Invasive cervical cancer and intrauterine device use.

Although the hypothesis that intrauterine device (IUD) use might promote cervical cancer has been considered since the introduction of IUDs in the early 1900s, previous studies are inconclusive. Data collected in interviews with 481 invasive cervical cancer cases and 801 general population controls from Birmingham, Chicago, Denver, Miami and Philadelphia were used to address this issue. These data were analysed to determine the relationship between IUD use and the risk of cervical cancer, with consideration of the type of IUD (copper and inert) and duration of use. A non-significant reduced risk of cervical cancer was associated with copper IUD use, indicated by an adjusted odds ratio (OR) of 0.6 (95% Cl: 0.3-1.2), but virtually no effect was found for inert IUD use (OR = 1.1, 95% Cl: 0.9-1.7). Decreased risk with increased duration of copper IUD use supports a possible protective effect of copper IUD use on the development of invasive cervical cancer.

PIP: The hypothesis that IUD use increases the risk of invasive cervical cancer was investigated in a case-control study conducted in 1982-84 in 5 metropolitan US centers--Birmingham, Chicago, Denver, Miama, Philadelphia. The study population consisted of 481 cases with invasive cervical tumors and 801 age- and race-matched controls selected by random digit dialing. 13% of cases and 20% of controls selected by random digit dialing. 13% of cases and 20% of controls reported a history of IUD use. The crude odds ratio for the association between IUD use and invasive cervical cancer was 0.6 (0.4-0.8, 95% confidence interval). Adjustment for all possible confounding factors (i.e., age, race, number of sexual partners, age at first intercourse, parity, cigarette smoking, number of marriages, previous genital or venereal infections, income, interval since last Papsmear, and use of oral and barrier contraception) resulted in an odds ration of 0.8 (0.5-1.2). The odds ratio was unaffected when study subjects were categorized according to duration of IUD use. On the other hand, the presence or absence of copper in the IUD did exert a significant effect on the degree of cervical cancer risk. A protective effect against invasive cervical cancer was observed for copper-containing IUDs (adjusted odds ratio of 0.6, 95% confidence interval 0.3-1.2) but not for inert devices (adjusted odds ration 1.1, 95% confidence interval 0.9-1.7). The reduced risk associated with copper IUDs increased with increased duration of use. Although prior studies have also failed to detect any association between IUD use and an increased risk of invasive cervical cancer, this is the first to suggest the possibility of a protective effect of copper IUDs on this risk.

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.

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.

IUDs: a state of the art conference. Introduction.

PIP: A conference sponsored by the US Department of Health and Human Services and the National Institute of Child Health and Human Development, in cooperation with the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine, sought to increase appreciation of the IUD as a safe, effective, and cost-beneficial contraceptive. The IUD is greatly underused in the US, selected by only 1% of contraception users. Lack of knowledge on the part of clinicians and patients about currently available devices and inadequate clinical training in IUD insertion are major obstacles to expanded utilization of this effective method. The vast majority of chief residents in obstetrics-gynecology have never inserted an IUD or have inserted too few to be considered proficient. Many concerns are related to the Dalkon Shield's adverse effects; which concerns are not generalizable to contemporary devices. Also limiting IUD use has been the perception that the device acts as an abortifacient. Current research suggests the device induces a local inflammatory response in the endometrium. The addition of copper further decreases the likelihood of sperm reaching the distal section of the fallopian tubes and diminishes fertilization capabilities. The copper-containing IUD in use today has a low expulsion rate (3%) and low rates of removal for pain and bleeding. Perforation rates remain steady at approximately 1 per 1000-2000 insertions. Return to fertility after removal is comparable to that associated with oral contraceptives and barrier methods.^ieng

Contraception for the woman aged 35 yr and over.

