By Rebecca H. Allen, MD, MPH, Editor
In this retrospective cohort study of 6,203 women, there was no difference in expulsion rates between individuals using the levonorgestrel intrauterine device (IUD) for heavy menstrual bleeding and those using it for contraception, using a protocol where the IUD for patients with heavy menstrual bleeding was inserted only after bleeding had ceased or lessened.
Furlani RM, et al. Expulsion rates of the levonorgestrel 52 mg intrauterine system are similar among women with heavy menstrual bleeding and users for contraception. Contraception 2022;105:75-79.
Studies have shown that intrauterine devices (IUDs) inserted for the indication of heavy menstrual bleeding, especially if inserted during an episode of heavy bleeding, have higher rates of expulsion compared to IUDs inserted for contraceptive indications.1,2 The authors of this study sought to determine if avoiding insertion during very heavy bleeding would decrease the risk of expulsion.
This was a retrospective cohort study performed at the University of Campinas Medical School in Brazil. The Department of Obstetrics and Gynecology maintained a database of 14,535 levonorgestrel (LNG) IUD insertions performed between 2007 and 2015. The study group consisted of women receiving LNG-IUD insertions for heavy menstrual bleeding (HMB) and a comparison group, without HMB, who were using the IUD for contraceptive purposes only. Participants had to have at least one follow-up visit after the IUD insertion and were followed up to four years. For the patients with HMB, the clinicians inserted IUDs after cessation of menstrual bleeding or, at least, after the reduction of heavy menstrual flow within the first 14 days of the menstrual cycle. For contraception, clinicians inserted IUDs within the first five days of the menstrual cycle or any time in the cycle if the patient was using another highly effective method of contraception. A complete or partial expulsion was defined when the IUD was absent on ultrasound after missing strings were found on exam or when the device was in the cervical canal. Other data collected included age, body mass index (BMI), years of schooling, pregnancy history, uterine sounding depth, and the type of provider who inserted the IUD. Women with known fibroids were excluded if they were discovered pre-insertion through ultrasound or exam; however, no routine ultrasounds were performed.
The authors included a total of 6,203 women, 548 with HMB and 5,655 using the IUD for contraception only. Women were older (38.5 years of age vs. 31.8 years of age, P < 0.001) and had a higher BMI in the HMB group (28.1 vs. 27.2, P < 0.004). A total of 71 (12.9%) women with HMB were using anticoagulant medications. The average length of follow-up was 45 months in both groups. There were 346 device expulsions with no difference between the two groups: 31 out of 548 women with HMB (5.6%) and 315 out of 5,655 women (5.6%) in the contraception group. However, there were more expulsions in the HMB group in the first six months compared to the contraception group (P = 0.001). The cumulative expulsion rate up to four years after placement was similar, 7.8 and 9.7 per 100 person-years in women with HMB and contraceptive users, respectively. After multiple regression analysis controlling for age, years of schooling, BMI, number of pregnancies, vaginal and cesarean deliveries, uterine position, uterine sounding depth, type of provider, and duration of IUD use, expulsion rates were associated with history of cesarean delivery only.
COMMENTARY
National guidelines now allow for IUD insertion at any time during the menstrual cycle as long as it is reasonably certain that the patient is not pregnant.3 The older recommendation that IUDs only be inserted at the time of menses is a barrier to IUD insertion. Studies show that the timing of IUD insertion does not seem to affect expulsion or complication rates.4 In patients who are recently pregnant, IUDs also may be placed immediately postpartum and postabortion. However, this calculus may change when the IUD is being inserted for the treatment of heavy menstrual bleeding.
For women with heavy menstrual bleeding, there have been documented higher rates of expulsion in past studies.5,6 Anecdotally, most clinicians have seen IUDs expelled in their patients who have heavy menstrual bleeding. Expulsion rates of up to 20% have been reported. Furthermore, if the patient has uterine fibroids, the risk of IUD expulsion also may be higher.5 Nevertheless, placement of the LNG-IUD in patients with fibroids that do not obstruct the cavity or adenomyosis causing HMB is a common and accepted practice to avoid surgery if that aligns with what the patient desires. The authors of this study attempted to decrease this expulsion risk by not inserting the IUD when heavy bleeding was occurring and were successful.
This finding is important and may help guide clinical practice in this population of patients. The strength of the study was the large sample size, long follow-up time, and the use of one type of LNG-IUD. The IUDs were inserted by residents, fellows, trained nurses, physician assistants, and attending physicians, which increases the generalizability of the study. The association of cesarean delivery with IUD expulsion differs from other studies.7 Given the small effect size (adjusted odds ratio, 1.93; 95% confidence interval, 1.36, 2.74), the finding may be caused by statistical noise or unmeasured confounding factors.
Alternatively, if true, cesarean deliveries could change the angle of the uterus to be more anteflexed or retroflexed or produce cesarean scar defects that may affect insertion success, depending on the experience level of the provider. At any rate, this study emphasizes that withholding IUD insertion for the treatment of HMB until bleeding has ceased or lessened likely can be considered.
REFERENCES
- Diaz J, et al. Acceptability and performance of the levonorgestrel-releasing intrauterine system (Mirena) in Campinas, Brazil. Contraception 2000;62:59-61.
- Harris S, et al. Timing of insertion affects expulsion in patients using the levonorgestrel 52 mg intrauterine system for noncontraceptive indications. Contraception 2021;103:185-189.
- Centers for Disease Control and Prevention. US selected practice recommendations (US SPR) for contraceptive use, 2016. Last reviewed March 3, 2022. https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html
- Whiteman MK, et al. When can a woman have an intrauterine device inserted? A systematic review. Contraception 2013;87:666-673.
- Zapata LB, et al. Intrauterine device use among women with uterine fibroids: A systematic review. Contraception 2010;82:41-55.
- Madden T, et al. Association of age and parity with intrauterine device expulsion. Obstet Gynecol 2014;124:718-726.
- Gilliam ML, et al. Relationship of parity and prior cesarean delivery to levonorgestrel 52 mg intrauterine system expulsion over 6 years. Contraception 2021;103:444-449.
