The safety of intrauterine devices among young women: a systematic review

doi:10.1016/j.contraception.2016.10.006

Contraception

Volume 95, Issue 1, January 2017, Pages 17-39

https://doi.org/10.1016/j.contraception.2016.10.006 Get rights and content

Abstract

Objective

The objective was to determine the association between use of intrauterine devices (IUDs) by young women and risk of adverse outcomes.

Methods

We searched Pubmed, CINAHL, Embase, Popline and the Cochrane Library for articles from inception of database through December 2015. For outcomes specific to IUD use (IUD expulsion and perforation), we examined effect measures for IUD users generally aged 25 years or younger compared with older IUD users. For outcomes of pregnancy, infection, pelvic inflammatory disease (PID), and heavy bleeding or anemia, we examined young IUD users compared with young users of other contraceptive methods or no method.

Results

We identified 3169 articles of which 16 articles from 14 studies met our inclusion criteria. Six studies (Level II-2, good to poor) reported increased risk of expulsion among younger age groups compared with older age groups using copper-bearing (Cu-) IUDs. Two studies (Level II-2, fair) examined risks of expulsion among younger compared with older women using levonorgestrel-releasing (LNG-) IUDs; one reported no difference in expulsion, while the other reported increased odds for younger women. Four studies (Level II-2, good to poor) examined risk of expulsion among Cu- and LNG-IUD users combined and reported no significant differences between younger and older women. For perforation, four studies (Level II-2, fair to poor) found very low perforation rates (range, 0%-0.1%), with no significant differences between younger and older women. Pregnancies were generally rare among young IUD users in nine studies (Level I to II-2, fair to poor), and no differences were reported for young IUD users compared with young combined oral contraceptive (COC) or etonogestrel (ENG) implant users. PID was rare among young IUD users; one study reported no cases among COC or IUD users, and one reported no difference in PID among LNG-IUD users compared with ENG implant users from nationwide insurance claims data (Level I to II-2, fair). One study reported decreased odds of bleeding with LNG-IUD compared with COC use among young women, while one study of young women reported decreased odds of removal for bleeding with LNG-IUD compared with ENG implant (Level I to II-2, fair).

Conclusion

Overall evidence suggests that the risk of adverse outcomes related to pregnancy, perforation, infection, heavy bleeding or removals for bleeding among young IUD users is low and may not be clinically meaningful. However, the risk of expulsion, especially for Cu-IUDs, is higher for younger women compared with older women. If IUD expulsion occurs, a young woman is exposed to an increased risk of unintended pregnancy if replacement contraception is not initiated. IUDs are safe for young women and provide highly effective reversible contraception.

Introduction

While the intrauterine device (IUD) is one of the most effective contraceptive methods, some health care providers have concerns about its use among young women [1]. Younger women are at higher risk of sexually transmitted infections (STIs) [2]. There remains concern about whether IUD insertion or use affects the risk of a lower genital tract infection ascending to the upper genital tract, leading to pelvic inflammatory disease (PID) and subsequent infertility. However, despite concerns, evidence shows that the risk of PID is low among IUD users and has not shown that IUDs cause infertility [3], [4], [5]. Additionally, women of any age who choose to use an IUD for contraception are potentially at risk for adverse events such as expulsion and perforation, changes in bleeding patterns related to IUD use and IUD failure [6]. There is concern that these risks may be greater in younger compared with older IUD users.

We originally conducted this systematic review to prepare for an Expert Working Group meeting to update the World Health Organization (WHO) Medical Eligibility Criteria for Contraceptive Use (MEC) in March 2014. The resulting fifth edition of the WHO MEC assigns a category 2 for use of copper-bearing (Cu-) and levonorgestrel-releasing (LNG-) IUDs among females from menarche until age less than 20 years [7]. A category 2 is defined as “a condition where the advantages of using the method generally outweigh the theoretical or proven risks.” For women 20 years and older, IUD use is a category 1, with no restriction on use. The objective of this review is to examine two key questions: (a) “Are young women with a Cu- or LNG-IUD at increased risk of expulsion or perforation compared with older women with a Cu- or LNG-IUD?” (b) “Are young women with a Cu- or LNG-IUD at increased risk of serious adverse events (specifically pregnancy, infection, infertility or delayed return to fertility, bleeding, and removals or discontinuations due to any of these outcomes) compared with either young women using other methods of contraception or older women using Cu- or LNG-IUDs?”

