUD within 10 years of the index date (RR = 0.84; 95% CI: 0.3-2.4) but risk was decreased among women who used an IUD in the more distant past (RR = 0.45; 95% CI: 0.2-1.0). Risk did not vary consistently with number of years of IUD use or with years since first use. Risk was not increased among women who used inert devices (RR = 0.46; 95% CI: 0.3-3.6) or those who used devices containing copper (RR = 1.08; 95% CI: 0.1-3.6). CONCLUSION: These data are reassuring in that they do not provide any evidence of an increased risk of endometrial cancer among women who have used IUD.

PIP: IUDs invoke acute and chronic inflammatory responses in the endometrium. The authors therefore explored whether the prolonged insertion of an IUD increases one's risk of developing endometrial cancer. The relation between the use of an IUD and endometrial cancer risk was examined using data from a multicenter case-control study involving 405 endometrial cancer cases and 297 population controls. 20 cases and 34 controls reported using an IUD. After adjusting for potential confounders, IUD use was not associated with an increased risk of endometrial cancer. A small reduction in risk was observed among women who last used an IUD within 10 years of the index date, with the risk further reduced among women who last used an IUD more than 10 years ago. Risk did not vary consistently with the number of years of IUD use or with years since first use. Furthermore, the level of risk was not increased among women who used inert devices or those who used copper-containing devices.

Intrauterine contraception in adolescent women. The GyneFix intrauterine implant.

Pregnancy rates among adolescents have not decreased over the last 10 years, despite numerous efforts. To solve this important health problem, the major strategy recommended is to encourage contraceptive use among sexually active teenagers. An important means of obtaining this is by promoting methods that are not dependent on daily administration in order to avoid noncompliance. One such method (Norplant) has already shown to be much more effective than the combination pill in preventing pregnancy in adolescent women. The frameless intrauterine implant system (fixed, frameless, and completely flexible) has been studied since 1985 in women between 14 and 50 years of age. The results in young nulligravid women confirm its very high effectiveness (cumulative pregnancy rate at 36 months: 1.4%), its low expulsion rate (cumulative rate at 36 months: 0.9%) and its optimal tolerance (cumulative removal rate for medical reasons at 36 months: 2.4%), resulting in a high acceptance of the implant and a high continued use. The system (GyneFix) offers long-term protection (5 years), and its insertion, with or without anesthetic, is easily accomplished in the office. The GyneFix should therefore be recommended as an excellent alternative for birth control pills for young women with low risk for STDs, especially when compliance is a problem, without an increased risk for complications and without systemic side effects. Removal of the device is accomplished by traction on the tail. It can also be used for emergency contraception and for insertion immediately after termination of pregnancy.

Low-tech innovation helps provide safer services.

PIP: The IUD is a highly popular contraceptive method, used by almost 500,000 women in Bangladesh alone. One concern with IUD use, however, is the potential risk of post-insertion pelvic inflammatory disease (PID), a serious disease which can lead to chronic lower abdominal pain, ectopic pregnancy, infertility, and death. An increased risk of PID exists for approximately 1 month after IUD insertion, presumably related to the introduction of bacteria into the uterus during the insertion procedure. Proper processing of IUD instruments and supplies and close attention to aseptic technique can help to reduce the risk of post-insertion PID. Concern over the ability to maintain aseptic technique is particularly high with regard to health care workers who travel between clinics in rural areas. In Bangladesh, providers in rural areas had problems transporting equipment, obtaining fuel and clean water, and finding the time needed to boil and cool instruments. A portable, easy-to-use steam sterilizer has now been developed and made available, allowing health workers to fully sterilize IUD instruments before visiting rural clinics, so that they no longer have to boil the instruments on site. AVSC was one of several organizations which worked with Bangladesh's National Task Force to develop the portable sterilizer for IUD instruments and supplies.^ieng

Contraceptive choice and reproductive morbidity in Istanbul.

A cross-sectional survey was conducted in Istanbul to investigate the relationship between contraceptive choice and reproductive morbidity. Altogether, 918 women who had ever used any means of avoiding pregnancy were interviewed at home, and, among these, 694 parous nonpregnant women were examined by three female physicians. The women were aware of bearing a considerable burden of ill health, with 81 percent reporting at least one episode of illness in the three months prior to the interview. Current users of the intrauterine device were significantly more likely than users of other methods to report menstrual disorders, but pelvic relaxation and reproductive and urinary tract infections, whether perceived or diagnosed, were not significantly related to any of the contraceptive methods. The relatively small amount of switching between methods suggests that most users tended to stay with the same method once chosen and that health concerns played an important part only in the initial choice of the method.

PIP: A cross-sectional survey was conducted in Istanbul to investigate the relationship between contraceptive choice and reproductive morbidity. Altogether, 918 women who had ever used any means of avoiding pregnancy were interviewed at home, and, among these, 694 parous nonpregnant women were examined by three female physicians. The women were aware of their bearing a considerable burden of ill health, with 81% reporting at least one episode of illness in the 3 months prior to the interview. Current IUD users were significantly more likely than users of other methods to report menstrual disorders, but pelvic relaxation and reproductive and urinary tract infections, whether perceived or diagnosed, were not significantly related to any of the contraceptive methods. The relatively small degree of switching between methods suggests that most users tended to stay with the same method, once chosen, and that health concerns played an important part only in the initial choice of the method.

