Year: 2015
Type: dissertation
Study design: Observational Study
Abstract: The proportion of nulligravid and nulliparous women is increasing as women delay childbirth in developed countries. Simultaneously, contraceptive failure, unintended pregnancies and abortions, especially in women below the common childbearing age, are a global problem. By promoting intrauterine devices (IUDs) and subdermal implants, referred to as long-acting reversible contraceptives (LARCs), among these women, contraceptive failure caused by non-compliance of the user can be minimized, in addition to providing easy and efficient long-term contraception. However, the risk of difficulties at IUD insertion in nulligravid/nulliparous women, as well as small uterine size, have both been considered as barriers limiting the use of intrauterine contraception (IUC) in these women. The present studies were designed to study the barriers to IUC in nulligravid and nulliparous women. To compare both types of IUC available, we used the levonorgestrel-releasing intrauterine system (LNG-IUS) and the copper-releasing NovaT (TCu380Ag), with identical frames measuring 32 x 32 mm. To exclude any effect of prior pregnancy on the uterine cavity or the cervix, only nulligravid women were included. Difficulties at insertion, menstrual diaries kept after insertion (months 1 3) and at the end of the study (months 10 12) as well as adverse events were compared against uterine cavity measurements and pre-insertion menstrual characteristics reported by the women. In addition, as uterine perforation is mainly seen as a complication related to insertion, we retrospectively analysed women treated for this rare complication between 1996 and 2009 in our hospital district area. We gave 165 nulligravid women requesting their first IUD a free choice between the two IUDs after contraceptive counselling. The majority, 113 women (68.5%), chose the LNG-IUS and 52 women (31.5%) chose the copper IUD. Insertion was easy in 89% of the women. The women were satisfied, with only 17/135 women (12.6%) available for follow-up discontinuing because of adverse events. The reported numbers of days of bleeding and pain were similar to that in earlier reports on parous women. Severe pain at insertion was reported by 56.5% of the women and severe dysmenorrhoea the only factor predicting severe pain (OR 7.9, 95% CI 2.5 24.9, p less than 0.001). Dysmenorrhoea was also related to more pain during the first months with both devices. Baseline spontaneous bleeding predicted bleeding with the LNG-IUS, but not with the copper IUD. Among women using the LNG-IUS, scanty menstrual bleeding (OR 8.2, 95% CI 1.4 48.2, p=0.02) and smoking (OR 8.2, 95% CI 1.8 38.6, p=0.007) predicted amenorrhoea at one year. Uterine measurements, particularly fundal cavity width, were small in comparison to the devices in a majority of the women. The odds of a difficult or failed insertion increased with shorter uterine length and a steeper flexion angle, but the great majority of insertions, even in small and more flexed uteri, were uneventful. Cervical tightness was the main reason for problems in cases of difficult insertion. No uterine threshold measurements predicting difficulties were found. Small uterine measurements were associated with both less bleeding and less pain among LNG-IUS users. Women with the widest fundal widths reported significantly more pain at the end of the one-year follow-up period compared with those with smaller widths. Uterine size did not affect bleeding in connection with the copper IUD, but there was a slight tendency towards more pain during long-term use among women with smaller uterine cavity measurements, although size groups were small with this device. Uterine size did not predict adverse events. We found 75 cases of surgically treated uterine perforation during the 15 year long study period. The incidence of perforation was low, 0.4/1000 insertions, and similar with both types of IUC. Postpartum insertion, earlier presented as the main risk factor of uterine perforation, was also common in this population (64%). The majority of cases, 71%, presented with complaints of abnormal bleeding or pain, but 29% were asymptomatic and diagnosed in connection with missing threads or pregnancy. Pregnancy was more common with a misplaced copper IUD, 33% vs. 7% with a misplaced LNG-IUS (p=0.009). We found no severe complications or intra-abdominal adhesions caused by the misplaced devices. Adhesions were local and more common in copper IUD users (58% vs. 20%, p=0.002). In conclusion, nulligravid women are satisfied users of modern IUC, with continuation rates and bleeding and pain profiles similar to those in parous women. Small uterine cavity measurements are not a barrier to IUC and pre-insertion ultrasonographic evaluation of uterine cavity size is unnecessary. As dysmenorrhoea predicts both severe insertion pain and pain during the first months of IUD use, analgesia and counselling for these women should be highlighted. Although rare, the risk of uterine perforation is increased during the postpartum period, probably reflecting uterine involution as the main reason for this complication. Neither symptoms nor surgical findings are severe in connection with current devices.
Source: Työväentutkimus Vuosikirja
Author: Janina Kaislasuo
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W1549226576