Section snippets

Materials and methods

We conducted this review according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines [8]. We searched the PubMed, Embase, Popline and CINAHL databases for all peer-reviewed articles in any language published from database inception through December 2015 using the search terms found in Appendix A. We also searched the Cochrane Library for relevant systematic reviews using the terms IUD and intrauterine. To identify additional relevant articles, we

Results

The search strategy yielded 3169 articles of which 16 met our inclusion criteria [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25]. Twelve studies answered our first key question and compared risk of expulsion or perforation among younger versus older women with a Cu- or LNG-IUD [10], [11], [12], [13], [16], [17], [19], [20], [21], [22], [24], [25]; 11 studies reported expulsions (Table 1), and 4 reported perforations (Table 2). Eleven studies

Discussion

The 16 studies included in this review provide direct and indirect evidence on whether young women who use IUDs are at increased risk of adverse events compared with similar-aged women using other contraceptive methods or compared with older women using IUDs.

For the outcome of expulsion, we examined 11 studies that compared younger women to older women using 4 different kinds of IUDs (Multiload 250, NovaT, LNG, TCu380A). All studies were of Level II-2 evidence, with three studies of good

Conclusion

Overall, this review does not support an association between the adverse outcomes of pregnancy, perforation, infection or bleeding and IUD use by young women aged less than or equal to 25 years. However, evidence suggests that young women are at increased risk for expulsion of Cu-IUDs and may be at increased risk for LNG-IUD expulsion compared with older women, although evidence is mixed and limited. While IUD expulsion is not a safety issue, these events may expose young women to an increased

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Cited by (108)

