International Journal of Gynecology and Obstetrics 115 (2011) 269272

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International Journal of Gynecology and Obstetrics

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o

CLINICAL ARTICLE

Complications among adolescents using copper intrauterine contraceptive devices

Salah M. Rasheed , Allam M. Abdelmonem
Department of Obstetrics and Gynecology, Faculty of Medicine, Sohag University, Sohag, Egypt

a r t i c l e

i n f o

Article history:
Received 31 March 2011
Received in revised form 30 June 2011
Accepted 27 July 2011
Keywords:
Adolescents
Complications
Copper IUD
Intrauterine contraceptive device

a b s t r a c t
Objective: To evaluate the rate and pattern of complications associated with use of the Copper T 380A
intrauterine device (IUD) among adolescents. Methods: A prospective comparative study of women eligible
for IUD insertion who attended the family planning clinic of Sohag University Hospital, Egypt, between July 1,
2008 and December 31, 2010. The participants were categorized as adolescents or adults. The Copper T 380A
IUD was inserted in all participants and follow-up visits were scheduled at 1, 3, and 6 months. Odds ratio and
2 square tests were used to compare the rates of complications at each visit. Results: Of 1512 patients eligible
for IUD insertion, 852 met the inclusion criteria: 281 adolescents and 571 adults. The rates of pain, bleeding,
displacement, expulsion, and removal of IUDs were signicantly higher in adolescents (P b 0.05). The rates of
these complications were high in adolescents younger than 16 years; the rates then decreased with age and
became comparable with the adult rates at 18 years of age. Conclusions: IUD-associated complications were
high in adolescents up to the age of 17 years. Our data suggest that adolescents younger than 18 years of age
should be counseled carefully before IUD insertion, and examined more frequently to detect displacement or
expulsion of the device.
2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction
The intrauterine contraceptive device (IUD) is one of the most
effective, safe, and globally used contraceptive methods [1]; however, its
use among adolescents is uncommon [2,3], although the reason for this
is unclear. Misconceptions surrounding the use of IUDs by adolescents,
such as an increased risk of pelvic inammatory disease (PID) and
delayed return of fertility, are common [46]. In an attempt to correct
these misconceptions, WHO issued a report declaring that the IUD is
a suitable and safe method for teenagers [7]. Moreover, in 2007, the
American College of Obstetricians and Gynecologists recommended
the IUD as the best contraceptive method for adolescents [8].
Despite these reports, data on the suitability and safety of IUDs in
adolescents, particularly young adolescents, are lacking, inconclusive,
and conicting. Furthermore, all studies concerned with IUD use among
adolescents have considered adolescence as a single or continuous
period of time, although its progression is highly variable [9] and the
genital organs including the uterus and cervix may continue to grow and
mature from one year to the next [10,11]. In addition, we know that the
uterus retains its prepregnancy size and measurement about 6 weeks
after delivery [12,13]. The relatively immature or small-sized uterus and

Corresponding author at: Department of Obstetrics and Gynecology, Faculty of

Medicine, Sohag University, University Street 1, 2334, Sohag, Egypt. Tel.: + 20
932320071; fax: + 20 394602963.
E-mail address: salahrasheed67@yahoo.com (S.M. Rasheed).

cervix of young adolescents may increase or change the rate and pattern
of IUD-associated complications.
The aim of the present study was to evaluate the suitability of use
of IUDs among adolescents by determining the rate and pattern of
IUD-associated complications, according to an individual's age.
2. Patients and methods
The present prospective comparative study was conducted from
July 1, 2008 to December 31, 2010, at the family planning clinic of the
Obstetrics and Gynecology Department of Sohag University Hospital,
Sohag, Egypt. The hospital is a tertiary center located in Sohag
Governorate in the center of Upper Egypt; it provides medical care for
patients of low socioeconomic status primarily. The local institutional
ethical committee provided approval, and written consent was
obtained from all participants.
During the study period, all women eligible for IUD insertion were
invited to participate in the study. Inclusion criteria were women
younger than 30 years of age at the time of IUD insertion who had 1
previous vaginal delivery (primiparous). The exclusion criteria were
presence of any contraindication to IUD insertion [7], nonacceptability
of the IUD by the patient, or refusal to participate in the study.
A careful history was obtained from each patient, followed by
complete general and gynecologic examinations, including transvaginal sonographic evaluation of the pelvis. Under sterile conditions, a
Copper T 380A IUD (DKT, Egypt) was inserted into each participant.
Transvaginal sonography using an Acuson XP (USA) was used to check
the optimal position of the IUD within the uterine cavity. The uterus

0020-7292/$ see front matter 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijgo.2011.07.014

