by Anne Eglash MD, IBCLC, FABM
Are breastfeeding mothers with intrauterine devices (IUD) more likely to experience uterine perforation as compared to other women with IUDs?
In the European Active Surveillance Study on Intra-Uterine Devices, 61,448 women with IUDs were tracked from 2006 to 2013 to assess the uterine perforation rate of copper verses progesterone IUDs. Within this study population, 70% had progesterone IUDs, 30% copper IUDs, and less than 15% of the women were breastfeeding at the time of IUD insertion. A perforation was defined as the IUD penetrating into the wall of the uterus.
Among all participants in this study, the uterine perforation rate was low, approximately 1.4 per 1000 insertions in the progesterone IUD users, and 1.1 per 1000 insertions in copper IUD users.
What do you think are true statements about breastfeeding women and IUD perforations in this study?
- Among breastfeeding women with IUDs, perforations were more common with the copper IUD than the progesterone IUD.
- Breastfeeding women with an IUD were approximately 6 times more likely to experience a uterine perforation as compared to non-breastfeeding women.
- Among breastfeeding women, perforation was ~3.5 times more likely if the IUD was placed less than 36 weeks after delivery, as compared to more than 36 weeks after delivery.
- Among all women who had an IUD placed less than 36 weeks after delivery, breastfeeding women were ~ 3 times more likely to experience a uterine perforation as compared to non-breastfeeding women.
See the Answer
The answers are Answers: B,C,D (not A)
Contraception. 2015 Apr;91(4):274-9. doi: 10.1016/j.contraception.2015.01.007. Epub 2015 Jan 16
Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the European Active Surveillance Study on Intrauterine Devices.
Heinemann K1, Reed S2, Moehner S2, Minh TD2
OBJECTIVES:
The objectives were to identify and compare the incidence of uterine perforation and other medically adverse events associated with levonorgestrel-releasing intrauterine systems (LNG-IUSs, releasing 20 mcg LNG daily) and copper intrauterine devices (IUDs) under routine conditions of use in a study population representative of typical users.
METHODS AND MATERIALS:
This is a multinational, prospective, non-interventional cohort study with new users of LNG-IUSs and copper IUDs. In addition to a baseline questionnaire, women and their treating health care professional completed a single follow-up questionnaire after 12 months. All patient-reported outcomes were validated by the treating physicians.
RESULTS:
A total of 61,448 women in six European countries were followed between 2006 and 2013 for more than 68,000 women-years of observation (70% LNG, 30% copper devices). Overall, 81 uterine perforations were reported: 61 for LNG-IUSs [1.4 per 1000 insertions (95% confidence interval {CI}: 1.1-1.8)] and 20 for copper IUDs [1.1 per 1000 insertions (95% CI: 0.7-1.7)], for an adjusted risk ratio (RRadj) of 1.6 (95% CI: 1.0-2.7) when adjusted for age, body mass index, breastfeeding at time of insertion and parity. Breastfeeding at time of insertion was associated with a sixfold increase (RR 6.1, 95% CI: 3.9-9.6), with no differences between LNG and copper IUD users. Sixty-three of the total 81 perforations were associated with previously suspected risk factors (e.g., breastfeeding, time since last delivery ≤36 weeks). No perforations led to serious illness or to injury of intra-abdominal or pelvic structures.
CONCLUSIONS:
Uterine perforation incidence in this study was low, with a benign clinical course thereafter. The LNG-IUSs and copper IUDs did not have clinically important differences in perforation rates.
IMPLICATIONS:
The European Active Surveillance Study on Intrauterine Devices is the first large-scale, prospective, non-interventional study to compare the perforation risk in LNG-IUS and copper IUD users. It is the first to examine the independent roles that breastfeeding status and postpartum status have on perforation risk. Conducted during routine clinical practice, the findings are generalizable to broader populations.
Milk Mob Comment by Anne Eglash MD, IBCLC, FABM
The good news in this study is that overall rates of perforation among IUD users is low. Even though breastfeeding women have higher rates of perforation, the rates are still quite low, 6 per 1000 for progesterone IUDs, and 3.7 per 1000 for copper IUDs.
The authors theorize that the higher risk of perforation among breastfeeding women may have to do with their lower estrogen levels, which may be associated with decreased uterine wall strength and thickness. In addition, oxytocin released during breastfeeding may increase the risk of uterine contraction, which could also cause the IUD to perforate the uterine wall. It would make sense that the risk is higher within the first 36 weeks postpartum vs after 36 weeks postpartum, since the estrogen level gradually rises over many months postpartum, as breastfeeding women resume menses.
Clinicians who place IUDs should consider counseling breastfeeding women about their slightly higher risk of uterine perforation with IUD placement, and that the risk declines after 36 weeks postpartum. Even though such a low rate of uterine perforation ought not to preclude IUD placement at the typical 6-week postpartum visit, my suspicion is that some breastfeeding families might decide to wait on IUD placement until after 36 weeks postpartum.