There are many contraceptive methods to prevent pregnancy, one of which is the insertion of an IUD. But inserting IUDs has risks or side effects that are often complained of by patients. Even these complaints cause patients to stop using IUDs.

Copper IUD: Side Effects and Discontinuing
Copper IUD
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What are IUDs?

Intrauterine devices (IUDs) are small contraceptive devices that are put into the uterus to prevent pregnancy. There are two types available of IUDs: copper IUDs and hormonal IUDs. The two types of IUDs have different mechanisms of action. The Copper IUD prevents sperm from reaching and fertilizing the ovum. In contrast, the Hormonal IUD is responsible for producing synthetic progesterone hormone, which affects the menstrual cycle.


Why choose Copper IUDs?

There are several reasons for patients to use the Copper IUD as a contraceptive, including good effectiveness, relatively low cost, reversible contraceptive ability, and long-lasting use. Additionally, copper IUDs are nonhormonal so that patients can avoid estrogen or progestin's side effects.



Side Effects of Copper IUD Insertion

a. Abdominal Pain
The insertion of the IUD into the uterus causes abdominal pain in the early months of use. In some cases, the pain can even last up to 6 months and cause discomfort.

b. Perforated Uterine wall
Due to its small shape and the letter T, spiral birth control can puncture the uterine wall, causing bleeding and infection. This condition is also known as uterine perforation. However, this case is rare.

c. Ectopic pregnancy
Because there is a change in the sperm pathway, it is possible to use spiral contraceptives to cause an ectopic pregnancy. Often it occurs in the fallopian tubes. Although it is a rare side effect, an ectopic pregnancy is a severe condition that can be life-threatening.

The occurrence of abdominal pain and cramps in copper IUD users is also a frequent reason for discontinuing this contraception method. Therefore, various studies were conducted to prove whether the copper IUD side effects would reduce over time. If true, this will certainly be a consideration for the patient when choosing a contraceptive method.


Studies Regarding Copper IUD Side Effects

a. Previous Research 
Most clinicians' views regarding the decrease in the prevalence of copper IUD side effects over time are generally based on studies from the 1980s to 1990s. These older studies using a serial measurement method have shown a reduced prevalence of copper IUD side effects such as stomach cramps and menorrhagia within the first year of insertion.

However, these studies have drawbacks. Many participants' data could not be recorded at the end of the period because of loss-to-follow or stopped the IUD early. In fact,  early termination of the IUD is often due to side effects. By only analyzing data from patients who remained on the IUD until the end of the period, the study was at risk of bias because only including satisfied patients.

Moreover, these studies only reported the prevalence of copper IUD side effects in the study population at specific time points. This can lead to undetected specific patterns and changes at the individual level.

b. Recent Research 
Recent studies on the side effects of copper IUDs use longitudinal data analysis methods to assess side effects changes without generalizing the entire sample. By learning from past research, recent studies have anticipated patient dropouts so that bias can be minimized.

Hubacher et al. performed a secondary analysis of a study that studied 1947 first-time copper IUD users for one year. During this period, they collected detailed side effect data and perform trend analysis. This study involved participants who consumed 1200 mg of ibuprofen per day during menstruation for the first 6 months and participants (as controls) who did not take painkillers.

Overall, the results show that menstrual cramps and abdominal pain increase compared to before insertion of the copper IUD. Bleeding during menstruation also continued to increase during the first 9 weeks. However, these effects gradually decreased in the first 12 months after the copper IUD insertion.
However, this study's results indicate an exception: no reduction in spotting and pain in the interval between menstrual periods. Intermenstrual spotting occurrence is thought due to increased secretion of prostaglandins in the endometrium.

There was variation in the subgroup of participants who experienced serious side effects requiring removal of the IUD. In this subgroup,  severe abdominal pain decreased over time, but the intermenstrual spots got worse. Menorrhagia did not change significantly but was reported to have worsened by participants who stopped using the IUD early.

Sanders et al.'s research in 2018 also showed results that were in line with the Hubacher et al. study. There was a decreasing incidence of menorrhagia and abdominal cramps, which was offset by increased patient satisfaction in the first six months of using the copper IUD. However, a limitation of this study is its small sample size of only 77 patients.  To confirm results may need further studies.


Patient Education regarding Copper IUD Side Effects

Using scientific evidence that currently exists, doctors need to educate patients about the benefits and side effects of the copper IUD. Since one of the main reasons for discontinuation of contraceptives was side effects, patients who have been informed about decreasing copper IUD side effects with time may be more able to tolerate temporary discomfort for long-term benefit.

The doctor can also explain that side effects such as pain and cramps that are often most intense during the first three months can be treated with non-steroidal anti-inflammatory drugs (NSAIDs) ibuprofen when needed.

A higher level of satisfaction was reported by patients who felt the decision to choose the type of contraception was their own. The opposite occurs with a low level of satisfaction when the patient feels the method chosen is influenced by the bias of health workers who directs towards or away from a particular method.



Summary
The current study results show that during menstruation, the copper IUD side effects of cramping, abdominal pain, and increased bleeding appear to decrease over time. However, these side effects do not diminish during the interval between menstruation. Further studies with larger populations may be needed to confirm this.

Information regarding the trend of decreasing copper IUD side effects over time needs to be conveyed to patients to make an informed decision when choosing a contraceptive method. Patients who are already informed about this downward trend in side effects may be better able to tolerate the copper IUD's temporary discomfort for its long-term benefit.


References
1. Bateson D, Harvey C, Trinh L, et al. User characteristics, experiences and continuation rates of copper intrauterine device use in a cohort of Australian women. Aust N Z J Obstet Gynaecol. 2016;56(6):655-661. DOI:10.1111/ajo.12534
2. Hubacher D, Chen PL, Park S. Side effects from the copper IUD: do they decrease over time?. Contraception. 2009;79(5):356-362.
3. Sanders JN, Adkins DE, Kaur S, et al. Bleeding, cramping, and satisfaction among new copper IUD users: A prospective study. PLoS One. 2018;13(11):e0199724. DOI:10.1371/journal.pone.0199724
4. United Nations Department of Economic and Social Affairs. Contraceptive Use by Method 2019: Data Booklet. 2019. https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/un_2019_contraceptiveusebymethod_databooklet.pdf