S.M. Rasheed, A.M. Abdelmonem / International Journal of Gynecology and Obstetrics 115 (2011) 269272

was scanned in a longitudinal plane and the distance between the top
of the vertical arm of the IUD and the junction between the
endometrium and the uterine cavity was measured (IUD-ED).
According to our protocol, the optimal IUD-ED was 5 mm or less. If
this distance was more than 5 mm, the IUD was immediately
removed, and another device was inserted. All IUDs were inserted
68 weeks after delivery. Patients who reported IUD insertion
performed after this period were excluded from the study.
Follow-up visits were scheduled at 1, 3, and 6 months after
IUD insertion. At each visit the patients were interviewed by the
authors and asked to describe any complication experienced, such as
postinsertion or intermenstrual pain, bleeding (spotting, breakthrough, menorrhagia or metrorrhagia), abnormal vaginal discharge,
compromised sexual intercourse caused by the husband's perception
of the device strings, and evidence of PID. Transvaginal sonography
was then performed for all participants to ensure the presence of
the IUD, and to assess the IUD-ED distance to detect the possibility
of expulsion or displacement. Displacement was dened as an
IUD-ED distance of more than 7 mm while the IUD was still within the
uterine cavity [14].
The women who met the inclusion criteria were allocated to the
adolescent study group (1319 years) or the adult control group (20
30 years). The rates of complications in both groups were recorded at
each visit. The odds ratios and their 95% condence intervals were
calculated for each complication and compared between the 2 groups.
The 2 test was used to evaluate the statistical signicance and
P b 0.05 was considered signicant. To evaluate the inuence of age on
the complication rates more precisely, adolescents were further
subdivided according to age into: younger than 16 years of age; 16 to
under 17 years of age; 17 to under 18 years of age; 18 to under
19 years of age; and 19 to under 20 years of age. The IUD-associated
complications reported in each age group at each visit were recorded.
3. Results
Of 1512 patients eligible for IUD insertion, 852 met the inclusion
criteria: 281 adolescents and 571 adults. When the adolescent group
was subdivided by age, 19 patients were younger than 16 years; 31
were aged 16 to under 17 years; 57 were aged 17 to under 18 years;
102 were aged 18 to under 19 years; and 72 aged 19 to under 20 years.
The average age of adolescents and adults was 18.1 0.8 years and
26.6 1.2 years, respectively; average body mass indices were
comparable (20.3 0.8 vs 22.1 1.4, respectively). The majority of
the patients (96.9%) were lactating at the time of IUD insertion.
In total, 657 (77.1%) participants attended the 1-month follow-up
visit (244 [86.8%] adolescents and 413 [72.3%] adults); 295 (34.6%)
participants attended the 3-month visit (148 [52.7%] adolescents and
147 [25.7%] adults); and 183 (21.5%) participants attended the 6-month
visit (96 [34.2%] adolescents and 87 [15.2%] adults).
Table 1
IUD-related complications at 1 month after IUD insertiona.
Complication
Pain
Bleeding
Compromised
intercourse
Vaginal discharge
PID
Displacement
Expulsion
Removal

Adolescents
(n = 244) b

Adults
(n = 413)

OR (95% CI)

P value

80

pain
bleeding

70

vaginal discharge
displacement

60

removal

50
40
30
20
10
0
< 16

16-< 17

113 (27.3)
99 (23.9)
81 (19.6)

2.52 (1.082.76)
1.46 (1.022.07)
1.95 (1.8621.18)

0.015
0.034
0.710

58
2
24
7
49

102 (24.7)
0 (0.0)
9 (2.2)
1 (0.2)
23 (5.6)

1.12 (1.593.70)
NA
1.93 (1.063.53)
12.16 (1.4899.50)
2.65 (1.405.03)

0.830
NA
0.001
0.001
0.001

Abbreviations: OR, odds ratio; CI, condence interval; PID, pelvic inammatory disease;
NA, Not applicable for statistical analysis due to the small sample size.
a
Values are given as number (%) unless otherwise indicated.
b
Participants may have more than one complaint.

17-< 18

18-< 19

19-< 20

20-30

Age, y
Fig. 1. Rates of IUD-related complications correlated with age at 1 month after IUD
insertion.

At the 1-month follow-up visit, pain was the dominant complication in both adolescents and adults. The rates of pain, bleeding,
displacement, and expulsion were signicantly higher in adolescents
than adults (P b 0.05; Table 1). The rates of these complications were
high in adolescents under the age of 16 years, then decreased steadily
and became comparable with those of adults at the age of 18 years
(Fig. 1). Two adolescents developed PID; the rst was 16.2 years and
presented about 3 days after IUD insertion, while the second was
16.7 years and presented about 1 week after IUD insertion. The IUD
removal rate in adolescents was signicantly higher than in adults
(20.1% vs 5.6%; P = 0.001). The reasons for IUD removal in adolescents
were IUD displacement in 24 patients (48.9%), pain in 17 (34.7%),
bleeding in 5 (10.3%), PID in 2 (4.1%), and compromised intercourse in
1 patient (2.0%); while in adults, bleeding was the most common
cause of removal, recorded for 12 patients (52.2%), followed by IUD
displacement in 9 (39.1%), and pain in 2 patients (8.7%).
At the 3-month follow-up visit, bleeding was the most common
complication, while the rates of pain, displacement, and expulsion of
the IUD dropped considerably in both groups (Table 2). Despite this
drop, the complication rates remained persistently high in adolescents aged under 16 years but stabilized at the age of 18 years (Fig. 2).
The IUD removal rates were comparable between the 2 groups
(P = 0.12). Pain was the most frequently cited reason for IUD removal
in both adolescents and adults (11 [68.8%] vs 4 [44.5%]) followed
by bleeding (3 [18.7%] vs 3 [33.3%]), and lastly IUD displacement
(2 [12.5%] vs 2 [22.2%]).
Table 2
IUD-related complications at 3 months after IUD insertiona.
Complication