Clinical Assessment of 3 Intrauterine Devices in Adolescent Girls: A Randomized Clinical Trial
2024, Journal of Pediatric and Adolescent Gynecology
To assess clinical performance, bleeding pattern, dysmenorrhea, and satisfaction up to 1 year after placement of 3 types of intrauterine devices (IUDs) (TCu380A, levonorgestrel 52 mg, and levonorgestrel 19.5 mg) in adolescents
The study was a randomized trial with 318 adolescents allocated to the 3 IUDs. We assessed reasons for removal, continuation, menstrual patterns, dysmenorrhea, and satisfaction.
Participants aged (mean ± SD) 17.9 ± 1.4 years, with 80.8% being nulligravidae. After 1 year, 265 (83.3%) continued using the IUD; however, the continuation rate of TCu380A (75.4 ± 4.2) was lower than that of both the levonorgestrel 52-mg (88.6 ± 3.1) and 19.5-mg IUDs (86.8 ± 3.3), and bleeding/pain and expulsion were the main reasons for removal of the TCu380A IUD. The duration of menstruation was longer among the TCu380A IUD users (6.0 ± 2.0 days) than those using the levonorgestrel 52 mg (2.5 ± 3.9) and 19.5 mg (3.2 ± 3.2) devices, P < .001. Amenorrhea was reported by 49.5% and 37.8% users of the levonorgestrel 52-mg and 19.5-mg devices, respectively, P < .001. Dysmenorrhea was reported in 68.5% of all participants at the baseline; this was 67.9% of the TCu380A group and 33.3% and 36.0% of the levonorgestrel 52-mg and 19.5-mg IUD groups, respectively, P < .001. Satisfaction ranged from 80.7% in the TCu380A group to 97.8% in the levonorgestrel 52-mg group (P = .03).
The 3 IUDs are suitable for adolescents, with high contraceptive efficacies and rates of continuation within 1 year of use and high degrees of satisfaction. Users of the hormonal IUDs reported lower expulsion rates, more favorable menstrual patterns, and less dysmenorrhea compared with the TCu380A IUD.
Uptake, discontinuation, and continuation rate of long-acting contraceptive methods when offered at no cost in Campinas, Brazil
2024, Contraception
This study aimed to compare the uptake, reasons for discontinuation, continuation, and satisfaction of long-acting contraceptive methods (LARC) when offered at no cost in Campinas, Brazil.
This was a prospective cohort study conducted at University of Campinas, Campinas, São Paulo, Brazil, including women aged 18 to 48 years, who adopted one of three methods. Participants underwent telephone follow-up every 3 months for up to 24 months after insertion. Satisfaction was assessed at the end of 2 years of use through the Likert scale.
We invited 1222 women, and among the 971 women who volunteered to participate in follow-up, 414 (42.6%) chose the levonorgestrel 52-mg intrauterine device (IUD), 358 (36.9%) chose the etonogestrel (ENG) implant, and 199 (20.5%) chose the TCu380A IUD. Discontinuation due to bothersome bleeding was higher among users of the ENG implant (10/358; 2.4%) and the TCu380A IUD (32/199; 8.9%), and expulsion was higher for the TCu380A IUD (30/199; 15.1%). Women continued at 24 months were 340/414 (82.1%), 270/358 (75.4%), and 119/199 (59.8%) among users of the levonorgestrel 52-mg IUD, ENG implant, and TCu380A IUD, respectively. The users of the levonorgestrel 52-mg IUD (301/339, 88.8%), the ENG-implant (222/270, 82.2%), and the TCu380A IUD (105/119, 88.2%) were satisfied or very satisfied by 24 months of follow-up.
The three LARC methods had great uptake, high continuation, and discontinuation due to bothersome bleeding was higher among users of the ENG implant and the TCu380A IUD, and expulsion was higher for the TCu380A IUD compared to the 52-mg levonorgestrel IUD. Most of the participants reported being very satisfied.
When the LARC methods were offered at no cost in a Brazilian public clinic the uptake, satisfaction and continuation were high by 24 months after device placement, and high level of satisfaction was reported by most of the participants.
Continuation rates of hormonal intrauterine devices in adolescents and young adults when placed for contraceptive and non-contraceptive indications
2024, Contraception
This study aimed to estimate and compare continuation rates of hormonal intrauterine devices (IUDs) when placed for contraceptive or menstrual management indications in adolescents and young adults.
We conducted a secondary analysis of a prospectively collected database of all hormonal IUD insertions from January 1, 2017 through December 31, 2020, with at least 1-year follow-up, across four Adolescent Medicine practices. IUD insertions without known indication were excluded.
A total of 936 IUD insertions were attempted, 45% for contraception only, 18% for menstrual management only, and 37% for both indications. Insertion was successful in 868 (93%) attempts, and success did not differ by indication (p = 0.74). The mean age at insertion was 18.9 years (SD = 2.4 years), with no difference by indication. Of the completed insertions, 650 (75%) had at least one follow-up during the data analysis period. Excluding those without follow-up, the overall continuation rates were 77% at 1 year, 66% at 2 years, and 54% at 3 years. While continuation rates did not differ by indication at 1 year, at 3 years, continuation was highest among those who sought the device for menstrual management only (contraception = 53%, menstrual = 57%, both = 53%, p < 0.01) Malposition was rare (4.0%), as was device expulsion (2.5%), and these did not differ by indication.
IUD continuation rates were high among adolescents and young adults and did not significantly differ when placed for contraceptive or non-contraceptive indication in the first year of use.
Adolescents and young adults may seek the hormonal IUD for contraception and/or menstrual management. Our study found that IUD continuation rates were high at 1 year regardless of the indication for utilization.
Adolescent Long-Acting Reversible Contraceptive Use, Same-Day Insertions, and Pregnancies Following a Quality Initiative
2023, Journal of Adolescent Health
To compare long-acting reversible contraceptive (LARC) use, pregnancy rate, and same-day LARC insertion among adolescents before and after a Kaiser Permanente Northern California quality initiative.
