The hidden dangers of Contraceptives intrauterine contraceptive devices

PAUL A. LIPPMAN, D.O. New York

Intrauterine contraceptive devices venient in the respect that they do not rely upon have been said to be safe and the patients knowledge or ability for accurate economical for the patient, relatively placement. It is the object of this report to pre- sent a case history and to discuss some of the innocuous, effective as a birth hazards incurred by the use of such devices, as control method, and convenient in the well as to demonstrate the importance of ob- respect that they do not rely upon taining an accurate history from a patient the patients knowledge or ability whose symptoms may be related to the presence for accurate placement. The case of these devices. history and discussion presented Case history illustrate some of the hazards A 28-year-old single woman was admitted to incurred by the use of such devices. the LeRoy Division of The Osteopathic Hospital Complications from their use may lead and Clinic of New York on Aug. 25, 1964, be- to permanent injury and/or disability. cause of lower right quadrant and suprapubic Emphasis is placed on the importance pain of 5 days duration. The pain began sud- of obtaining an accurate history from denly, increasing in severity over the few days prior to admission. The complaints were accom- a patient whose symptoms may be panied by a temperature elevation of 100 to 101 referable to the presence of such F. (rectal) , chills, vaginal discharge, dysuria, devices. These plastic devices offer and polyuria. Her gynecological history was un- a potentially reliable and acceptable remarkable, and she denied ever having been contraceptive method for selected pregnant. Her past personal history and sys- tems review were also unremarkable. populations and individuals, but it The patient was a well-nourished Caucasian is evident that more studies are woman in moderate distress. Blood pressure was required to reduce or eliminate 100/70, pulse 88 per minute, temperature 99.8 certain undesirable features. F. (rectal). There was marked tenderness in the lower right quadrant as well as in the supra- pubic area. There was, however, no rebound tenderness or muscle splinting. Vaginal exami- nation revealed a profuse yellowish, watery dis- charge arising from the external os. There was marked tenderness noted in the posterior cul- de-sac and adnexa bilaterally. The uterus did With the ever-increasing search for better meth- not appear enlarged, nor were any masses pal- ods of birth control, intrauterine contraceptive pable. The remaining findings on physical ex- devices have in recent years attracted the inter- amination were unremarkable. est of many gynecologists. These devices are The laboratory findings were as follows : said to have the advantages of being safe and white blood cells 11,850; hematocrit 40 per economical for the patient, relatively innocuous, cent; hemoglobin 12.1 gms. per 100 cc. ; differ- effective as a birth control method, and con- ential count, eosinophils 2, stab cells 2, poly-

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morphonuclear leukocytes 60, lymphocytes 27. Urinalysis disclosed a specific gravity of 1.008, with 2+ albumin. The sedimentation rate (Wes- tergren) was 59 mm. in 1 hour. On the basis of the above information a tenta- tive diagnosis of acute pelvic inflammatory dis- ease was made. Treatment was instituted with penicillin and oxytetracyclines. Vaginal smears and cultures were negative for gram-negative intracellular Diplococcus. The predominant or- ganism appeared to be a Streptococcus. On Aug. 27 the patients temperature re- turned to normal, but her abdominal complaints and vaginal discharge persisted. Upon addi- tional questioning the patient admitted that a plastic intrauterine contraceptive device had been inserted by a gynecologist approximately 3 years previously. A flat plate x-ray was taken of the abdomen (Fig. 1), revealing a foreign body within the area of the uterine cavity. Fol- lowing a negative Aschheim-Zondek test dilata- tion and curettage were performed on Sept. 1, 1964. A plastic intrauterine contraceptive device, measuring approximately 3 x 3.5 cm. (often re- ferred to as the Lippes S-shaped loop, named Fig. 1. X-ray of the abdomen showing a plastic intra- after its inventor, Dr. J. Lippes) was subse- uterine contraceptive device. quently removed. The patient made a rapid and uneventful recovery and was discharged from the hospital two days following surgery, in good condition. pessary is exposed to the vaginal mucosa and lies within the endocervix, partially extending Discussion into the uterus, thus permitting an avenue for Although a thorough survey into the past and ascending infection. One entirely intrauterine de- present use of intrauterine contraceptive devices vice, the Grafenberg Ring (named after its dis- is not the intent or purpose of this article, it is coverer, Ernest von Grafenberg), was intro- believed that a brief discussion of the evolution duced as a contraceptive device approximately of such devices would be of interest to the 30 years ago. Since its introduction many re- reader. ports have been published concerning its effec- Intrauterine contraceptive devices were prob- tiveness as a birth control measure and the ably derived from stem pessaries which were various hazards inherent in its use. used as far back as the 1890s. In contradistinc- It has generally been thought that complica- tion to wholly intrauterine devices, the stein tions such, as infection are relatively "minor"

