Data from a population-based case-control study were used to evaluate the risk of endometrial cancer among women who have used an intra-uterine device (IUD). Incident cases were identified between 1985 and 1991 among women aged 45-74 years who were residents of one of 3 counties in Washington State. Controls were selected by random digit dialing, and both groups of subjects received an in-person detailed interview. In this study population, women who had ever used an IUD were estimated to have a risk of endometrial cancer that was 0.61 times that of other women (95% CI 0.41-0.89). The reduction in cancer risk was not found to be dependent on duration of IUD use. There was a suggestion that women who had used intra-uterine contraception relatively late in reproductive life experienced a greater reduction in risk than those whose use was more distant or at a younger age. The relative risk among the small number of women who were currently using an IUD was 0.49 (95% CI 0.12-2.80). These results apply to the use of inert and copper IUDs as there was no use of progestin-releasing IUDs among women in the study population. To date, 4 studies have examined the possibility that use of an intra-uterine device (IUD) alters a woman's subsequent risk of endometrial cancer. Two have observed that women who had ever used an IUD had half or less the risk of endometrial cancer as never-users (Castellsagué et al., 1993;Parazzini et al., 1994), while in a third, risk among users was 0.7 that of non-users (Rosenblatt et al., 1994). However, the 4th study found that IUD users and non-users had a similar incidence (Shu et al., 1991).The presence of an IUD is known to alter the intra-uterine environment. The IUD evokes a number of immunological and biochemical changes, including localized acute and chronic inflammation (Moyer and Mishell, 1971) and increases in cytokine expression (Ammala et al., 1995). IUDs also have been associated with elevations in uterine prostaglandins (Toppozada, 1985) and fibrinolytic activity (Liedholm et al., 1983). IUDs induce morphological changes such as ulceration and erosion of surface epithelium and exposure of the underlying basement membrane (Shaw and Macaulay, 1979). It is not clear whether these or other responses to the presence of an IUD ought to alter the risk of endometrial cancer development after the device has been removed.Although use has declined in the United States in recent years, an IUD is used by over 93 million women internationally (Shah, 1994), so the question of a relation to endometrial cancer is an important one. Furthermore, understanding the relationship between IUD use and development of endometrial cancer, if one exists, may suggest mechanisms by which endometrial cancer may be prevented.Previous studies of endometrial cancer have included relatively few women who had used IUDs and, therefore, have not been able to examine specific patterns of use. As part of several case-control studies investigating endometrial cancer risk in western Washington, we were able to evaluate t...