Intrauterine device use among women with uterine fibroids: a systematic review

BackgroundThere are concerns that intrauterine device (IUD) use by women with uterine fibroids might increase their uterine bleeding or risk for device expulsion. The objective of this systematic review was to evaluate evidence concerning the safety and effectiveness of IUD use among women with uterine fibroids. Key questions included whether IUD use is associated with increased risk for uterine bleeding among women with uterine fibroids and whether the presence of uterine fibroids is associated with an increased risk for device expulsion among IUD users.Study DesignWe searched the PubMed database for peer-reviewed articles relevant to IUD (copper or levonorgestrel-releasing) use and uterine fibroids published in any language from database inception through June 2009. We used standard abstract forms and a grading system to summarize and assess the quality of the evidence.ResultsFrom 202 articles found in the database search, we identified 11 studies that met our inclusion criteria, all of which examined outcomes among users of the levonorgestrel-releasing IUD (LNG-IUD). Evidence from 10 of 11 noncomparative studies (Level II-3, fair) suggests that LNG-IUD use among women with fibroids does not increase menstrual bleeding, and results from all 11 showed that menstrual blood loss decreased among women who continued to use the LNG-IUD through the end of the study period. Overall, serum levels of hemoglobin, hematocrit and ferritin increased among LNG-IUD users in studies that assessed these outcomes. Several studies reported some occurrences of irregular bleeding. Findings from two cohort studies (Level II-2, fair to poor) showed rates of LNG-IUD expulsion to be higher among women with uterine fibroids (11% in each) than among women without uterine fibroids (0% and 3%); however, in one study the difference was not statistically significant, and in the other significance testing was not conducted. Six prospective noncomparative studies reported expulsion rates of 0–20% among women with uterine fibroids.ConclusionsMost women with uterine fibroids are likely to have less menstrual blood loss and higher serum levels of hemoglobin, hematocrit and ferritin after insertion of an LNG-IUD, despite some occurrences of irregular bleeding. LNG-IUD users with uterine fibroids may have higher rates of expulsion than those without fibroids.