Int J Gynaecol Obstet 15: 150-152, 1977

The Benefits and Risks of IUD Use Louise B. Tyrer Planned Parenthood Federation of America, Inc., New York, New York, USA



Tyrer, L. B (Planned Parenthood Federation of America, Inc., New York, New York, USA). The benefits and risks of IUD use. Int J Gynaecol Obstet 15: 150-152, 1977 Next to combination oral contraceptives (OCs), intrauterine contraceptive devices (IUDs) are the most effective form of contraception available. IUDs require only one-time motivation, cause no systemic metabolic effects, and do not depend on continued action of the user for effectiveness. Risks, side effects, and complications of this method, including expulsion, perforation, pain, bleeding and infection, are reviewed.

Some specific advantages of IUD use are that (a) once the device is inserted, the method does not depend on any continuing action of the user for effectiveness, i.e., it requires only one-time motivation; (b) it has none of the systemic metabolic side effects occasionally associated with hormonal contraception; and (c) among successful users there is no delay in the return of fertility after the method is discontinued. IUDs are highly effective in preventing pregnancy, ranking just below combination oral contraceptives (OCs). In addition, the risk of mortality with IUD use appears to be lower than that associated with OC use and does not increase with age as does the mortality associated with OC use. Tietze et al. (8) documented that the risk of mortality remains constant at about 1.2 per 100000 IUD users.

INTRODUCTION Intrauterine devices (IUDs) have an established place in modern contraceptive technology. In 1974 and 1975, the Ad Hoc Advisory Committee to the United States Food and Drug Administration affirmed that this method of contraception is both safe and effective. However, like all other methods currently available, the method must be considered carefully in light of its potential advantages and disadvantages to a particular user. CONTRAINDICATIONS TO IUD USE In reviewing the risks and benefits of IUD use, we must first assume that only women with no absolute and few if any relative contraindications to IUD use will be given the IUD. Potential contraindications to IUD use, as outlined by the American College of Obstetricians and Gynecologists (1), include: 1.


Major a. Pelvic infections (acute, subacute, or recurring); b. Known or suspected cervical or uterine malignancy, including unresolved, abnormal Papanicolaou smears; c. Pregnancy; Relative a. Uterine abnormalities such as congenital anomalies and myomas distorting the uterine cavity; b. Hypermenorrhea; c. Dysmenorrhea.

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DISADVANTAGES OF IUD USE While mortality rates are lower, morbidity rates are generally higher with IUD use than with OC use. About 2 per 1000 IUD users (compared to 1 per 1000 OC users) require hospitalization for treatment of a method-related condition. This higher morbidity rate is reflective of a number of specific side effects and complications of IUD use, which are discussed in detail below. SIDE EFFECTS ASSOCIATED WITH IUD USE Pain and bleeding Pain and bleeding associated with IUD insertion and use cause more IUD removals than all other side effects combined. These two symptoms, commonly temporally associated, occur in a high percentage of women. They are usually more of a problem in the month following insertion, but decline over the first 3 months of use and do not remain a problem for the successful user. Careful patient education prior to insertion and good professional support during the adjustment phase can help reduce the incidence of early removal for these symptoms.

IUD use

Pain on insertion varies from slight cramping to severe pain, occasionally associated with a serious vasovagal response. If the patient is subject to syncopal attacks, intravenous atropine administered prior to insertion will avert such a reaction. Management of postinsertional pain depends on the degree of discomfort. Sometimes removal is required. Dysmenorrhea may be initiated or aggravated by IUD insertion. However, studies in England and Canada have shown that dysmenorrhea can be decreased by the use of the Progestasert ® device (Alza, Palo Alto, Cal., USA). Dyspareunia and pelvic pain are common during the initial postinsertion adjustment period. But if these symptoms occur after months or years of successful use, they may signal the onset of a pelvic infection. Hypermenorrhea usually results from IUD use. The amount of increase varies with the individual and the device. Inert plastic IUDs such as the Lippes Loop and Saf-T-Coil® (Schmid Laboratories, Inc., Little Falls, N. J., USA) may increase the amount of menstrual flow 50 to 100% or more. There is probably less increase with the Cu-7 and Progestasert® devices. Moreover, in some instances, the latter may even diminish menstrual flow. Intermenstrual bleeding and spotting frequently occur during the first 3 months of IUD use, but may occur at any time. Occasionally they occur after intercourse. In cultures where irregular bleeding is unacceptable, this problem can cause discontinuation. The occurrence of a foul-smelling, bloody discharge after a considerable period of asymptomatic use often signals the onset of a pelvic infection, especially if it is associated with pain. Expulsion Expulsion rates are related to the time of insertion (postabortion, postpartum, or interval), IUD configuration (e.g., M-devices have lower rates), and the skill of the inserter. Risk of expulsion is highest during the first month of use. Particularly during the early months of IUD use when there is a higher risk of expulsion, it is also important to recommend the concomitant use of a barrier method to reduce the number of accidental pregnancies. About 50% of the patients who undergo reinsertion retain the devices. Infection Recent medical literature indicates that the approximate risk of pelvic infection is three to five times higher for IUD users than for nonusers (3, 4, 11). Since pelvic infection may impair fertility, the patient should be informed (before insertion) about


