Reed SD, Saltus CW, Getahun D, Schoendorf J, Armstrong MA, Peipert JF, Raine-Bennett TR, Ritchey ME, Ichikawa LE, Zhou X, Fassett MJ, Alabaster A, Xie F, Merchant M, Chiu VY, Shi JM, Frenz A-K, Im TM, Takhar HS, Lynen R, Asiimwe A, Anthony MS. Menorrhagia and risk of intrauterine device (IUD) expulsion and uterine perforation: results from the APEX IUD study. Presented at the Virtual 76th Scientific Congress of the American Society for Reproductive Medicine (ASRM); October 17, 2020. [abstract] Fertil Steril. 2020 Sep 1; 114(3 Suppl):e12. doi: 10.1016/j.fertnstert.2020.08.059

OBJECTIVE: IUDs are an effective form of contraception, and the most common levonorgestrel (LNG) IUD has an FDA indication for heavy menstrual bleeding. We assessed the risk of IUD expulsion and uterine perforation in women with and without a recent diagnosis of menorrhagia.

APEX IUD was a retrospective cohort study that used electronic health records from three Kaiser Permanente sites (Northern California, Southern California, Washington) and Regenstrief Institute (Indiana).

This study included 228,834 women aged ≤50 years with an IUD inserted from 2001–2018 without a delivery in the prior 52 weeks (including nulliparous women). Diagnosis of menorrhagia was identified via ICD code within 12 months before IUD insertion. Expulsion included complete and partial (IUD in cervical canal). Perforation was defined as complete (in pelvis or abdomen) or partial (embedded in myometrium). Crude incidence rates, hazard ratios adjusted for confounding with propensity scores via Cox regression, and 95% confidence intervals (CI) were estimated.

Expulsions occurred more often among women with a menorrhagia diagnosis. Among 31,600 women with menorrhagia, 2% of IUD insertions were copper; and among 197,234 women without menorrhagia, 20% were copper. The expulsion rate among those without menorrhagia was lower for those with LNG versus copper IUDs. For those with menorrhagia, expulsion was lower in the few with copper IUDs. Perforation rates were higher among women with menorrhagia but low in all groups. After adjusting for confounding, women with menorrhagia had a 2.84-fold increased risk of expulsion and a 1.53-fold increased risk of perforation over women without.

CONCLUSIONS: Increased rates of expulsion and perforation with menorrhagia may be due to physiological differences related to menorrhagia including adenomyosis and uterine fibroids. Providers should be aware of these risks for patient counseling and exercise caution at the time of insertion. We recommend informing women regarding the higher risk of IUD expulsion and the importance of recognizing expulsion in prevention of unwanted pregnancy.

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