Intrauterine contraceptive devices (IUCDs) were first used by caravan drivers who used intrauterine stones to prevent pregnancies in their camels during long journeys 1. IUCD is the most widely used contraceptive method in the world. In 1995, it was reported that IUCDs were being used by more than 100 million women worldwide and it was considered the second most reliable method of contraception after oral hormonal contraceptives 2. The contraceptive action of all IUCDs mainly takes place in the uterine cavity. Ovulation is not affected, and the IUCD is not an abortifacient 3. It acts by initiating a sterile inflammatory reaction in the endometrial cavity, which interferes with sperm function so that fertilization is less likely to occur 4. Irregular uterine bleeding due to IUCDs is one of the main problems faced by women using this method of contraception. Following the insertion of a copper IUCD, menstrual blood loss increases by about 55% and continues for the duration of IUCD use. In the first year after insertion of IUCDs, 5–15% of women have their IUCDs removed because of bleeding 5. Abnormal uterine bleeding secondary to IUCD insertion is called iatrogenic dysfunctional uterine bleeding 6. The bleeding associated with IUCD use may occur either as heavy and/or prolonged menstruation (menorrhagia) or in the form of intermenstrual bleeding and spotting (metrorrhagia).
Imaging, specifically sonography, has a crucial role in the evaluation and management of IUCD-associated complications, including a low position 7. Three-dimensional (3D) ultrasound provides useful information on the location of the IUCD after insertion. A 3D ultrasound is more accurate than a 2D ultrasound in the identification and location of IUCDs. It can accurately define the position of the IUCD and detect any displacement 8. This study aimed to assess the relationship between the position of the IUCD inside the uterus and abnormal uterine bleeding using 3D ultrasound.
Materials and methods
A total of 200 patients selected from among those attending Kasr-El-Aini and National Research Centre gynecology outpatient clinics were enrolled in this study. Informed consent was obtained from all participants. The ethical committee of Cairo University gave its approval for the study. All patients were copper T 380 IUCD users. All the patients included in this study were between 20 and 40 years of age and multipara, and the IUCD had been inserted within the last 3 years. The patients were excluded from the study if they had any of the following conditions: associated uterine, cervical, or adnexal pathology; associated pelvic infection; generalized bleeding disorders; and medical disorders increasing bleeding tendency, for example, liver disease. Patients on medications causing coagulation defects were also excluded from this study.
The patients were then divided into two groups according to their menstrual history. Group A included 100 patients (study group) who complained of menstrual disturbances after insertion of the Cu-T380 IUCD. According to the menstrual history of the patients, this group was further subdivided into two subgroups: group A1 (68 patients), comprising women who complained of menorrhagia, and group A2 (32 patients), comprising women who complained of metrorrhagia. Group B represented the control group and it included 100 patients without any form of menstrual disturbances following IUCD insertion. All women were subjected to a detailed clinical history taking with special consideration to age, parity, duration of IUCD use, timing of insertion of the IUCD, and history of use of other contraceptive methods before insertion of the IUCD. Menstrual history before and after insertion of the IUCD was taken, including duration and amount of menstrual flow, regularity and length of the cycle, intermenstrual bleeding or spotting, contact bleeding, and any associated symptoms or complaints. In addition, history of any medications, blood diseases, or any medical disorders was considered. General, abdominal, pelvic, and speculum examinations were carried out to exclude other general or local causes of bleeding and to visualize the threads of the IUCD.
A 3D transvaginal ultrasound using the Medison Accuvix-XQ live 3D/4D ultrasound scanner (Accuvix-XQ, Medison, Korea) was taken after instructing the patients to empty their bladders. The IUCD was detected by its highly echogenic linear structure, with a much greater echogenicity than that of the normal endometrium, which is characteristic of an IUCD. Provided the Cu-T380 IUCD was placed correctly in the cavity, the device was visualized sonographically in the longitudinal section as a hyperechogenic stripe lying in the midline of the endometrial canal, equidistant from the uterine margins. In the transverse section, the Cu-T380 was observed as a hyperechogenic point in the middle of the corpus; in the fundal area, the arms of the device could be seen as a hyperechogenic horizontal line. In the frontal view all parts of the IUCD, that is, the shaft and the arms, could be visualized.