PIP: Women 35 years old must choose their contraceptive method by balancing between an acceptable failure rate and manageable side effects. In Birmingham, England, 1985 data show that among those women 35 years old, 28.8% chose oral contraceptives (OCs), 38% IUDs, 31.1% barrier methods, and 2.1% other methods. The incidence of irregular menstrual cycles, luteal phase deficiency, and short cycles increases with age. On the other hand, the frequency of intercourse declines with age thereby reducing fertility. These and other factors increase couples' anxiety about pregnancy as they grow older therefore establishing a need for adequate and informed counseling concerning all available contraceptive methods. Any counseling on choice or change of method should start before age 35 to allow the couples to make a logical choice based on their needs. Individuals must 1st consider the risk factors of combined OCs, especially smoking, obesity, and family history of cardiovascular diseases, before agreeing to use them. Progestogen only OCs provide a safer alternative. The IUD provides effective protection from pregnancy with minimal side effects, particularly copper IUDs. The death rate/year for IUDs for women 35-39 years old is 2/100,000 compared to 13.4 for smoking OC users, 4.5 for nonsmoking OC users, 5 for users of barrier methods, and 20.8 for women using no method at all. Since fertility declines with age, many women may choose barrier methods, but must realize that the chance of conception is higher than for the other methods and therefore must consider postcoital contraception or abortion. Sterilization is a popular contraceptive method for these women, but they should receive adequate counseling before the operation.^ieng

Postpartum IUDS: keys for success.

Intrauterine device (IUD) insertion is convenient and efficient in the postplacental and immediate postpartum periods. Insertion at these times is demonstrably safe, having a low incidence of infection, few bleeding problems, and low perforation rates. IUD expulsion rates can vary widely, and are a function of timing of insertion, type of IUD, and insertion technique. When a copper T device is inserted postplacentally or immediately postpartum by an experienced and trained clinician, expulsion rates of about 7-15 per 100 users at six months can be expected. Women must be told how to detect expulsions and instructed to return for reinsertion or for another method. Most investigators emphasize that high fundal IUD placement will reduce the expulsion rate. Unplanned pregnancy rates for postplacental IUD insertion range from 2.0-2.8 per 100 users at 24 months when using modern copper IUDs, correct insertion technique, careful postinsertion instructions and good follow-up. Postplacental insertions are performed manually or with a ring forceps. Immediate postpartum insertions (10 minutes to 48 hours after delivery) are performed with the ring forceps.

PIP: Postpartum IUD insertions include postplacental, immediate postpartum, puerperal or delayed, post puerperal, and interval. IUDs can even be inserted safely after a 1st trimester abortion. Various studies show that postpartum IUD infection rates vary from 0.1-1.1% and do not increase the chance of infection. It appears that manual or ring forceps insertion result in very low perforation rates, e.g., 1/1150 immediate postpartum IUD insertions in 1 study. In studies comparing immediate postpartum IUD insertions with interval insertions, the removal rate due to bleeding is lower for the immediate postpartum IUD insertions, e.g., 13.7% vs. 23.6% in a study in India. IUDs inserted postplacentally and in the immediate postpartum period are more likely to be expelled than those inserted in the interval period. This is less likely to occur with copper T IUDs, postplacental insertions, high fundal placement, and clinicians trained and experienced in insertions, however. 90-95% of women are able to detect their own expulsions. Further reinsertion rates range from 73-95%. Pregnancy rates of postplacental insertions correspond with those for interval IUDs. 24 month postinsertion pregnancy rates vary from 1-2.8%. Long term continuation rates for postpartum IUDs tend to be somewhat lower than interval IUDs. For example, a study shows that 65.5% of postpartum IUD women still had the IUD after 2 years compared to 71.3% of interval IUD women. In Lima, Peru, overall contraceptives prevalence is 13% higher among women in inhospital family planning services that offer postplacental and immediate postpartum IUD insertion than it is in those that do not include them. Contraindications for postpartum IUD use are the same as for any IUD use. In a cesarean section, IUD placed in the uterus before closure rarely result in infection, perforation, or bleeding. Clinicians should encourage women with postpartum IUDs to return for follow up 1 month after insertion.

One-year clinical experience with FlexiGard.

In 1988, a clinical study with a new copper-containing IUD, the FlexiGard, was initiated at the Family Planning Center of the UMSD, Debrecen, Hungary. The aim of this trial was to measure the overall performance of the device with special attention to its frameless design and anchoring system. In one year (from May 1988 through May 1989), 344 FlexiGard devices were inserted in parous women during the first seven days of their menstrual cycle. This report summarizes the one-year results. By the end of the 12 -month follow-up period, 3484 woman-months of use (WMU) were accumulated. The number of women who completed the one-year follow-up period was 264. During this period, 33 cases were terminated for different reasons. The net continuation rate is 89.7 at the end of the first year of use. The device was well retained by the uterus (cumulative expulsion rate 1.5 at 12 months). The cumulative removal rate for bleeding/pain is 4.4 at 12 months and the cumulative pregnancy rate 0.6 at 12 months. The results confirm those of previously conducted multicenter studies with the device. This new generation intrauterine copper contraceptive (ICC) is well tolerated, which is attributed to its design characteristics. Besides, the device is highly effective, and its insertion is easy and safe. Removal of the ICC is equally easily accomplished.

