By Rebecca H. Allen, MD, MPH
Associate Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI
Dr. Allen reports she receives grant/research support from Bayer and is a consultant for Merck.
SYNOPSIS: In this case series from Colorado, seven women experienced IUD expulsion with menstrual cup removal.
SOURCE: Seale R, Powers L, Guiahi M, Coleman-Minahan K. Unintentional IUD expulsion with concomitant menstrual cup use: A case series. Contraception 2019;100:85-87.
This is a case series of seven intrauterine device (IUD) expulsions associated with menstrual cup use. Cases were identified by chart review and provider referrals at the University of Colorado or Children’s Colorado Hospital outpatient clinics. Subjects were contacted by phone to obtain more details on the IUD expulsion.
Participants ranged from 16 to 26 years of age, had body mass index (BMI) between 19.8 kg/m2 and 31.4 kg/m2, and were nulligravid. There were five Lilettas, two Mirenas (from the same subject), and three Paragards (from the same subject) that expelled. Time to expulsion ranged from one week to 13 months. All IUD expulsions occurred during menstrual cup removal, with many subjects reporting inadvertently pulling or pinching the strings of the IUD during menstrual cup removal. Three participants chose to switch to the contraceptive implant, one woman underwent IUD reinsertion and stopped using menstrual cups, one woman underwent IUD reinsertion and continued using menstrual cups, and two women underwent IUD reinsertion and had the IUD strings cut flush with the cervix to facilitate the use of menstrual cups.
COMMENTARY
The use of menstrual cups for the management of menstrual bleeding has increased in popularity given that they are environmentally friendly.1 The menstrual cup forms a tight seal in the vagina to collect blood; that suction must be broken to remove the menstrual cup. The menstrual cup can then be emptied, washed, and reused. Similarly, the prevalence of IUD use has increased in the United States.2 Seale et al sought to evaluate the association between menstrual cup use and IUD expulsion. In a 2012 study, Wiebe et al did not find any difference in IUD expulsion rates between menstrual cup and tampon use; however, subjects were followed for only six weeks after IUD insertion.3
Seale et al speculated that women were either 1) unintentionally pulling the IUD strings when removing the cup or 2) the suction created during cup application dislodged the IUD. Given that more manipulation is required for menstrual cup removal compared to tampon removal, it makes sense that inadvertent IUD expulsion would occur more frequently with menstrual cups. All study participants were young and nulligravid; however, this is the population most likely to use both IUDs and menstrual cups. It is impossible to draw any conclusions regarding the influence of parity on this phenomenon based on a case series. Depending on the study, the risk of IUD expulsion is approximately 4% in the first year of use, with slightly higher rates for copper IUD users compared to levonorgestrel IUD users.4 Risk factors for IUD expulsion include previous expulsion, history of heavy menstrual bleeding, young age, and immediate postpartum or post-second trimester abortion.4,5,6 Nulliparity and insertion immediately after first trimester uterine evacuation are not considered risk factors for IUD expulsion based on recent studies.4,5,6 Women who previously have expelled an IUD spontaneously are at higher risk for repeat expulsion, with one study estimating the risk to be 14%.4
Based on this case series, it makes sense to query patients opting for IUDs about their use of menstrual cups. If they do use menstrual cups, they should be cautioned to be careful during removal. This information is also mentioned on many of the menstrual cup instructions for use. Patients might be offered the option of cutting the IUD strings flush with the cervix to avoid inadvertent removal, with the caveat that this might make IUD removal more difficult.
REFERENCES
- Howard C, Rose CL, Trouton K, et al. FLOW (finding lasting options for women): Multicentre randomized controlled trial comparing tampons with menstrual cups. Can Fam Physician 2011;57:e208-215.
- Daniels K, Daugherty J, Jones J, Mosher W. Current contraceptive use and variation by selected characteristics among women aged 15-44, United States, 2011-2013. Natl Health Stat Rep 2015;86:1-14.
- Wiebe ER, Trouton KJ. Does using tampons or menstrual cups increase early IUD expulsion rates? Contraception 2012;86:119-121.
- Aoun J, Dines VA, Stovall DW, et al. Effects of age, parity, and device type on complications and discontinuation of intrauterine devices. Obstet Gynecol 2014;123:585-592.
- Madden T, McNicholas C, Zhao Q, et al. Association of age and parity with intrauterine device expulsion. Obstet Gynecol 2014;124:718-726.
- American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice; Long-Acting Reversible Contraceptive Expert Work Group. Committee Opinion No. 672: Clinical Challenges of Long-Acting Reversible Contraceptive Methods. Obstet Gynecol 2016;128:e69-77.
