New research shows that perforation from intrauterine devices (IUDs) is incredibly rare, although the risk is slightly higher with breastfeeding at the time of insertion.1
“A [previous] large cohort study in the United Kingdom suggested an increased risk of uterine perforation with breastfeeding and when the IUD is in service within 36 hours of delivery,” says Susan D. Reed, MD, MPH, MS, lead study author and professor and vice chair for research in the department of obstetrics and gynecology at the University of Washington. “As a clinician who has been [inserting] IUDs for 35 years, I have always felt the data that I use to counsel patients is flimsy.”
For example, most studies followed participants with IUDs for just 12 months. This does not answer patients’ questions about the long-term effects of IUDs. Patients want to know what their risks are for an IUD perforation over the lifetime of the device in their body — not just for one year.
“Some progesterone IUDs are used for seven years,” Reed notes. “A woman wants to know, ‘If I get an IUD, what’s the chance of ever getting a perforation?’”
Reed and colleagues studied the experiences of hundreds of thousands of people, looking at the risk of perforation from IUDs that were inserted for five years or 10 years. Overall, the rate of any perforation was fewer than two per 1,000 person-years.
“What our study found and confirmed was the finding that there is a slightly increased risk of uterine perforation while women are breastfeeding,” Reed says. “This makes physiological sense because, while breastfeeding, the uterus has lower hormones and the tissues are not very flexible. They’re stiffer, thinner, and are remodeling.” The large uterus that held the full-term infant now is shrinking back to its lemon and orange size. This requires a lot of biological activity, she adds.
Robert Hatcher, MD, MPH, chairman of the Contraceptive Technology Update editorial board, points out information from the latest edition of Contraceptive Technology.
“The most important determinant of the risk of perforation is the skill of the person placing the IUD,” Hatcher and co-authors noted in Contraceptive Technology. “In experienced hands, the risk of perforation is one in 1,000 insertions or fewer. Particular care is required for women who are breastfeeding, as perforation is more likely. However, in a large cohort study, no uterine perforation led to serious illness or to injury of intra-abdominal or pelvic structures.”2
From a physician’s perspective, it is challenging to describe risks to patients. Does one discuss the risk rates, the one-year rate, the five-year rate, the cumulative rate?
“What does a woman care about? My patients want to know what is the chance this IUD will ever cause a perforation in me,” Reed says.
The benefits of breastfeeding outweigh the risks associated with IUDs, but the chance of perforation with an IUD inserted during a period of breastfeeding is 30% greater than for people who did not breastfeed. But that 30% greater risk has to be viewed in the context that in both cases, the risk remains extremely low, Reed explains.
In a separate study, investigators looked at the expulsion rates of IUDs. They found an incidence rate of fewer than 15 per 1,000 person-years.3
“It’s the role of the clinician to put everything in context for the patient,” Reed says.
The context of the modern IUD is that it is one of the safest and most effective forms of contraception available. It is safer than tubal ligation for most patients. In fact, researchers found the lowest risk of perforation in young women who have never been pregnant.
“If you are a 20-year-old and want an effective form of contraception, you would be in our lowest risk group,” Reed adds.
Providers may consider the benefits of IUDs for younger patients who have never been pregnant. But they also need to consider the barriers to IUD initiation, including patients’ fear of pain from the procedure. If they can help patients overcome that obstacle, it might make IUDs more accessible to young women.
For women who have had a vaginal delivery, IUD insertion is straightforward and less problematic. But for young women who have never undergone an office procedure, it could be terrifying. “The provider needs to make that patient feel comfortable and give them medications to help them not feel as much,” Reed explains.
Physicians could give patients 800 mg of ibuprofen before the procedure and use a paracervical block of local anesthetics. “For my youngest patients, who’ve never had a [pelvic] exam, but really want an IUD and are scared about the pain, I give them a paracervical block — the same medication we use at the dentist’s office,” Reed says. “It’s no more painful than going to the dentist when we use similar medications to decrease this discomfort during placement. Most providers understand these examinations are challenging for young women, and we’re trained to help young individuals, when they really want an IUD, to do it with minimal discomfort and in a safe situation where people feel empowered.”
Build patient trust by letting them know they are in the driver’s seat at every step of the contraceptive initiation process. “The first thing I say is, ‘If you want me to stop, I am stopping. You are in power here,’” Reed explains. “I say, ‘This is your choice,’ so they don’t feel vulnerable.”
The goal is to give a top-notch IUD experience to younger patients. “Help them feel in charge of a procedure,” Reed says. “It’s not being done to them — they’re choosing this, and they can say when the procedure is done.”
REFERENCES
- Reed SD, Zhou X, Ichikawa L, et al. Intrauterine device-related uterine perforation incidence and risk (APEX-IUD): A large multisite cohort study. Lancet 2022;399:2103-2112.
- Hatcher RA, Nelson AL, Trussell J, et al. Contraceptive Technology: Twenty-first Edition. New York: Ayer Company Publishers, 2018.
- Gatz JL, Armstrong MA, Postlethwaite D, et al. Association between intrauterine device type and risk of perforation and device expulsion: Results from the Association of Perforation and Expulsion of Intrauterine Devices study. Am J Obstet Gynecol 2022;S0002-9378(22)00264-2.
New research shows that perforation from IUDs is incredibly rare, although the risk is slightly higher with breastfeeding at the time of insertion. Overall, the rate of any perforation was fewer than two per 1,000 person-years.
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