PIP: During May 1988-May 1989, an obstetrician-gynecologist inserted the new frameless copper-releasing IUD, Flexigard, in 344 18-45 year old women attending the Family Planning Center at the University Medical School in Debrecen, Hungary. The physician was able to examine 336 patients during at least 1 follow-up visit during the 12 months, for a lost-to-follow-up rate of only 2.3% which is lower than the recommended 10%. At the end of 12 months 264 women continued to use Flexigard. The number of cumulative woman months of use stood at 3484. The net termination rate was 10.3 at 12 months. The leading reason for removal was bleeding/pain (cumulative removal rate= 4.4). The only personal reason for removal was planning a pregnancy (6 cases, rate = 1.9). The 12-month net continuation rate was 89.7. The low expulsion rate was only 1.5 which was probably due to the anchoring system which allows the upper part of the IUD to penetrate no more than 1 cm into the fundal myometrium. The 12-month cumulative pregnancy rate was 0.6. In conclusion, the design characteristics of Flexigard made it well tolerated. Further, it proved to be very effective, and insertion and removal were easy and safe.

Intrauterine adhesions.

Anticipation and suspicion are critical aspects to any discussion of intrauterine adhesions. Curettage between the second and fourth week postpartum is more likely to cause adhesions than is any other endometrial trauma. Infertility, recurrent abortion, or menstrual aberrations after any uterine trauma should cause the physician to suspect the presence of intrauterine adhesions. Hysterosalpingography and hysteroscopy are the ideal methods to make the diagnosis of IUA, and the latter is the safest, least traumatic, and most precise method of treating adhesions. The addition of an intrauterine splint and high-dose estrogen therapy completes the therapeutic approach. Before attempting conception the cavity should be inspected to verify its normality.

PIP: This paper reviews what has been reported about intrauterine adhesions (IUAs) from their earliest description. Endometrial trauma, most often caused by curettage associated with pregnancy, must occur before IUAs will develop. Postpartum curettage will most likely cause IUAs if it is performed between the second and fourth week postpartum. The symptoms of IUAs are amenorrhea/hypomenorrhea, infertility, recurrent abortion, and/or adherent placenta. The menstrual pattern is usually predictive of the extent of intrauterine scarring, with amenorrhea being associated with the most extensive damage. Diagnosis can be confirmed and classified by hysteroscopy. The safest, least traumatic, and most precise method of operative treatment involves adhesiolysis, using hysteroscopy with the use of a postoperative intrauterine splint and administration of postoperative high-dose estrogen therapy. Before conception is allowed, the uterus should be examined to verify its normality. This treatment results in a pregnancy rate of 60-75%, regardless of the pretreatment extent of disease in an otherwise normal uterus. Preconception examination and verification of normality insures against the occurrence of an adherent placenta during subsequent pregnancy.

Intra-uterine contraceptive devices.

PIP: Among the advantages of IUDs are the device's high continuation rate, the lack of systemic side effects, and the absence of a need for continual motivation to practice contraception. The effectiveness of plastic IUDs is directly proportional to their surface area, but the degree of excessive bleeding experienced is inversely related to device size. Thus, devices represent a compromise between large size for effectiveness and small size for acceptability. The optimum time to fit an IUD is during the 1st hald of the menstrual cycle. Absolute contraindications to IUD use include the presence of active pelvic inflammatory disease, undiagnosed irregular bleeding, a history of ectopic pregnancy or tubal surgery, and a distorted uteine cavity. Failure rates associated with IUD use range from 2-3% in the 1st year and then decrease. Since the main mechanism of action appears to be production of a sterile inflammatory reaction in the uterine cavity, the IUD prevents intrauterine pregnancy more effectively than ectopic pregnancy. Nonetheless, there is little evidence to suggest that IUD use actually increases the incidence of ectopic pregnancy. Resumption of fertility after IUD removal is not delayed. There is not need to change inert plastic IUDs in women who remain symptom free. The copper devices should be changed every 3-4 years. A search is under way for antifertility agents that can be incorporated into the device to reduce side effects. In general, the IUD is most suitable for older, parous women.^ieng

Intrauterine devices in Singapore today.

