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IUDs and bleeding changes

The fact that copper-containing intrauterine devices (Cu-IUDs) can increase bleeding and discontinuation rates compared to levonorgestrel-releasing IUDs (LNG-IUDs) does not mean clinicians should steer patients toward the latter, according to a review published in BMC Women’s Health. Due to high satisfaction rates with both devices, authors recommend letting patients choose based on their needs and preferences.

“Intrauterine contraception is highly effective, and generally has higher satisfaction and continuation than many other contraceptive methods,” study co-author Stephanie Teal, MD, MPH, told Contemporary OB/GYN®. “However, both copper and progestin IUDs cause bleeding changes that can be unacceptable to users and can be an important reason why IUD users decide to stop using that method.” She is Obstetrician/Gynecologist-in-Chiefand Chair of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, and Arthur H. Bill Professor and Chair, Obstetrics and Gynecology and Reproductive Biology, Case Western Reserve University School of Medicine, both in Cleveland, Ohio.

Women who discontinue IUDs early typically switch to less effective contraception methods such as abstinence or withdrawal. To better understand the impact of IUD-associated bleeding changes on discontinuation rates, authors systematically reviewed 4540 citations; 41 studies met inclusion criteria.

In 31 prospective studies involving LNG-IUDs, most women consistently experienced reduced bleeding, with some reporting amenorrhea; rates of both increased over time.1 Conversely, in Cu-IUD studies that reported bleeding patterns (n = 3), 35% to 43% of women reported heavy and/or prolonged bleeding.2,3

Among 10 studies that reported LNG-IUD discontinuation rates due to bleeding, several reflected rates of 2% or less at intervals ranging from 3 months to 7 or more years.4-8 Rates were slightly higher in most studies comparing LNG-IUD doses9,10 or LNG-IUDs versus implants.11-13

Among 8 studies reporting discontinuation due to bleeding with Cu-IUDs, rates ranged from less than 5%14 up to 22%.15 In most of these studies, more than 1/3 of women who had Cu-IUDs removed did so due to bleeding and/or pain.

“Women using copper IUDs were more likely to have heavier periods after the IUD was placed, especially in the first year, and were more likely to report that they wanted their IUD removed because of heavy bleeding problems,” Teal said. “However, it is important to note that satisfaction with both types of IUDs was high. So healthcare providers should listen to their patients’ preferences and concerns and not make assumptions about which type of IUD might be better for any given patient.”

Authors found the fact that bleeding-related discontinuation usually occurs, with either LNG-IUDs or Cu-IUDs, within the first year reassuring. “Most of the bothersome bleeding side effects show up early enough that women who are having a pattern that doesn’t work for them can let their clinicians know, and consider treating the bleeding or making a change,” said Teal.

Conversely, women who experience an acceptable bleeding pattern after the first year of IUD use likely will remain happy with that bleeding pattern. “And for a long-acting method like IUDs, which can be used for 8 to 10 years,” Teal added, “that is good news.”

REFERENCES:

1. Costescu D, Chawla R, Hughes R, Teal S, Merz M. Discontinuation rates of intrauterine contraception due to unfavourable bleeding: a systematic review. BMC Womens Health. 2022;22(1):82. Published 2022 Mar 21. doi:10.1186/s12905-022-01657-6

2. Yaron M, Viviano M, Guillot C, Aharon A, Shkolnik K. Real-world experience with the IUB Ballerine MIDI copper IUD: an observational study in the French-speaking region of Switzerland. Eur J Contracept Reprod Health Care. 2019;24(4):288-293. doi:10.1080/13625187.2019.1618447

3. Bateson D, Harvey C, Trinh L, Stewart M, Black KI. User characteristics, experiences and continuation rates of copper intrauterine device use in a cohort of Australian women. Aust N Z J Obstet Gynaecol. 2016;56(6):655-661. doi:10.1111/ajo.12534

