The response of endometrial blood vessels to intrauterine contraceptive devices: an electron microscopic study

The effect of vitamin B1 on bleeding and spotting in women using an intrauterine device: a double-blind randomised controlled trial

OBJECTIVES

Excessive menstrual bleeding, the most common complication caused by intrauterine devices (IUDs), often leads to discontinuation of use. Our study investigates the effect of vitamin B1 on menstrual bleeding and spotting after insertion of the TCu380A IUD.

METHODS

This double-blind, randomised controlled trial involved 110 Iranian women. We recruited women who noted that their menstrual flow (duration, amount, and number of sanitary pads needed) or intermenstrual spotting had increased one month after the insertion of a TCu380A, and randomly assigned them to two groups. The intervention group and the control group received 100 mg of vitamin B1 or a placebo, respectively, daily, for three months. We followed all participants for four months. The Higham scale was used for estimating the volume of menstrual bleeding. The Mann-Whitney test, paired t-test, independent t-test and Repeated Measure test were used for statistical purposes.

RESULTS

In the intervention group the duration of menstrual bleeding, the number of sanitary pads and the amount of spotting decreased significantly compared to the control group (p < 0.001).

CONCLUSION

Vitamin B1 is a safe, natural and cost-effective supplement that is devoid of side effects and reduces menstrual bleeding and spotting caused by a copper bearing-IUD.

The quantification of vascular beds: a stereological approach

The main objective of the stereological approach is to make estimations of parameters of geometrical structures using sampled information. The nature of the structure under study in itself does not matter. It may include any macro or microstructure in biology, materials sciences or indeed geology. This approach allows inference of geometrical parameters such as volume, surface area, number, thickness and spacing. In the stereological approach, the exact nature or function of the structure is not important. Holes can also be considered as structures. The wide applicability of this approach is because it relies on basic facts of geometry and statistics. In Biology, it provides a spatial framework upon which to lay physiological and molecular information. Stereology has been applied to a wide variety of problems in Biology in fields such as Neurobiology, Reproductive Biology and Cancer Cell Biology. In this presentation, the application of this approach to a variety of vascular beds will be illustrated with examples including the nervous system (brain and spinal cord) and the reproductive system (endometrium). The stereological approach can provide access to the three-dimensional spatial framework of complex vascular beds. The aim of this paper is to highlight the usefulness of this approach to the study of the vasculature.

Endometrial morphometry in users of intrauterine contraceptive devices and women with ovulatory dysfunctional uterine bleeding: a comparison with normal endometrium

Copper-bearing intrauterine contraceptive devices (IUCD) are commonly associated with menorrhagia. They cause certain morphological changes in the endometrium. These have been extensively reported and the mechanisms of menorrhagia have been investigated in a number of studies. By contrast, ovulatory dysfunctional uterine bleeding has not been as widely studied and mechanisms of menorrhagia in these patients are still not well understood. In this study, we examined endometrial morphometry in a group of women using IUCD, a group of women with ovulatory dysfunctional bleeding, and a control group of women with entirely normal cycles. There was increased leukocytic infiltration of the endometrium in both groups of women with menorrhagia compared to control cases. In addition, IUCD use was associated with greater luteal phase glandular epithelial height, supporting the concept of a secretory function defect in glandular epithelium. Possible links are postulated between static morphometric observations and dynamic biochemical changes.

Intra-uterine contraception and the risk of endometrial cancer

Despite the increasing world-wide popularity of contraceptive intra-uterine devices (IUDs), their potential long-term effects on the risk of developing endometrial carcinoma have been poorly studied. This paper reports on the relationship between intra-uterine contraception and endometrial cancer by analyzing epidemiological data from a large, multicenter, population-based, case-control study of epithelial endometrial cancer. Cases were 437 women, 20 to 54 years of age, with histologically confirmed epithelial endometrial cancer ascertained through 6 population-based cancer registries in the United States. Controls were 3200 women selected at random from the populations of these areas. The age- and parity-adjusted odds ratio (OR) for the association between ever having used intra-uterine contraception and endometrial cancer was 0.51 (95% confidence interval (CI) 0.3-0.8). Although the protective effect increased with duration of use, a dose-response relationship among users was not statistically demonstrable. The association did not vary significantly with age at first or last IUD use or with time elapsed since first or last IUD use. Years of education significantly modified the effect of intra-uterine contraception. Thus, intra-uterine contraception appeared to be strongly protective for women with at least 13 years of education (OR = 0.29, 95% CI, 0.15-0.6). It is proposed that intra-uterine contraception exerts its protective effect through local structural and biochemical changes in the endometrium that may alter endometrial sensitivity and response to circulating estrogen and progesterone.