PIP: The IUD has been selected by less than 1% of contraceptive users in Singapore in the past 15 years, largely because of concerns about uterine perforation and a lack of professional training in insertion techniques. However, increased public awareness of the possible complications of oral contraceptives has led to an interest in the IUD as a family planning method and the Singapore Family Planning and Population Board has introduced the Multiload Cu 250 device at its clinic. The IUD is now considered a feasible method of contraception for women in Singapore, many of whom achieve their ideal family size of 2 children between the ages of 20-25 years. Successful use of the IUD is dependent upon placement of the device at the top of the uterine cavity by an experienced physician. All devices should be changed after 4 years to reduce the risk of complications. The newer IUDs have many advantages over inert and early copper-bearing IUDs in terms of safety and efficacy.^ieng

A description of the intrauterine device, polygon (antigon).

PIP: The polygon (Antigon) is a closed, rodlike figure with the shape of a polygon, 24 mm wide and 30 mm high. It consists of 2 short upper members meeting at an angle, and 2 longer lower members, meeting the upper at an angle, and forming an arc at the base. Pressure on the lower members makes it take the form of a probe so that it can be inserted easily through the cervical canal, and dilation is seldom required. Its elasticity causes it to return to its original form as soon as it enters the uterine cavity, and pressure upon its upper members causes the lower segment to widen, thus reducing the tendency to expulsion. The inserter itself is never introduced into the cervical canal, and the polygon is flexible enough to follow the direction of the canal, thereby reducing the risk of performation to a minimum. The device is designed to remain sterile under storage, and can be introduced without being touched by hand, eliminating the risk of infection. A small powerful magnet in the polygon permits detection without x-rays, probing, or the need of a tail protruding through the cervix. Removal is done by using specially devised "forceps", and can be performed without much discomfort to the patient, and no analgesics or anaesthesia are required.^ieng

Are you a good candidate for IUD use?

PIP: This patient education supplement outlines the advantages and disadvantages of IUD use. The IUD has an effectiveness rate of 97-99%. Another advantage of the IUD is its convenience. It requires little maintenance once in place, and provides continuous contraception for a long period of time. In addition, nonmedicated and copper IUDs do not affect milk volume or composition in women who are breastfeeding. The progesterone-releasing devices often decrease menstrual bleeding and menstrual cramps. On the other hand, IUD use is generally contraindicated in women with the following medical conditions: current or past pelvic inflammatory disease (PID), known or suspected pregnancy, history of ectopic pregnancy, gynecologic bleeding disorders, suspected cancer of the genital tract, uterine abnormalities or benign tumors that prevent proper IUD placement, and anemia. Since IUD users are more likely to develop PID than other women, and are thus at greater risk of tubal obstruction or infertility, many clinicians advise women who have not yet had a child to select another method of contraception. Other complications of IUD use include a slight risk of ectopic pregnancy, uterine perforation, and undetected IUD expulsion. IUD users should know now to check for IUD strings, how to recognize common side effects of IUD use, and when to seek medical attention. IUD users should be re-examined 3 months after IUD insertion and annually thereafter.^ieng

Allaying the fears in the use of intrauterine devices.

PIP: Women's perceptions of the hazards of birth control devices centers on fears of sterility from IUD use and the permanence of bilateral tubal ligation. In March, 1992, an International Conference on the IUD gathered scientists and physicians from around the world to compare and contrast research findings on the risk and benefits of IUD use. Scientific examination pertained to IUD clinical performance, mechanisms of action, medical problems and their prevention, ectopic pregnancy, infertility, and post removed conception rates. Some of the findings were summarized. 1) The copper T 380 was recommended by WHO, because of the very low pregnancy rates, the long duration and relative ease of use, and low manufacturing costs. 2) IUD users, who are at low risk of contracting sexually transmitted diseases (STDs), do not have an elevated risk of pelvic inflammatory diseases (PID) due to use. Those who have multiple partners are strongly advised to use other forms of contraception. 3) Pregnancy rates are high after discontinuation; 80% conceive in the first year, and 90% within 2 years. 4) The mechanism of action is to decrease the number of viable sperm and interfere with egg transport, before the fertilization process. 5) The monofilament string is not associated with an increased risk of PID; PID is related to introduction of bacteria during insertion. 6) The IUD may be unsuitable in areas with high prevalence of STDs and/or anemia; screening may present a challenge. In areas with poor infrastructure, IUD use can be optimized by improving method selection and providing interventions for those who may develop problems. consensus was very high that all women planning IUD use should be screened for risk of infections that could lead to PID. Clients would need to be interviewed about their own sexual behavior and the behavior of their male partners. If programs are not capable of identifying women at risk or testing and treating STDs, the IUD should either not be used or be used only if incidence of venereal disease is low.^ieng

IUD update: what family planners should know.