1060/96 Fig. 2. Above, Margulies spiral. Fig. 3. Left, below, Lippes S-shaped loop. Fig. 4. Right, below, Birnberg bow in small and regular sizes.

hazards. However, reports have cited findings ring was approximately 2.5 per cent, the length which are contrary to these assumptions. Cases of time the user was exposed to the risk of have been reported where the ring was found in pregnancy was not taken into consideration. a cul-de-sac abscess ; 1 in a case of acute pelvic In a recent extensive study of use of the infection the ring was found within the uterine Grafenberg ring, 37 per cent of patients ex- mucosa ;2 and in one case in which a laparotomy perienced some type of complication or there was performed the ring was found within the was histologic evidence of infection or inflamma- broad ligament. 3 One report also mentioned a tion. In most patients, the ring was inserted 6 case in which the ring had eroded through the to 8 weeks postpartum. Complications included uterine wall and a loop of small bowel had changes in menses ; extrusion of the ring ; passed through the ring, resulting in obstruc- symptoms unrelated to menses, i.e., pain, cramp- tion.4 Finally, there have been cases of sterility ing, bleeding, discharge, fever, etc. ; and preg- resulting from the patients inability to recall nancy. Histologic specimens were available in that such a device had been previously inserted.6 90 per cent of the patients involved in the study. Although in one series of cases the average In 10 per cent of these, there was microscopic pregnancy rate with the use of the contraceptive evidence of inflammation and symptoms sug-

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gestive of infection. In five cases hysterectomy Summary was performed because of stress incontinence From the case presented in this article and the due to symptomatic cystourethrocele. The con- above discussion, it is evident that there are clusions stated that the ring was not innocuous, hidden dangers inherent in intrauterine contra- that there were complications or evidence of in- ceptive devices. Complications from their use fection in a significant percentage of patients, may lead to permanent injury and/or disability. and that the Grafenberg ring was unsuitable as It is of the utmost importance to obtain an a general contraceptive device. accurate history from a patient whose symp- In recent years, newer intrauterine contra- toms may be referable to the presence of such ceptive devices have been evolved in an attempt devices. As in the case presented, the use of to minimize the side effects and complications such a device was thought to be rather remote associated with the use of the Grafenberg ring from the first history given by the patient. Only and its variations. Since many of the objections after careful and detailed questioning did the to the earlier devices stemmed from the mate- actual cause of her complaints become evident. rials being used, the newer plastics offered a means by which complications arising from the introduction of foreign materials into the uterine cavity could be reduced. These inert polyethy- The author gratefully acknowledges the assistance and advice of Dr. Martin J. Bell and Dr. Jerry G. lene contraceptive devices are of low cost, flex- Rosenblatt. ible for easy insertion, presumably innocuous to tissues, and are said to provide a safe, reliable 1. Clark, H. C.: Foreign bodies in uterus. Amer J Surg 39:631-4, method of contraception. Mar 38 Of the most widely used plastic devices today, 2. Bowles, H. E.: Graefenberg ring, its use and abuse, with case report. Jap J Obstet Gynec 21:2-8, Jan 38 the Margulies spiral (Fig. 2) and the S-shaped 3. Murphy, M. C.: Migration of Grilfenberg ring. Lancet 2:1369- Lippes loop (Fig. 3) have attracted most atten- 70, 16 Dec 33 4. Price, C. W. R.: Unusual cause of intestinal obstruction. Med tion. The newest variation in shape is the Birn- J Aust 1:106-7, 22 Jan 55 berg bow (Fig. 4), consisting of two asymmet- 5. Rozin, S., and Ekerling, B.: Forgotten intrauterine pessary as cause of sterility: Report of 6 cases. Fertil Steril 7:363-7, Jul- rical triangles joined at their apex. Its primary Aug 56 6. Jessen, D. A., Lane, R. E., and Green, R. R.: Intrauterine advantage is reported to be that spontaneous foreign body: A clinical and histopathologic study on the use of expulsion is markedly reduced, an objection the Graefenberg ring. Amer J Obstet Gynec 85:1023-32, 16 Apr 63 7. Birnberg, C. H., and Burnhill, M. S.: A new intrauterine con- present with the use of other types of devices. traceptive device. Amer J Obstet Gynec 89:137-8, 1 May 64 Although these plastic devices offer a potential- ly reliable and acceptable contraceptive method for selected populations and individuals, it is This paper was written during an internship at The Osteopathic Hospital and Clinic of New York, Inc., under the direction of Dr. evident that more studies are required to reduce William D. Miller. or eliminate certain undesirable features. Dr. Lippman, LeRoy Hospital, 40 E. 61st St., New York, 10021.

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