Browsing by Author "Rothman, Kenneth J."

Now showing 1 - 2 of 2
  • Thumbnail Image
    Item
    Demographic, Reproductive, and Medical Risk Factors for Intrauterine Device Expulsion
    (Wolters Kluwer, 2022-12) Anthony, Mary S.; Zhou, Xiaolei; Schoendorf, Juliane; Reed, Susan D.; Getahun, Darios; Armstrong, Mary Anne; Gatz, Jennifer; Peipert, Jeffrey F.; Raine-Bennett, Tina; Fassett, Michael J.; Saltus, Catherine W.; Ritchey, Mary E.; Ichikawa, Laura; Shi, Jiaxiao M.; Alabaster, Amy; Wahdan, Yesmean; Wang, Jinyi; Xie, Fagen; Merchant, Maqdooda; Hunter, Shannon; Chiu, Vicki Y.; Postlethwaite, Debbie; Rothman, Kenneth J.; Im, Theresa M.; Chillemi, Giulia; Takhar, Harpreet S.; Asiimwe, Alex; Pisa, Federica; Obstetrics and Gynecology, School of Medicine
    Objective: To explore to what extent intrauterine device (IUD) expulsion is associated with demographic and clinical risk factors. Methods: The APEX-IUD (Association of Perforation and Expulsion of IntraUterine Devices) study was a U.S. cohort study using electronic health records from three integrated health care systems (Kaiser Permanente Northern California, Southern California, and Washington) and a health care information exchange (Regenstrief Institute). These analyses included individuals aged 50 years or younger with IUD insertions from 2001 to 2018. Intrauterine device expulsion cumulative incidence and incidence rates were estimated. Using Cox regression models, hazard ratios with 95% CIs were estimated before and after adjustment for risk factors of interest (age, race and ethnicity, parity, body mass index [BMI], heavy menstrual bleeding, and dysmenorrhea) and potential confounders. Results: In total, 228,834 individuals with IUD insertion and no delivery in the previous 52 weeks were identified (184,733 [80.7%] with levonorgestrel-releasing intrauterine system). Diagnosis of heavy menstrual bleeding-particularly a diagnosis in both recent and past periods-was the strongest risk factor for IUD expulsion. Categories with the highest risk of IUD expulsion within each risk factor included individuals diagnosed with overweight, obesity, and morbid obesity; those in younger age groups, especially among those aged 24 years or younger; and in those with parity of four or more. Non-Hispanic White individuals had the lowest incidence and risk, and after adjustment, Asian or Pacific Islander individuals had the highest risk. Dysmenorrhea was not independently associated with expulsion risk when adjusting for heavy menstrual bleeding. Conclusion: Most risk factors for expulsion identified in this study appear consistent with known physiologic factors that affect uterine anatomy and physiology (age, BMI, heavy menstrual bleeding, parity). The increased risk of IUD expulsion among individuals of color warrants further investigation. Intrauterine devices are an effective long-term contraceptive; expulsion is uncommon, but patients should be counseled accordingly.
  • Thumbnail Image
    Item
    Risks of Uterine Perforation and Expulsion Associated With Intrauterine Devices
    (Wolters Kluwer, 2023) Fassett, Michael J.; Reed, Susan D.; Rothman, Kenneth J.; Pisa, Federica; Schoendorf, Juliane; Wahdan, Yesmean; Peipert, Jeffrey F.; Gatz, Jennifer; Ritchey, Mary E.; Armstrong, Mary Anne; Raine-Bennett, Tina; Postlethwaite, Debbie; Getahun, Darios; Shi, Jiaxiao M.; Xie, Fagen; Chiu, Vicki Y.; Im, Theresa M.; Takhar, Harpreet S.; Wang, Jinyi; Anthony, Mary S.; Obstetrics and Gynecology, School of Medicine
    Objective: The APEX-IUD (Association of Perforation and Expulsion of Intrauterine Devices) study evaluated the association of postpartum timing of intrauterine device (IUD) insertion, breastfeeding, heavy menstrual bleeding, and IUD type (levonorgestrel-releasing vs copper) with risks of uterine perforation and IUD expulsion in usual clinical practice. We summarize the clinically important findings to inform counseling and shared decision making. Methods: APEX-IUD was a real-world (using U.S. health care data) retrospective cohort study of individuals aged 50 years and younger with IUD insertions between 2001 and 2018 and with electronic health record data. Cumulative incidences of uterine perforation and IUD expulsion were calculated. Adjusted hazard ratios (aHRs) and 95% CIs were estimated from proportional hazards models with control of confounding. Results: Among the study population of 326,658, absolute risk of uterine perforation was low overall (cumulative incidence, 0.21% [95% CI 0.19-0.23%] at 1 year and 0.61% [95% CI 0.56-0.66% at 5 years]) but was elevated for IUDs inserted during time intervals within 1 year postpartum, particularly among those between 4 days and 6 weeks postpartum (aHR 6.71, 95% CI 4.80-9.38), relative to nonpostpartum insertions. Among postpartum insertions, IUD expulsion risk was greatest for insertions in the immediate postpartum period (0-3 days after delivery) compared with nonpostpartum (aHR 5.34, 95% CI 4.47-6.39). Postpartum individuals who were breastfeeding had a slightly elevated risk of perforation and lowered risk of expulsion than those not breastfeeding. Among nonpostpartum individuals, those with a heavy menstrual bleeding diagnosis were at greater risk of expulsion than those without (aHR 2.84, 95% CI 2.66-3.03); heavy menstrual bleeding also was associated with a slightly elevated perforation risk. There was a slightly elevated perforation risk and slightly lower expulsion risk associated with levonorgestrel-releasing IUDs compared with copper IUDs. Conclusion: Absolute risk of adverse outcomes with IUD insertion is low. Clinicians should be aware of the differences in risks of uterine perforation and expulsion associated with IUD insertion during specific postpartum time periods and with a heavy menstrual bleeding diagnosis. This information should be incorporated into counseling and decision making for patients considering IUD insertion.