Observation of the activity of factor VIII in the endometrium of women pre- and post-insertion of three types of IUDs

The endometrial materials were obtained from 90 women who had been randomly inserted with three types of IUDs (Stainless steel ring, SS; copper T 220, TCu 220, and levonorgestrel-releasing device, LNG). An immunoperoxidase reaction, PAP method, with the antiserum of Factor VIII as the primary antibody, was carried out to detect the Factor VIII activity in the endometrial endothelium pre- (control) and post-insertion of the IUDs. The results revealed that: 1. There was a generalized lower Factor VIII activity in the endometrium of women post-insertion of IUDs (except LNG). 2. Comparison of the Factor VIII activity in the endometrium of women using different types of IUDs showed that the TCu type and the SS type decreased the activity significantly whereas the activity remained unchanged after 3-6 months' use of the LNG-IUD. The different types of IUDs seemed to influence the coagulation regulatory system in different ways; the lower Factor VIII activity, the more tendency to bleeding. 3. The Factor VIII activity in the endometrium of women using IUDs was lower in all phases of the menstrual cycle including the proliferative phase when the Factor VIII activity is normally high. It cannot be excluded that this could be a contributing factor to IUD-induced bleedings.

The effect of copper IUD on microcirculation of blood flow in rabbit uterus

A survey of the rabbit's normal microcirculation of blood flow volume in the endometrium and myometrium with or without a copper intrauterine device (IUD) was made. It was found through statistical analyses that the IUD stimulated the endometrium so that microcirculation of blood flow volume in the endometrium increased significantly, but it did not change the microcirculation of blood flow volume in the myometrium and in the opposite uterus.

Endometrial morphological changes in IUD users: a review

The introduction of an intrauterine device into the uterine cavity induces a foreign body reaction in the surrounding endometrium which is characterized by the infiltration of polymorphonuclear leucocytes and macrophages into the endometrial stroma and subsequently through the surface epithelium. Leucocyte migration is greater with copper IUDs than with inert IUDs. Ulceration of the surface epithelium, haemorrhage of erythrocytes and microthrombosis of stomach capillaries occur in the functional endometrium in contact with inert and copper IUDs. In endometrium adjacent to, but not in contact with, the IUD gaps appear in the endothelial lining of small blood vessels without a haemostatic response. The most striking response in endometrium exposed to progesterone-releasing IUDs is the occurrence of dilated, thin-walled vesicles, associated with a thinning of the surface epithelium and a decidual reaction in the stroma. A uniform suppression of the endometrium in progesterone IUD users is always found after six months of treatment, whereas the insertion of IUDs releasing 20-30 micrograms levonorgestrel induce a profound uniform suppression of the functional endometrium throughout the uterus after only four weeks.

Rat uterine tissue and cell responses to the presence of plain and indomethacin-delivering IUDs

Plain silastic intrauterine devices or those containing 270 micrograms of indomethacin were inserted into the caudal portion of one uterine horn of mature Wistar rats. After a 3-week period animals were fixed by perfusion on the morning of day 2 after estrus. Segments of uterine tissue corresponding to regions adjacent to and cranial to the devices as well as an equivalent portion of the contralateral horn were embedded in glycol methacrylate. A group of control animals without any form of device were treated in an identical manner. Sections cut from these segments were evaluated by grid-point stereology to ascertain changes in tissue volumes and cell populations. It was found that the presence of plain devices induced hypertrophy in the stroma and myometrium of the portion of the uterus adjacent to the device. The presence of indomethacin in such devices prevented stromal hypertrophy. No changes in populations of fibroblasts or areas of glandular or vascular tissue were evident in any treatment group. Cell populations of neutrophils, eosinophils, and mononuclear cells, however, were elevated in the superficial stroma of the horns bearing either type of device; this feature was more pronounced for neutrophils in the presence of the indomethacin devices. Neutrophils, rather than eosinophils, predominated in the epithelia of the uterus bearing either type of IUD. Conversely, eosinophil populations were reduced in the superficial tissues cranial to the devices delivering indomethacin. Neutrophils and mononuclear cells were also found to be elevated in the deep stroma of tissues adjacent to both the plain and medicated device.