A 2016 Kaiser Permanente Northern California initiative aimed to increase adolescent LARC access. Interventions included patient education resources, electronic protocols, and insertion training for pediatric, family medicine, and gynecology providers. This study examined a retrospective cohort of adolescents aged 15–18 years who used contraception before (2014–2015, n = 30,094) and after (2017-2018, n = 28,710) implementation. Contraceptive types included LARC (intrauterine device or implant), injectable, and contraceptive pill, patch, or ring. We reviewed a random sample of LARC users (n = 726) to identify same-day insertions. Multivariable analysis examined the effects of year of provision, age, race, ethnicity, LARC type, and counseling clinic.
Preintervention, 12.1% of adolescents used LARC, 13.6% used injectable, and 74.3% used pill, patch, or ring. Postintervention, the proportions were 23.0%, 11.6%, and 65.4%, respectively, with the odds of LARC provision of 2.57 (95% confidence interval (CI) 2.44–2.72). The pregnancy rate decreased from 2.2% to 1.4% (p < .0001). Higher rates of pregnancy were observed with injectable contraception and in Black and Hispanic adolescents. Same-day LARC insertion rate was 25.1% without significant variation post intervention (OR 1.44, 95% confidence interval 0.93–2.23). Contraceptive counseling in gynecology clinics increased the odds of same-day provision, while non-Hispanic Black race lowered odds.
A multifaceted quality intervention was associated with a 90% increase in LARC use and a 36% decrease in teenage pregnancy rate. Future directions may include promoting same-day insertions, targeting interventions in pediatric clinics, and focusing on racial equity.
Migrated intrauterine device: Case series report
2023, International Journal of Surgery Case Reports
Implantation of an intrauterine device (IUD) is a common method of contraception in Saudi Arabia. Although rare, IUD migration and colon perforation have been reported. The current report presented three cases of IUD migration into the colon and recto-uterine pouch.
The study included a series of three cases of migrated IUDs. The first case was a 25-year-old female, Gravida 2, Para 2 + 0, at 28 week-gestation, who presented with abdominal pain with a history of IUD placement that had not been removed or imaged before. The patient submitted to the caesarian section (CS), where IUD was found in the sigmoid colon. Elective laparoscopic removal of IUD with resection and primary repair of sigmoid colon was done later. The second case was a 37-year-old female, Gravida 1, Para 1 + 0, non-pregnant hypothyroidism, and a history of IUD placement. The patient got pregnant and gave birth through CS. She was then presented with abdominal pain and requested the removal of the IUD. On colonoscopy, IUD was seen in the pouch of Douglas with no evidence of a fistulous tract. IUD was removed through laparoscopy. The third case was a 47-year-old female, Gravida 14, Para 14 + 0, with a history of previous CS presented with a missing IUD that had been inserted 20 years ago after she had five pregnancies and subsequent deliveries. On colonoscopy, IUD was embedded on the wall of the transverse colon, and through abdominal surgery, IUD was removed by cutting through the colon and primary repair was done.
the presentation of IUD migration cases was foundto vary according to the site of migration and type of IUD.however the cases are usually present with abdominal pain. An abdominal pelvic imaging with CT in these patients are essential in diagnosis.
Retrival of migrating IUDs may be done through colonoscopy, laparoscopy, and in some cases with adhesion laparotomy is the solution.
Abdominal and pelvic CT scan are very important in the diagnosis and the localization of IUD. Elective colonoscopy and laparoscopy are successful management approaches for these cases.
Pain and ease of insertion of three different intrauterine devices in Brazilian adolescents: A participant-blinded randomized trial
2023, Contraception
To compare pain and ease of insertion of the copper 380 mm², levonorgestrel 52 mg, and levonorgestrel 19.5-mg intrauterine devices (IUDs) in Brazilian adolescents.
We conducted a participant-blinded randomized trial at two clinics in Brazil. We enrolled 318 adolescents<19 years old in a 1:1:1 ratio from November 2021 to February 2022. We informed the adolescents about the IUD type inserted after they evaluated the pain associated with the IUD insertion using a Visual Analogue Scale and immediately after that the healthcare provider who placed the IUD evaluated the ease of the procedure.
The VAS pain level was significantly higher after the levonorgestrel 52-mg IUD placement, median and [interquartile range, IQ] 8.0 [4.0] than the copper 380-mm² IUD 7.0 [4.0], and the levonorgestrel 19.5-mg IUD 7.0 [6.0] (p = 0.001). The placement was easier after the copper 380-mm² IUD (87/106, 82.1%) and the levonorgestrel 19.5-mg IUD (91/106, 85.8%) when compared with the levonorgestrel 52-mg IUD (75/105, 70.7%). After multiple logistic regression analyses, the higher VAS pain scores were associated with the levonorgestrel 52-mg IUD (OR = 2.90), low number of pregnancies (OR –0.48), and with a history of dysmenorrhea (OR = 2.67).
The placement of the copper 380-mm² IUD and the levonorgestrel 19.5-mg IUD was associated with lower pain according to the adolescent and was easier according to the provider when compared with the levonorgestrel 52-mg IUD. However, the small observed differences may not be clinically relevant.
We found that the three types of IUDs were generally easy to place; however, mean pain scores were high during insertions. Our findings of high pain scores reinforce the need for interventions to reduce pain for adolescent IUD insertion.

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^☆: The authors have no financial disclosures or conflicts of interest to disclose.

^☆☆: Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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Review articleThe safety of intrauterine devices among young women: a systematic review☆,☆☆

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

J Pediatr Adolesc Gynecol

Contraception

Lancet

Am J Prev Med

J Pediatr Adolesc Gynecol

Contraception

Am J Obstet Gynecol

Am J Obstet Gynecol

Contraception

Int J Gynaecol Obstet

Contraception

Am J Obstet Gynecol

Contraception

Contraception

Review article
The safety of intrauterine devices among young women: a systematic review☆,☆☆