Pain and heavy bleeding with intrauterine contraceptive devicesBMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39288.584086.80 (Published 30 August 2007) Cite this as: BMJ 2007;335:410
- Sally B Rose, research fellow
- Women's Health Research Centre, Department of Primary Health Care and General Practice, University of Otago, Wellington. School of Medicine and Health Sciences, PO Box 7343, Wellington, New Zealand
The two types of intrauterine contraceptive device have very different menstrual side effects. The newer hormonal levonorgestrel intrauterine system (LNG-IUS or Mirena) reduces menstrual flow, whereas the copper bearing devices may induce longer, heavier, and more painful periods. Pain and heavy menstrual bleeding are common reasons for discontinuing use of an intrauterine device within the first year. Non-steroidal anti-inflammatory drugs (NSAIDs) can reduce cramping and blood flow in women with and without devices.
A recent Cochrane review by Grimes and colleagues evaluated data from 15 randomised controlled trials investigating the effect of NSAIDs on treatment or prevention of pain and bleeding due to an intrauterine contraceptive device.1 Trials meeting selection criteria were conducted in 10 countries using a range of treatments (NSAID compared with placebo, another NSAID, or another type of drug) and a variety of quantitative and qualitative outcome measures—factors that precluded a meta-analysis of the data. Although many of the trials had methodological weaknesses, data from treatment trials showed an overall beneficial effect of NSAIDs on pain and bleeding outcomes, but data from prevention trials were inconsistent. In otherwise asymptomatic women NSAIDs reduced pain or bleeding (or both) in three studies, did not differ from placebo in two studies, and reduced bleeding but not pain in another. A large rigorously conducted trial of 2019 first time users in Chile did not support the prophylactic use of ibuprofen compared with placebo to reduce rates of removal of devices because of pain or bleeding.2
Given the availability, low cost, and general safety of NSAIDs in women of reproductive age, this review supports a therapeutic practice many clinicians will be familiar with. A short course of NSAIDs during menses is appropriate to treat persistent or troublesome pain or bleeding with an intrauterine device, providing there are no contraindications. Grimes and colleagues concluded, however, that there are insufficient data to recommend the optimal type and dose of NSAID. Prescribers must weigh up the risk of adverse effects, convenience related to dosing frequency, cost, and local availability.1
For women in whom NSAIDs do not reduce bleeding to an acceptable level, tranexamic acid is effective but can have more unpleasant side effects.1 These conclusions are consistent with a recent evidence based guide on long term use of intrauterine devices which also recommended that, where pain or heaving bleeding persist for more than six months, women should be checked for gynaecological problems and clinical signs of anaemia.3 Unless prohibited by availability or cost, the levonorgestrel intrauterine system may be considered for women who cannot tolerate menstrual problems caused by a copper bearing device. This hormone bearing device has both contraceptive and (off-label) therapeutic uses, with evidence to support its role in treating women with anaemia, dysmenorrhoea, and menorrhagia.4
Intrauterine contraceptive devices are suitable for use by most women (including younger and nulliparous women),5 are cost effective when continued long term (Mirena is approved for five years, copper devices for up to 10 years), and have health benefits beyond simple contraception.4 6 Fertility is restored on their removal, and unlike other forms of contraception their efficacy does not depend on the user's behaviour. Consequently, such devices are an excellent alternative to female sterilisation (which women may later regret),7 and are a long term alternative to other methods of birth control prone to misuse or failure. Despite being the most common form of reversible contraception used by women of reproductive age worldwide, these devices are underused in developed countries.8 Nearly half of all users are in China, while only 6% of women of reproductive age in the United Kingdom, 4.6% in Australia and New Zealand, and fewer than 1% in the United States use this method of contraception.8
Reluctance to offer or use intrauterine devices seems to stem largely from the experience with the Dalkon Shield in the 1970s, which caused pelvic infections that had serious health consequences for many thousands of women. Legal action against manufacturers of that and other devices led to a sharp decline in the use of all intrauterine contraceptive devices and their subsequent withdrawal from the US market in the 1980s.9 Since then, misconceptions based on outdated information have persisted, such as the belief that these devices cause pelvic inflammatory disease and infertility. Evidence from randomised controlled trials and from case-control and cohort studies suggests there might be a small increased risk in the first 20 days after insertion, but beyond that the risk of upper genital tract infection does not differ from that in non-users.10 Pelvic inflammatory disease is frequently caused by untreated Chlamydia,11 and it is good practice to test for and treat asymptomatic infection before inserting a device10 and to advise the use of condoms to protect against sexually transmitted infections.
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.