The relationship between infection and the tailed IUD.

PIP: To clarify the association between the tailed IUD and pelvic infection, vaginal smears from 111 Chinese IUD users (40 acceptors of tailed IUDs and 71 of tailless devices) were analyzed for bacterial microorganisms. All study subjects had used the IUD for at least 5 years. Of the 11 samples positive for bacteria taken from the internal os, eight were from users of tailed IUDs (p 0.01). Of the 7 positive samples taken from the uterine cavity, 5 were linked to a tailed device. Although the correlation between the tailed IUD and pelvic symptoms was not significant, infected users of the tailed device were slightly more likely to be symptomatic. The tailed IUD did not increase leukorrhea excretion.^ieng

Menstrual bleeding changes with different contraceptive methods.

PIP: This patient handout describes changes in menstrual bleeding patterns associated with use of oral contraceptives (OCs), IUDs, contraceptive implants, and injectables. Patients are encouraged to keep a menstrual diary of changes that accompany use of a new method and to continue method use if changes occur until a clinician has been consulted. Although OCs regulate menstrual cycles to predictable lengths, about 30% of users experience breakthrough bleeding. The IUD should not cause bleeding between periods, although the copper IUD can cause heavier bleeding during menstruation. Menstrual disturbances (e.g., irregular cycles, a greater number of bleeding days, spotting, heavy bleeding) occur in almost all subdermal implant users in the first year of use, but these changes subside with time. Injectable contraception may initially cause irregular cycles and bleeding between periods. After a year of use, half of injectable users stop menstruating. Patients are advised to consult a clinician if they have been having regular cycles and suddenly develop breakthrough bleeding or if bleeding becomes prolonged or heavy.^ieng

A risk-benefit assessment of the levonorgestrel-releasing intrauterine system.

The levonorgestrel-releasing intrauterine system (LNG-IUS), has been developed by Leiras Pharmaceuticals, Turku, Finland. It is a new systemic hormonal contraceptive that releases levonorgestrel 20 micrograms every 24 hours. The device provides fertility control comparable with that of female sterilisation, complete reversibility and convenience, and has an excellent tolerability record. The low dosage of levonorgestrel released by its unique delivery system ensures minimal hormone-related systemic adverse effects, which tend to be in the category of 'nuisance' rather than hazardous, and gradually diminish after the first few months of use. In some respects, the contraceptive characteristics of the LNG-IUS have over-shadowed a substantial range of noncontraceptive beneficial effects that are rarely seen with inert or copper-releasing intrauterine contraceptive devices (IUDs), and have important and positive gynaecological and public health implications. This applies particularly to the profound reduction in duration and quantity of menstrual bleeding, and alleviation of dysmenorrhoea, which are associated with the use of the device. Recent studies have shown that the LNG-IUS is effective in preventing endometrial proliferation associated with oral or transdermal estradiol therapy, and in inducing regression of endometrial hyperplasia. Further research is required to determine whether it has a role in regulating the growth of uterine fibroids, and preventing pelvic inflammatory disease. The unique unwanted noncontraceptive effects of the system, including possible development of functional ovarian cysts, and the relationship between menstrual bleeding pattern and ovarian function, also require better understanding, in order to offer appropriate patient counselling and maximise acceptability and continuation of use of the method.

PIP: The levonorgestrel-releasing intrauterine system (LNG-IUS) provides fertility control comparable to female sterilization, convenience, and complete reversibility. This method appears to combine the benefits of oral contraception and the IUD, while avoiding most of their side effects. The low level of LNG released (20 mcg every 24 hours) minimizes the systemic adverse effects associated with hormonal contraception. Unlike inert or copper IUDs, the LNG-IUS is associated with a profound reduction in the duration and quantity of menstrual bleeding and alleviates dysmenorrhea. Moreover, there is evidence that the LNG-IUS prevents the endometrial proliferation associated with estradiol therapy and induces regression of endometrial hyperplasia; its potential for regulating the growth of uterine fibroids and preventing pelvic inflammatory disease remains undetermined. Although large multicenter studies have not detected differences in cervical cytology or breast cancer incidence between copper IUD and LNG-IUS users, long-term epidemiological studies are needed to confirm this finding. Fundal positioning of the LNG-IUS is essential to ensure uniform exposure of the endometrium to the progestogen, prevent expulsion, and maximize efficacy. A promising future use for the LNG-IUS is in protecting the endometrium during postmenopausal hormone replacement therapy. Overall, the research suggests that the LNG-IUS comes close to meeting many of the requirements of an ideal contraceptive.

The determinants of IUD discontinuation in China: a discrete-time competing risk model analysis.

This research examines the social, demographic, and family-planning-program factors that influence the occurrence of IUD discontinuation among Chinese women, using a sample of 14,639 IUD use segments from the 1988 Chinese National Survey of Fertility and Contraceptive Prevalence. A discrete-time competing-risk event history method is employed to identify the determinants of IUD discontinuation by five kinds of reasons: contraceptive failure, expulsion, switching method, side-effects and other nonmethod-related reasons. The predictors of IUD discontinuation suggest that a number of mechanisms are in operation. Some of the determinants may reflect the effects of the family planning program; some may illustrate women's physiological and biological reactions to IUD's; some may be related to women's previous history of contraceptive use; and still others may indicate social characteristics of women that lead them to have their IUD's removed.