Factors associated with low-lying intrauterine devices: a cross-sectional ultrasound study in a cohort of African-American women

The use of a menstrual cup as a risk factor for displacement of intrauterine devices: a case-control study

BACKGROUND

Menstrual cups (MC) are being increasingly used for menstruation management as an alternative to tampons and sanitary pads. Intrauterine devices (IUD) are commonly and increasingly used for birth control. Displacement of an IUD from the uterine fundus can reduce its efficiency, potentially leading to unwanted pregnancies. Recently, concerns have been raised regarding a possible increase in the risk of IUD displacement, associated to the use of MC. This study measures the association between MC use and IUD displacement, taking into account the already known risk factors of IUD displacement.

METHODS AND FINDINGS

Women consulting for follow-up of an IUD in two primary care facilities in Paris were enrolled in the study between March 2020 and May 2021. IUD position was assessed by transvaginal ultrasound. Use of MC and exposition to known risk factors for IUD displacement were assessed by a standardized investigator-administered questionnaire. Frequency of MC use was compared between patients with well-positioned IUD and patients with displaced IUD. A linear regression model looked for an independent association between MC use and IUD displacement, with respect to known risk factors for IUD displacement. 747 patients were included, out of which 6.8% had a displaced IUD. MC use was reported by 17.0% of patients with a well-positioned IUD versus. 41.2% of patients with a displaced IUD. After adjustment for known risk factors of IUD displacement, MC use appeared to be significantly and independently associated with IUD displacement (aOR [95CI]: 3.09 [1.56-6.05]).

CONCLUSIONS

The use of a menstrual cup seems to be an independent risk factor for intrauterine device displacement.

CLINICAL TRIAL REGISTRATION

NCT04782583.

Considerations for hormonal contraception and people with larger bodies

People with larger bodies face discrimination in accessing health care, including equitable contraceptive care. Conscientious provision of person-centered contraception counseling is consistent with principles of the Health at Every Size and the Reproductive Justice movements. One facet of this care includes integration of evidence around unique considerations for steroid hormone efficacy and safety for patients with bigger bodies. Ultimately, this information should be used to empower and support reproductive decision making amongst patients of larger body sizes.

Incidence and Risk Factors for a Malpositioned Intrauterine Device Detected on Three-Dimensional Ultrasound Within Eight Weeks of Placement

OBJECTIVES

To estimate the incidence of intrauterine device (IUD) malpositioning detected on three-dimensional (3D) transvaginal ultrasound within 8 weeks of placement and identify risk factors for malpositioning.

METHODS

Retrospective study of women who had an IUD placed at a large obstetrics and gynecology practice from January 1, 2015, to December 31, 2020. All patients underwent two-dimensional ultrasound at the time of insertion and routine three-dimensional ultrasound within 8 weeks. Baseline characteristics and potential risk factors were compared between women with correctly positioned and malpositioned IUDs. Odds ratios were calculated by logistic regression to identify risk factors independently associated with malpositioning.

RESULTS

A total of 763 IUD placements were included, and 127 malpositioned IUDs were identified representing an overall rate of malpositioning of 16.6% (95% confidence interval [CI] 14.0-19.3) with 8.8% (95% CI 6.8-10.8) requiring removal. Patients with malpositioned IUD had higher rates of morbid obesity (13.4% versus 3.8%, adjusted odds ratio [aOR] 2.46, 95% CI 1.10-5.50), prior uterine window or rupture (9.0% versus 2.2%, aOR 2.78, 95% CI 1.06-7.30), copper IUD placement (64.2% versus 47.4%, aOR 1.99, 95% CI 1.31-3.03), and symptoms such as bleeding or pain at follow-up (35.8% versus 20.1%, aOR 2.58, 95% CI 1.67-3.98). Parity, breastfeeding, difficult insertion, and uterine size and positioning were not significant.

CONCLUSIONS

The incidence of malpositioned IUD within 8 weeks of placement on 3D ultrasound is 16.6%, with 8.8% requiring removal. Significant risk factors for malpositioning include morbid obesity, prior uterine window or rupture, and copper IUD placement. These findings support the importance of routine follow-up 3D ultrasound after seemingly successful IUD placement.