PIP: Although all US pharmaceutical companies except one have stopped US sales of IUDs, for economic reasons, intrauterine contraception continues to offer distinct advantages for certain women. Moreover, family planners are concerned that the US situation may cause contraceptive providers and potential acceptors outside the US to reject the IUD out of erroneous fears that this device has been found unsafe. The profile of the ideal IUD user--mothers 30-39 years of age who are seeking to limit their family size--matches the profile of the majority of 1st-time contraceptive acceptors in developing countries. The IUD is associated with high continuation rates and high effectiveness. New-generation IUDs allow easier insertion and better retention in the uterus. Research is underway to address the occurrence of IUD-associated complications such as pain, bleeding, and association with infection. In general, women who have more than one sex partner and those with a prior history of pelvic inflammatory disease should be cautioned against IUD use, however, because of the risk of infection. Alternative methods of contraception should also be sought for nulliparous women, since they experience the adverse effects of IUDs more often and severely than women with children. At present, the IUD accounts for 13% of contraceptive use among married women in Asia (35% in China) and there are an estimated 70 million users worldwide.^ieng

Chlamydial serologic characteristics among intrauterine contraceptive device users: does copper inhibit chlamydial infection in the female genital tract?

OBJECTIVE: Our objective was to assess the association between copper intrauterine contraceptive device use and the level of antichlamydial antibodies. STUDY DESIGN: Fifty-four women (29 with history of ectopic pregnancy, 2 with non-tubal factor infertility, 1 with tubal factor infertility, and 22 with intact intrauterine pregnancies) with current or prior intrauterine contraceptive device use were compared with 60 prenatal control subjects with respect to antichlamydial antibodies. RESULTS: When the intrauterine contraceptive device user group was subdivided into copper users and Lippes Loop device users, a significantly lower geometric mean serum antibody titer among copper intrauterine contraceptive device users was detected. The odds ratio estimates for past chlamydial exposure (> or = 1:64 immunoglobulin G, > or = 1:128 immunoglobulin G) in users of noncopper versus copper intrauterine contraceptive devices were 9.1 (95% confidence interval 1.9 to 43.0) and 10.5 (95% confidence interval 1.5 to 71.8), respectively. CONCLUSIONS: The lower geometric mean serum antibody titer of antichlamydial antibody among copper versus Lippes Loop device users and the large association measured between past chlamydial infection and noncopper intrauterine contraceptive device use suggest that copper may have a protective effect against Chlamydia trachomatis infection or a suppressive effect on development of antichlamydial antibodies.

PIP: In Alexandria, Egypt, clinicians compared data on 54 women who were either current or prior IUD users with data on 60 pregnant women who had never used any contraception to examine the association between IUD use and the level of antichlamydia antibodies. The IUD users had a history of ectopic pregnancy (29), intact intrauterine pregnancy (22), nontubal-factor infertility (2), and tubal factor infertility (1). The cases and controls had essentially the same geometric mean serum antibody titers for Chlamydia trachomatis (10.47 vs. 6.17). Yet, women who used copper-releasing IUDs had a lower geometric mean titer than did those who used the Lippes Loop IUD, but the difference was only significant for IUD only users and IUD users with a history of ectopic pregnancy. Specifically, among women who had used a copper IUD, the geometric mean serum antibody titers for those who only used 1 type of IUD, had used an IUD just for contraception, and those who had a history of ectopic pregnancy were 4, 5.9, and 3.8, respectively, while they were 24, 25.1 and 25.1, respectively, for their Lippes Loop counterparts (p 0.05). Among IUD users who had had an intrauterine pregnancy, the titer for women using a copper IUD was 5 compared to 14.8 for those using a Lippes Loop. When the researchers used a serum titer of 1:64 as a cutoff point for the 2 subgroups of IUD users, the Lippes Loop group had a higher proportion with titers above 1:64 than did the copper IUD group (47.6% vs. 9.09%; odds ratio [OR] = 9.09). Further, a higher proportion of Lippes Loop users had a titer greater than 1:128 than did copper IUD users (OR = 10.5). These results suggest that copper either inhibits the biologic effect of C. trachomatis or suppresses the immune response to chlamydia. Based on these findings and those of previous studies, the researchers believe the former is the most likely explanation.

