The lost intrauterine device: removal by hysterectomy

Abstract

A case of migration of an intrauterine device (IUD) deep within the endometrium, presenting as heavy vaginal bleeding and abdominal pain, is discussed. The IUD had been in situ for 31 years. Standard retrieval techniques failed and removal necessitated hysterectomy. The complications of 'lost IUDs' are discussed and the need to enquire about removal in all women on approaching the menopause is emphasised. Case reportA 55-year-old woman presented to the gynaecology outpatients department with an 8-month history of painful vaginal bleeding since commencing hormone replacement therapy (HRT). She had an intrauterine device (IUD) in situ that had been inserted some 31 years previously.On speculum examination the IUD threads were not visible, and simple retrieval failed. HRT was stopped and hysteroscopy, curettage and removal of the IUD were arranged, under general anaesthesia. At hysteroscopy the IUD was not seen within the cavity, and the curettings were unremarkable. An X-ray reported that the IUD was sited 'within the pelvis'.On review 1 month later the patient was well and reported no further bleeding or abdominal pain. In view of this fact she was not keen to pursue further surgery. However, because of severe vasomotor symptoms she was recommenced on HRT.At review 3 months later, however, the patient reported unacceptable vaginal bleeding and abdominal pain following the recommencement of HRT. It seemed possible that the lost IUD was actually lying deep within the endometrium, provoking a reaction within the endometrium and the symptoms described. This possibility was discussed with the patient who opted to undergo hysterectomy.Surgery was undertaken. Following hysterectomy the removed uterus was dissected. The IUD was located deep within the endometrium as anticipated (Figures 1 and 2). The patient made an uneventful recovery and was commenced on oestrogen-only HRT. At review 2 months later she was well. DiscussionAn IUD is a safe, effective and economical method of contraception, used by more women worldwide than any other reversible method of birth control. 1 Longer-term use of IUDs may be associated with problems. An IUD that remains in situ beyond the menopause can cause both vaginal bleeding and difficulties in removal, as the present case clearly demonstrates.Bleeding problems can be due to erosions of the surface epithelium and micro-thrombosis in the underlying endometrial capillaries. The perimenopausal endometrium is at increased risk. 2 Bleeding may also occur because the IUD evokes both acute and chronic inflammatory responses within the endometrium. 3 It has been postulated that, over a prolonged period, this same inflammatory response could predispose to endometrial carcinoma (akin to chronic irritation and vulval carcinoma). The available data are, however, for the most part reassuring, suggesting even a possible protective effect. This may be either through the generation of an inflammatory response, which leads to early elimination of hyperplastic epithelial cells, or more complete...

Risk factors for delayed intrauterine device removal among menopausal women in rural China

“…The second dependent variable was whether IUD removal was on-time or late. The timing of menopause is determined retrospectively and may be difficult to fix exactly, and recommendations for when IUDs should be removed have varied 21,22 . We therefore defined “on-time” removal broadly as anywhere between 6 and 24 months after last menses.…”

“…The timing of menopause is determined retrospectively and may be difficult to fix exactly, and recommendations for when IUDs should be removed have varied. 21,22 We therefore defined "on-time" removal broadly as anywhere between 6 and 24 months after last menses. Two groups of independent variables were considered: personal and health service characteristics.…”