4. Gemzell-Danielsson K, Inki P, Boubli L, O'Flynn M, Kunz M, Heikinheimo O. Bleeding pattern and safety of consecutive use of the levonorgestrel-releasing intrauterine system (LNG-IUS)—a multicentre prospective study. Hum Reprod. 2010;25(2):354-359. doi:10.1093/humrep/dep426

5. Shimoni N, Choudhury T, Goldman AR, Frondelli M, Chen PH. Bleeding and spotting with the levonorgestrel 13.5 mg intrauterine system: the impact of insertion timing. Contraception. 2019;99(6):340-344. doi:10.1016/j.contraception.2019.02.004

6. Cristobal I, Lete LI, Viuda E, Perulero N, Arbat A, Canals I. One year quality of life measured with SEC-QoL in levonorgestrel 52 mg IUS users. Contraception. 2016;93(4):367-371. doi:10.1016/j.contraception.2015.12.014

7. Darney PD, Stuart GS, Thomas MA, Cwiak C, Olariu A, Creinin MD. Amenorrhea rates and predictors during 1 year of levonorgestrel 52 mg intrauterine system use. Contraception. 2018;97(3):210-214. doi:10.1016/j.contraception.2017.10.005

8. Armitage CM, Mitchell C, Wigan C, Smith DA. Uptake and continuation rates of the intrauterine system in a university student general practice population in the UK. J Fam Plann Reprod Health Care. 2013;39(3):186-189. doi:10.1136/jfprhc-2012-100392

9. Gemzell-Danielsson K, Apter D, Hauck B, et al. The effect of age, parity, and body mass index on the efficacy, safety, placement, and user satisfaction associated with two low-dose levonorgestrel intrauterine contraceptive systems: subgroup analyses of data from a phase III trial. PLoS One. 2015;10(9):e0135309. Published 2015 Sep 17. doi:10.1371/journal.pone.0135309

10. Nelson A, Apter D, Hauck B, et al. Two low-dose levonorgestrel intrauterine contraceptive systems: a randomized controlled trial. Obstet Gynecol. 2013;122(6):1205-1213. doi:10.1097/AOG.0000000000000019

11. Apter D, Briggs P, Tuppurainen M, et al. A 12-month multicenter, randomized study comparing the levonorgestrel intrauterine system with the etonogestrel subdermal implant. Fertil Steril. 2016;106(1):151-157.e5. doi:10.1016/j.fertnstert.2016.02.036

12. Short M, Dallay D, Omokanye S, Stauch K, Inki P. Acceptability of long-acting, progestin-only contraception in Europe: a two-year prospective, non-interventional study. Eur J Contracept Reprod Health Care. 2014;19(1):29-38. doi:10.3109/13625187.2013.862230

13. Short M, Dallay D, Omokanye S, Hanisch JU, Inki P. Acceptability of the levonorgestrel releasing-intrauterine system and etonogestrel implant: one-year results of an observational study. Eur J Contracept Reprod Health Care. 2012;17(1):79-88. doi:10.3109/13625187.2011.636088

14. Jagroep SR, Pichardo MS, Arribas L, Heredia G, Coccio E, Palermo TM. A retrospective evaluation of the intrauterine device in a patient population in Buenos Aires, Argentina. J Fam Plann Reprod Health Care. 2016;42(2):88-92. doi:10.1136/jfprhc-2014-101153

15. Flamant A, Ouldamer L, Body G, Trignol-Viguier N. Rates of continuation and satisfaction of immediate intrauterine device insertion following first- or second-trimester surgical abortion: a French prospective cohort study. Eur J Obstet Gynecol Reprod Biol. 2013;169(2):268-274. doi:10.1016/j.ejogrb.2013.04.006

DISCLOSURES:

Teal has received research funding from Merck & Co, Sebela, Medicines360, and Bayer Healthcare, and has served on scientific advisory boards for Organon and Merck & Co.