IUDs: current perspectives.

PIP: Intrauterine devices (IUDs) have been under much adverse media publicity and many product liability lawsuits have been filed since the mid-1970s, when reports of the association of the Dalkon Shield with septic abortion and pelvic inflammatory disease (PID) surfaced. Yet, worldwide, it is estimated that 70 million women are using IUDs (50 million in China). In Scandinavia they are the most popular form of contraception. An international meeting on the current status of IUDs in New York in 1992 concluded that the IUD is a safe and excellent method of contraception for many women. The newest devices, such as Copper TCu380A and the Multiload Cu375, are the most effective. The risk of PID compared with women using no contraception is elevated by a factor of 7.02 only within the first 20 days after IUD insertion. In Norway, where around 40% of women use IUDs, there has been no increase in subfertility rates compared with the US and UK. A large WHO multicenter study in 1989 found that IUD users were 50% less likely to experience ectopic pregnancy than women using no contraception (90% with Copper TCu 380A). The risk of spontaneous abortion is more than doubled and the risks of preterm delivery increased 10-13% with an IUD in situ; therefore, IUDs should be removed as soon as pregnancy is confirmed. If uterine perforation by the device is suspected, it should be located by ultrasound or x-ray and promptly removed. After contraceptive counselling, even experienced general practitioners can insert IUDs at any time during the menstrual cycle, after induced abortion, or complete spontaneous abortion. Heavy menstrual loss or dysmenorrhea are the most common reasons for removing IUDs. Partial or complete IUD expulsion by uterine contractions is most likely during the first 3 months after insertion. Infection should be suspected in any user who develops pelvic pain.^ieng

Endometrial cancer in relation to intra-uterine device use.

Data from a population-based case-control study were used to evaluate the risk of endometrial cancer among women who have used an intra-uterine device (IUD). Incident cases were identified between 1985 and 1991 among women aged 45-74 years who were residents of one of 3 counties in Washington State. Controls were selected by random digit dialing, and both groups of subjects received an in-person detailed interview. In this study population, women who had ever used an IUD were estimated to have a risk of endometrial cancer that was 0.61 times that of other women (95% CI 0.41-0.89). The reduction in cancer risk was not found to be dependent on duration of IUD use. There was a suggestion that women who had used intra-uterine contraception relatively late in reproductive life experienced a greater reduction in risk than those whose use was more distant or at a younger age. The relative risk among the small number of women who were currently using an IUD was 0.49 (95% CI 0.12-2.80). These results apply to the use of inert and copper IUDs as there was no use of progestin-releasing IUDs among women in the study population. The data from this and several other studies of the question support the hypothesis that use of an IUD has a favorable effect on the subsequent risk of endometrial cancer. The reason(s) for such a reduced risk is unclear.

[Steroid intra-uterine contraception: progesterone-releasing devices. II. Insertion, clinical problems and contraceptive dependability]. / Contraccezione intrauterina steroidea. Dispotivi liberanti progesterone. II. Inserzione, problemi clinici e sicurezza contraccettiva.

PIP: The advantages and disadvantages of the progesterone-releasing intrauterine device (IUD), Progestasert, are investigated, relying on the published literature and the authors' own experiences. Insertion of the Progestasert presents very few problems except in certain cases, particularly in nulliparous women. A complete gynecologic examination is indispensible before insertion to guarantee the absence of contraindications (e.g., pregnancy, anatomically abnormal uterus, tumors, pelvic inflammatory disease, acute cervicitis). Pain or discomfort at insertion appears infrequently, except among nulliparas. Similarly, pain after insertion is rare, but occurs most often in nulliparous women. Because of the insertion technique required for this IUD, cases of perforation of he uterus or cervix are virtually nonexistent. Expulsion of the Progestasert is very infrequent; it appears that incorrect insertion is the primary cause of expulsion. All studies verify a decrease in the expulsion rate after the 1st month of use. The incidence of pelvic inflammatory disease in Progestasert users is significantly lower than in users of other IUDs. This may be due, in part, to the shape of the device, which does not have wide surface areas and has no sharp or pointed edges which can become embedded in the endometrial wall. Additionally, the nature of the insertion device, guaranteeing lack of contact between the transverse arm of the IUD and the vagina, assures the sterility of the IUD even at the moment of introduction into the uterus, limiting the transport of bacteria into the cavity. Lack of sufficient data on ectopic pregnancies in Progestasert users impedes a complete evaluation and definition of the problem with this particular device. One of the most frequent reasons for discontinuing use of the IUD is distrubance of the menstrual cycle. Increase in menstrual blood loss, prolongation of the menstrual period, and intermenstrual bleeding are disturbances found in users of most IUDs. The Progestasert, however, appears to decrease menstrual bleeding and shorten the menstrual period in all cases. The advantages of the Progestasert are indisputable in treating dysmennorhea. All studies agree on the attributes of topical release of progesterone in treating this illness. Studies report disappearance of symptoms in 35% of dysmennorheic patients and a marked reduction of symptoms in 65%. Not enough data exist to draw any conclusions about the teratogenic action of the Progestasert. In normal pregnancies, however, natural progesterone is found in much higher levels than that released by the IUD. Theoretically, the hormone released by the IUD should not interfere with normal fetal development. The failure rate of Progestasert is equal to or lower than that of other IUDs. Overall, the Progestasert represents a remarkable improvement over conventional IUDs.^ieng