The effects of intrauterine contraceptive devices on the ultrastructure of the endometrium in relation to bleeding complications

The effects of inert (Lippes Loop D and Dalkon Shields) and medicated (copper 7, copper T, and Progestasert) intrauterine contraceptive devices (IUDs) on the ultrastructure of the endometrium were studied in intact human uteri. The most striking morphologic changes induced by the inert and copper-bearing devices were erosion of the surface epithelium and extensive microthrombosis in stromal capillaries of the endometrium in contact with the device. These abnormalities were associated with extravascular thrombi, erythrocytes, and fibrin deposition in the adjacent stroma. Capillary microthrombosis and leukocyte infiltration into the uterine cavity were most extensive around the active part of the copper-bearing devices. With the Progestasert erosion of surface epithelium was rarely seen, but the intact epithelial lining had fewer ciliated cells with flattened and shortened cilia. Large dilated venules were a common finding below the surface epithelium adjacent to the active part of the Progestasert; capillary microthrombosis was found only below the inert arms of the Progestasert. The vascular response of the endometrium to IUDs appears, therefore, to be directly related to the type and proximity of the device. The morphologic changes induced in both surface epithelium and the microvasculature of the endometrium are the likely explanation of the uterine bleeding problems associated with IUDs but are probably intrinsic to the mode of action of the IUD in interfering with implantation.

An ultrastructural study of menstrual blood in normal menstruation and dysfunctional uterine bleeding

Menstrual fluid was obtained from the uterine cavity and vagina in 20 women within the first 48 h of menstruation. Ten of the women had normal menstrual cycles and blood loss and ten were patients with dysfunctional uterine bleeding. The menstrual samples were examined by electron microscopy for the presence of fibrin and platelets and nearly all were found to contain both fibrin and aggregating platelets. By a simple quantitative system no differences in fibrin and platelet content were found between samples collected from the uterine cavity or the vagina. Likewise no difference was found in the morphology of fibrin and platelets between women with normal menstrual loss and patients with dysfunctional uterine bleeding.

The effect of the progesterone-releasing intrauterine device on uterine endometrium and fallopian tube epithelium

A scanning and transmission electron microscopy study was undertaken of the effect of the progesterone releasing intrauterine device (Progestasert, Alza Corporation, USA) on the uterine endometrium and fallopian tube epithelium. Small erosions of surface epithelium and microthrombosis of stromal capillaries were found in the endometrium below the inert part of the device. A reduction of ciliated cells and shortened cilia were seen in the endometrium below the active part of the device and large dilated venules were present in the underlying stroma. Fallopian tubes from IUD patients contained fewer ciliated cells than those of the controls. The morphological changes described are likely to be major factors responsible for the irregular bleeding which occurs with Progestasert IUDs and the possible increase in tubal pregnancy.

Haemostasis in menstrual endometrium in the presence of an intrauterine device

The histology and ultrastructure of the haemostatic response in the endometrium have been studied in 12 uteri containing an inert or copper wound intrauterine contraceptive device (IUCD). The uteri were removed during the premenstrual phase or during the first 96 hours of menstruation. The results have been compared to earlier observations in non-IUCD influenced endometrium. In all uteri the tissue shedding proceeded more slowly in the presence of an IUCD and considerably fewer haemostatic plugs were found. The platelets in these plugs were more loosely packed and less degranulated, and the plugs contained less fibrin than in the absence of an IUCD. Haemostatic plugs were still observed at times when no such plugs were seen in uteri without an IUCD. Unoccluded vessel lesions were regularly seen and vessels open to the shedding surface were occasionally encountered. These observations suggest that IUCD-induced menorrhagia is caused by the combination of delayed shedding and a decreased haemostatic reaction in the endometrium.

Scanning and transmission electron microscopy of material adherent to intrauterine contraceptive devices

The material adherent to intrauterine contraceptive devices (IUCDs) has been studied by transmission and by scanning microscopy coupled with X-ray microprobe analysis. Inert (Lippes Loop D, Saf-T-Coil and Dalkon shield) and medicated (Copper 7 and Progestasert) IUCDs were removed for examination from uteri immediately after hysterectomy. The cellular material identified on the surface of all inert IUCDs consisted mainly of macrophages with some polymorphonuclear leucocytes, erythrocytes, a few platelets and fibrin fibres. Polymorphonuclear leucocytes were the principle cells on the copper devices. Larger numbers of cells were evident on the inert arms than on the active part of the Progestasert device. All the devices examined exhibited varying amounts of surface calcium deposition. The IUCDs which had been in utero for longer periods showed the greatest amount of calcium deposition. Although a less rapid calcium deposition appeared to occur on the Progestasert device, this deposition may influence the release of medications from IUCDs which are retained in utero for longer periods than one year.