The Intrauterine device (IUD) has a success rate of more than 99%. The device that contains progestin has a variety of medical applications and releases local hormones continuously. The method has many advantages, but it can also have some complications.
Takeaways:
- IUDs can cause a number of complications including both immediate and delayed side effects.
- Immediate complications can occur immediately after and during the device insertion. Most commonly, women experience vasovagal syndrome, vaginal blood, uterine pain, and cramps.
- The most common complaints of chronic side effects are changes in menstrual flow, pelvic discomfort, the displacement or expulsion from the device, as well as failure to protect against pregnancy.
- When evaluating symptoms, it is important to always consider the possibility of pregnancy and ectopic conception.
The most commonly used IUDs are T-shaped copper (Cu-IUD) and levonorgestrel-containing (LNG-IUS) devices. The two methods have similar contraceptive properties, but the LNG-IUS has an advantage due to its progestin. The LNG-IUD is used to manage abnormal uterine bleeding, and provides endometrial protective effects in patients receiving hormone replacement therapy.
What are the risks of IUD contraception
IUDs have a long-term effectiveness. LNGs can be used for 3 to 5 continuous years, whereas Cu-IUDs last up to 10 years. This long period of use raises the question: Is it risky to use an IUD during this time?
The placement and use of IUDs can carry a higher risk for some women, despite the wide safety window. Complications are more likely to occur in women who are younger, have uterine anomalies, or have a distorted uterine cavity. The length of the endometrial chamber and the position or size of the uterus are not linked with a high risk for complications.
IUD contraception: complications associated with it
Vasovagal Reaction
The vasovagal response is a group of symptoms that occur in response to the manipulation or insertion of the device. Syncope, nausea, bradycardia and hypotension are all symptoms of the vasovagal reaction. Women who have not given birth or women in their postmenopausal years may collapse and experience hypotension as a result of the cervical dilation. Misoprostol may be used for cervical ripening, even though it is not recommended as a routine treatment.
Uterine perforation
The uterus can be perforated. This is rare, but it could happen. IUD perforation is suspected to be linked with lactation. According to a report from six European countries that was published, women who were breastfeeding at the time the IUD was inserted had a sixfold higher risk of perforation than non-breastfeeding IUD users.
Vaginal bleeding
In 94% of cases, bleeding can occur immediately after the insertion. This is usually caused by minor traumas, and lasts four to five days. It is important to note that the bleeding after the procedure should not be more intense and prolonged than normal menstrual blood. These symptoms usually resolve on their own. If the condition is affecting your quality of life, you may want to consider taking nonsteroidal antiinflammatory drugs as a preventative measure.
IUD users should also be made aware of irregular vaginal bleeds for the first 3 to 6 months. This includes spotting, prolonged bleeding, and heavy bleeding. In the first three month after IUD placement, 15% of LNG IUS users and 71% Cu IUD users report increased bleeding. By six months, bleeding symptoms have decreased in 62% LNG-IUS users and 81% Cu-IUD. This difference could be explained by the progesterone in LNG-IUS.
Uterine cramping and pain
Women often report mild to medium discomfort or uterine pain after IUD placement. To relieve these symptoms, painkillers (NSAIDs), heating pads and heating pads can be used. Further, 32% of LNG IUS users and 63% Cu IUD users reported uterine cramping three months after IUD placement.
IUD misplacement or displacement
The IUD can be positioned in the cervical canal, or even rotated around its axis. Malposition is reported to occur at 10% of the time, but it is not known how common this is. IUDs that protrude through the uterine walls or are displaced into cervical canals should be removed if they cause symptoms.
Expulsion
The device may move downwards immediately after the IUD is removed. It can be replaced as soon as it is detected to ensure protection. Expulsion (falling from the uterine chamber) can occur later in 2-10% of IUD users. IUD expulsions are more likely to occur in women younger than 20 who have a large submucosal uterine myoma that distorts the uterine anatomy. They also tend to suffer from dysmenorrhea, painful menstrual periods, and heavy menstrual blood. IUDs inserted immediately after a second-trimester or postnatal abortion can be prone to expulsion because of the vaginal bleeding that follows. Unrecognized IUD expulsions can lead to unwanted pregnancies.
The device is lost
The bottom of the T-shaped device is attached with a string that remains outside the cervical opening and can be used to remove it when necessary. Loss of the IUD string can lead to displacement or accidental removal. A missing IUD can lead to pregnancy complications that are uncommon and uterine rupture.
If the IUD is not visible, it should be ruled out as a pregnancy. The emergency contraception should also be recommended, until the IUD is found in the uterine cavity. At this stage, its effectiveness as a contraceptive is still questionable. If the IUD cannot be seen by ultrasound, it should then be found using X-rays of the abdomen and the pelvis.
Feeling the String with a Partner
During sexual contact, the partner may feel the string that is used to manipulate the IUD. The string is usually trimmed to fit the individual case after insertion. The string can be further cut if the partner complains of discomfort.
Infections
Research has focused on the risk of developing pelvic inflammation disease (PID). The Contraceptive ‘CHOICE’ Project in the USA analyzed more than 9,000 women, and reported a 1% or lower PID risk among IUD users.
Pregnancy without preventing it
Unintentional pregnancy occurs in 0.6% of women using copper IUDs and 0.2% who use 19.5mg LNGIUSs.
Women aged 15-19 years have a 30-40% greater risk of failure than women aged 20-44. Another factor is a misplaced IUD or a history of IUD removal.
The risks to both mother and child are increased when an IUD is in place during pregnancy. Women are more susceptible to infections such as septic abortions and chorioamnionitis. IUDs are associated with miscarriage risks of 47-57%, but this can be reduced by 20-54% if removed during early pregnancy. IUDs can increase the risk of premature birth by five times in later pregnancy stages.
IUD removal is recommended for all women who want to continue their pregnancy. The IUD may be lost as the weeks progress. It is not recommended to remove the IUD in this situation.
Ectopic pregnancy
Cu-IUDs are responsible for 11-15% pregnancies, while LNG-IUS are responsible for 27-53%. These are conceived outside of the uterine cavity. When the endometrial cavity is not involved in the treatment of an ectopic pregnancy, it’s not necessary to remove or replace a normally located IUD.
Hormonal side-effects
Levonorgestrel, a synthetic progestin is the main ingredient in the LNG-IUS. The hormonal component can cause acne, headaches, weight changes, and hirsutism. LNG-IUs, contrary to popular belief, do not cause weight gain compared to Cu IUDs.
The success rate of intrauterine contraceptives is very high (more than 99%). Long-term use is generally considered to be safe. Side effects, such as abnormal bleeding, pelvic discomfort, and contraceptive failure, should also be acknowledged and addressed when they occur.
Resources
- EuropePMC. Committee Opinion No 672: Clinical Challenges of Long-Acting Reversible Contraceptive Methods.
- NIH. Association of Age and Parity With Intrauterine Device Expulsion.
- NIH. Length of the endometrial cavity and intrauterine contraceptive device expulsion.
- NIH. Association of Short-term Bleeding and Cramping Patterns with Long-Acting Reversible Contraceptive Method Satisfaction.
- OBSTETRICS&GYNECOLOGY. Malpositioned Intrauterine Contraceptive Devices.
- NIH. Positive Testing for Neisseria gonorrhoeae and Chlamydia trachomatis and the Risk of Pelvic Inflammatory Disease in IUD Users.