Intrauterine devices Wang S.S Cu 380 as compared to ML Cu 375, Nova T, T Cu 300, 7 Cu 200, Lippes Loop and Ohta Ring: clinical / physiopathological parameters.

PIP: IUDs are rigid and heavy thus irritating the endometrium. Their design accounts for many side effects and encourages pelvic infections. IUDs may even facilitate transmission of HIV. Since some health professionals and patients consider some IUDs to be harmful or unacceptable, researchers have worked on developing a newly designed IUD which meets the criteria for and ideal IUD. Some criteria include soft and flexible in nature and inside the uterus, safe, no migration, and light in weight. Taiwanese researchers have developed such an IUD. The silicone skeleton of the Wang SS (soft and safe) Copper 380 and 300 IUDs is bow-shaped with each arm of the bow tapering off from the middle and ending with a small rounded knob. Copper wire (0.31 mm x 380 sq mm or 0.31 mm x 300 sq mm) coils around the holeless vertical stem (3 cm). The monofilament nylon string is fixed in the middle of the stem by an enlarged top. Researchers designed the Wang SS Cu 300 for nulliparous women and the Wang SS Cu 380 for multiparous women. If physicians use a Wang IUD from a sterilized package, they can insert it without wearing sterile gloves. They need to clean the cervix. They must use a single tooth tenaculum to stabilize the uterus and to straighten the uterine axis. After placing the Wang IUD in the inserter, adjusting the flange, and putting the plunger on the inserter, they need to safely introduce the inserter into the uterine cavity to the point where the inserter touches the fundus or the flange touches the cervix. They then must push the plunger to insert the IUD. Insertion should be done immediately after menstruation. Clinicians need to conduct clinical trials to test the safety and effectiveness of the Wang Ss Cu IUDs.^ieng

Selecting patients and inserting the Progestasert.

PIP: In this article, the author discusses what is presently known about the Progestasert IUD, a progesterone delivery system. Progestasert delivers progesterone on a daily basis and in continuous fashion into the endometric cavity. It has no systemic effects, although there is increasing evidence of its effects on hypermenorrhea na dysmenorrhea. Evidence suggests that Progestasert may avoid one of the major problems associated with former IUDs (particularly the Dalkon Shield): salpingitis. More than 10 years ago, physicians observed during sterilization procedures that a large number of women wearing inert or copper IUDs had salpingitis. Data from 27 Progestasert users show that none had salpingitis at the time of sterilization. Progestasert may also carry a lower risk of pelvic inflammatory disease associated with IUD use. A study in Helsinki found only 3 cases of pelvic inflammatory disease in 20,000 women years use of progestin (Levonorgestrel) impregnated IUDs, compared to the expected incidence (according to the Center for Disease Control) of 1/100 woman years. Additionally, in a study involving over 300 patients, the use of prophylactic antibiotics after insertion twice a day for 5 days and inserting Progestasert during the time ovulation rather at the time of menstruation produced no cases of the pelvic inflammatory conditions usually associated with the insertion procedure. Concerning the risks of ectopic pregnancy, evidence suggests that progestasert tends towards more ectopics when compared to the copper IUDs, but towards less when compared to not using any contraception. Although Progestasert is not contraindicated in nulliparous patients, caution should be taken with such patients.^ieng