this danger and its potential impact on her future fertility. (Nulliparous women, especially, should weigh this risk against the benefits of IUD use.) Furthermore, IUD users should be warned to report immediately any signs of pelvic infections, i.e., foul-smelling vaginal discharge, unexplained fever, pelvic and/or abdominal pain. Any change in the user's uterine bleeding pattern or suspicions of pregnancy should also be reported immediately. Current medical literature also documents the increased risk of septic abortion (possibly resulting in death) if a pregnancy occurs with the IUD in place. In such cases of continuing pregnancy, the risk of death from spontaneous septic abortion is estimated to be 50 times greater than that from a spontaneous abortion without an IUD present (2). Thus, the IUD should be removed immediately after pregnancy is diagnosed if the string is visible and the IUD can be easily withdrawn. If the IUD cannot be removed, the risk of septic abortion (and death) should be explained to the patient and pregnancy termination offered. If the patient elects to continue her pregnancy with the IUD in place, she should be warned to report immediately any flu-like symptoms, fever, abdominal pain, bleeding, or leakage of fluid. If a spontaneous septic abortion occurs, the uterus should be emptied immediately and antibiotic and supportive therapy initiated. Perforation The risk of perforation is very rare, averaging about 1 per 1000 insertions (9); but it may be higher when the inserter is inexperienced. The sequelae of perforation are serious because they usually require surgical removal of the device. Pregnancy Although the IUD is a highly effective contraceptive method, some pregnancies do occur. If the IUD is inserted by an experienced professional, the pregnancy rate for the device is about 3 per 100 women during the first year of use. For some devices, this rate declines in subsequent years to about 1-2 per 100 women per year. The risk of pregnancy can be reduced even further if a woman uses a barrier method such as foam during midcycle. Although the risk of pregnancy is small, the chance that any accidental pregnancy occurring with the IUD in situ will be an ectopic pregnancy is increased. In a study of 90 accidental pregnancies among women using IUDs, Vessey et al. found that the overall incidence of ectopic pregnancy was 8.9% (10). In another study (7), Tatum found that the incidence of ectopic pregnancy was significantly lower among women who had used IUDs 1 year or less than among those who had used IUDs for

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longer periods. Preliminary data also suggest that women who become pregnant after IUD removal may have higher than normal incidences of ectopic pregnancy. These two findings suggest an interference with tubal transport possibly caused by ascending genital infection. This hypothesis is also supported by data from pathology reports on tubal segments removed from IUD wearers who underwent tubal sterilization. Data also show that the ectopic pregnancy rate for IUD users with copper-bearing devices in situ is 2.5%, a significantly lower rate than that for inert devices. Among IUD users, the risk of abortion subsequent to accidental pregnancy is 50% when the device is left in place, but is reduced to 25% if the IUD is removed (9). In addition, the abortion may be complicated by sepsis. CONCLUSION All the benefits and risks of IUD use should be considered by the health care professional and the patient together before a device is inserted (5). Moreover, only when the risks and benefits of a particular IUD for a particular patient are weighed together can an appropriate choice be made.

REFERENCES 1. American College of Obstetricians and Gynecologists. The Intrauterine Device. Tech Bull No. 40, June 1976.

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2. Cates, W, Jr. Cry. H W, Rochat, R W & Tyler. C W: The intrauterine device and deaths from spontaneous abortion. N Engl J Med 295.1149, 1976. 3. Eschenbach, D A & Holmes, K K: Acute pelvic inflammatory disease: current concepts of pathogenesis, etiology, and management. Clin Obstet Gynecol 18(1):35, March 1975. 4. Faulkner, W L & Ory, H W: Intrauterine devices and acute pelvic inflammatory disease. JAMA 2^5:1851, 1976. 5. Intrauterine Device. Population Reports, Series B, No. 2, January 1975. 6. Smith, M R & Soderstrom, R: Salpingitis: a frequent response to intrauterine contraception. J Reprod Med 40:159, 1976. 7. Tatum, H: Contraception and sterilization practices and extrauterine pregnancy: a realistic perspective. Fértil Steril 2Í.-407, 1977. 8. Tietze, C, Bongaarts, J & Schearer, B: Mortality associated with the control of fertility. Fam Plann Perspect

The benefits and risks of IUD use.

Int J Gynaecol Obstet 15: 150-152, 1977 The Benefits and Risks of IUD Use Louise B. Tyrer Planned Parenthood Federation of America, Inc., New York, N...
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