After identification of the IUCD within the uterine cavity, two measurements were taken: first, the distance from the top of the vertical arm of the IUCD to the fundus including the endometrium and the myometrium (IUCD-FD), and second, the distance from the top of the vertical arm of the IUCD to the top of the uterine cavity, that is, the inner endometrium (IUCD-ED). For all patients, the uterine size and endometrial thickness were measured. Presence of any associated uterine or adnexal lesions was detected. The patients were examined postmenstrually in order to properly measure the IUCD displacement distance, as the IUCD position in the uterine cavity could be influenced by the growth and thinning of the endometrium. For group A patients, after obtaining verbal consent, the IUCD was removed and they were followed up 1 month later to observe for symptomatic relief.
Data were statistically described in terms of range, mean±SD, frequencies (number of cases), and relative frequencies (percentages) when appropriate. Comparison of quantitative variables between the study groups was made using the Student t-test for independent samples. For comparing categorical data, the χ 2-test was used. The exact test was used instead when the expected frequency was less than 5. A P-value less than 0.05 was considered statistically significant. All statistical calculations were performed using computer programs Microsoft Excel 2003 (Microsoft Corporation, New York, USA) and SPSS version 15 for Microsoft Windows (SPSS Inc., Chicago, Illinois, USA).
In this study, the demographic criteria (age and parity) and duration of use of the IUCD among different groups of patients were compared, which showed no statistically significant difference. The mean ages were 30.6±4.1, 29.9±4.5, and 30.8±4.2 years in the menorrhagia, metrorrhagia, and control groups, respectively (P>0.05). The mean parity was 3.0±1.2, 3.0±1.1, and 3.0±1.2 in the same groups, respectively (P>0.05). Further, no significant difference was observed among the groups with respect to duration of use of the IUCD; in the menorrhagia, metrorrhagia, and control groups, the mean duration of use was 16.0±8.2, 16.4±8.1, and 17.5±8.0 months, respectively (P>0.05).
In this study, the IUCD-FD was measured by 3D transvaginal ultrasonography. The mean IUCD-FD was 21.2±3.2 and 19.4±3.3 mm in the menorrhagia and control groups, respectively, showing no significant difference (P>0.05; Table 1). In contrast, the same distance was compared between the metrorrhagia and control groups; the mean distance was 28.4±4.9 and 19.4±3.3 mm in the two groups, respectively, showing a statistically significant difference (P<0.05; Table 2). When the IUCD-FD was compared in the menorrhagia and metrorrhagia groups, the mean distance was 21.2±3.2 and 28.4±4.9 mm in the two groups, respectively, and the difference was statistically significant (P<0.05) (Table 3).
We also measured the IUCD-ED, by 3D transvaginal ultrasound. The mean IUCD-ED was 4.2±1.9 and 3.3±1.7 mm in the menorrhagia and control groups, respectively, showing no statistically significant difference (P>0.05; Table 1). In contrast, when the same distance was compared between the metrorrhagia and control groups, the mean distance was 10.7±3.3 and 3.3±1.7 mm, respectively, and the difference between the two groups was statistically significant (P<0.05; Table 2). The mean IUCD-ED in the menorrhagia and metrorrhagia groups was 4.2±1.9 and 10.7±3.3 mm, respectively, with the difference showing statistical significance (P<0.05; Table 3).
In this study, the IUCD was considered as displaced if the IUCD-ED was beyond 8 mm or if the IUCD-FD was beyond 27 mm. Accordingly, patients with displaced IUCDs were identified, and a comparison was made among the study groups.
Within the study group 5/68 (7.4%) patients with displaced IUCDs were identified in the menorrhagia group and 26/32 (81.2%) in the metrorrhagia group. In the control group 6/100 (6%) patients with displaced IUCDs were identified. There was no significant difference in the number of displaced IUCDs between the menorrhagia and control groups (P>0.05), whereas there was a significant difference in the number of displaced IUCDs between the metrorrhagia and control groups (P<0.05). In addition, there was a statistically significant difference in the number of displaced IUCDs between the menorrhagia and metrorrhagia groups (P<0.05; Fig. 1). Thus, we conclude that menorrhagia in group A1 patients after IUCD insertion was not affected by the location of the IUCD.
The IUCD was removed from the patients in the study group and further observation 1 month later showed an improvement in the pattern of bleeding in 36 of 45 patients (80%) in the menorrhagia group and in 21 of 23 patients (90%) in the metrorrhagia group.
In the literature, some foregoing studies showed a possible relationship between the position of the IUCD inside the uterus and abnormal uterine bleeding.
In our study, 7.4% of patients in the menorrhagia group had displaced IUCDs, whereas this percentage increased to 81.2% in the metrorrhagia group.
One of the main advantages of 3D ultrasonography is its potential for both surface and volume rendering. It enables imaging of the entire IUCD, that is, the shaft and the arm, simultaneously. Complete simultaneous imaging of all parts of the IUCD was possible in 95% of cases examined by 3D-transvaginal sonography 9.
Faundes et al. 10 studied 481 women who had been using CuT-200 or 380 devices for at least 6 months. When the generally accepted IUCD-FD of 25 mm was used as the limit of normality above which IUCD removal is recommended, no correlation was found between the presence of bleeding and pain and the IUCD position.
In the study by Jiménez et al. 11 it was stated that the presence an IUCD in the uterine cavity, regardless of its position, can be related to abnormal uterine bleeding, particularly menorrhagia. There is no direct relationship between the position of the IUCD and bleeding.
In the study by Suzin and Respondek 12, who performed transvaginal ultrasonography on 68 women 2–3 days after IUCD insertion and 3–24 months after IUCD insertion, it was found that prolonged menstruation and spotting between menstruation occurred most often in patients in whom transvaginal ultrasonography showed an abnormal IUCD position.
Demidov 13 reported that around 50% of women using IUCD and complaining of metrorrhagia and hypermenorrhea have an incorrect IUCD position.
In the study by Bernaschek et al. 14 the IUCD-FD was measured by transvaginal ultrasonography, and it was found that this distance should not exceed 4/3 of the mean thickness of the anterior and posterior uterine walls. Further, the position of the IUCD can be construed as correct if the IUCD-FD does not exceed the thickness of the uterine wall by more than one-third – that is, in all 4/3 of the thickness – and there is a correlation between this distance and side effects such as bleeding and pain.
It can be suggested that our results are in accordance with the findings of Suzin and Respondek 12, Bernaschek et al. 14, and Demidov 13 with respect to the correlation between the position of the IUCD inside the uterus and abnormal uterine bleeding.
Further, our findings coincide with those of the study by Faundes et al. 10 and Jiménez et al. 11, who reported that the presence of an IUCD in the uterine cavity, regardless of its position, can be related to abnormal bleeding, particularly menorrhagia.
In contrast, we found in our study that there is a direct relationship between the position of the IUCD and bleeding. This contradicts with the findings of Faundes et al. 10 and Jiménez et al. 11 who found that there was a lack of correlation between the presence of bleeding, pain and the IUCD position.
According to the results of our study, it can be suggested that displacement of the IUCD from its proper position within the uterine cavity can induce abnormal uterine bleeding, especially in the form of metrorrhagia. The higher the position of the IUCD, the lesser the incidence of metrorrhagia. However, the presence of an IUCD, regardless of its position in the uterine cavity, can cause menorrhagia. A 3D ultrasound could be proposed as a good tool for assessing the proper position of an IUCD in situ by measuring either the IUCD-FD or the IUCD-ED. Removal of the displaced IUCD can improve the bleeding pattern. Further studies with a larger number of patients are needed to confirm or negate our results.
Conflicts of interest
There are no conflicts of interest.
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