86 (56.9)
77 (35.2)
44 (18.0)
(23.8)
(0.8)
(9.8)
(2.9)
(20.1)

90

Complication, %

270

Pain
Bleeding
Compromised intercourse
Vaginal discharge
Missed threads
Displacement
Expulsion
Removal

Adolescents
(n = 148) b

Adults
(n = 147)

42 (28.4)
55 (37.2)
21 (14.2)
19 (12.8)
9 (6.1)
2 (1.4)
1 (1.7)
16 (10.8)

21 (14.2)
37 (25.1)
26 (17.7)
41 (27.7)
24 (16.3)
2 (1.3)
0 (0.0)
9 (6.1)

OR (95% CI)

P value

2.38
1.76
0.49
0.38
2.33
1.00
NA
1.09

0.004
0.030
0.410
0.001
0.006
1.00
NA
0.120

(1.324.26)
(1.072.90)
(0.092.71)
(0.210.69)
(0.152.74)
(0.137.19)
(0.815.34)

Abbreviations: OR, odds ratio; CI, condence interval; NA, Not applicable for statistical
analysis due to the small sample size.
a
Values are given as number (%) unless otherwise indicated.
b
Participants may have more than one complaint.

S.M. Rasheed, A.M. Abdelmonem / International Journal of Gynecology and Obstetrics 115 (2011) 269272

271

90

70

pain
bleeding

pain

60

80

vaginal discharge
removal

husband bothering

50

70

vaginal discharge

40

Complication, %

Complication, %

bleeding

30
20
10
0

60
50
40
30
20

< 16

16-< 17 17-< 18 18-< 19 19-< 20

20-30

Age, y

10

Fig. 2. Rates of IUD-related complications correlated with age at 3 months after IUD
insertion.

0
< 16

16-< 17

17-<18

18-<19

19-< 20

20-30

Age, y
At the 6-month follow-up visit, the rates of bleeding and IUD
removal had increased considerably in the 2 groups of participants,
while the rate of pain dropped markedly compared with at the
previous visit (Table 3). Despite these changes, the complication rates
remained higher in young adolescents (Fig. 3). Bleeding was the
most common cause of IUD removal in both adolescents and adults
(26 [65.0%] vs 19 [67.9%]). The other causes of IUD removal in adolescents
and adults were IUD displacement (6 [15.0%] vs 0 [0.0%]), desire for
pregnancy (5 [12.5%] vs 8 [28.6%]), and pain (3 [7.5%] vs 1 [3.5%]).
4. Discussion
The extent of IUD use has been reported to range from 3%20% in
European countries and it may be less than 1% in the USA [15].
However, these rates were estimated among all women and may,
therefore, be even less among adolescents. The misconception about
the increased risk of PID, risk-taking behavior by adolescents, and
nonprotection against sexually transmitted infections are the main
concerns behind the limited use of IUDs by adolescents [5].
IUDs are among the most common contraceptive methods used by
both adults (52%) and adolescents (36%) in Upper Egypt [16]. The
relatively low risk of sexually transmitted infections [16], in addition
to the social and religious prohibition of extra-marital sexual relations
in this relatively conservative Upper Egyptian society, may render the
participants included in the current study ideal for IUD insertion. On
the other hand, myths such as frequent migration of the IUD to other
organs outside the uterus, and its adherence to and injury of the
husband during sexual intercourse, are deeply rooted and were
reported by many patients in the present study (unreported data).

Table 3
IUD-related complications at 6 months after IUD insertiona.
Complication
Pain
Bleeding
Compromised intercourse
Vaginal discharge
Missed threads
Displacement
Removal

Adolescents
(n = 96) b

Adults
(n = 87)

15 (15.6)
52 (54.2)
3 (3.1)
65 (67.7)
0 (0.0)
6 (6.2)
40 (41.7)

6 (6.9)
40 (45.9)
3 (3.4)
42 (48.3)
5 (5.7)
0 (0.0)
28 (32.2)

OR (95% CI)

P value

2.47
1.42
0.89
2.30
NA
NA
1.14

0.075
0.230
0.890
0.010
NA
NA
0.690

(0.91-6.68)
(0.79-2.55)
(0.17-4.54)
(1.26-4.20)

(0.61-2.10)

Abbreviations: OR, odds ratio; CI, condence interval; NA, Not applicable for statistical
analysis due to the small sample size.
a
Values are given as number (%) unless otherwise indicated.
b
Participants may have more than one complaint.

Fig. 3. Rates of IUD-related complications correlated with age at 6 months after IUD
insertion.

Nevertheless, these myths may lead to considerable patient apprehension and may eventually lead to either nonacceptability of the
device or its early removal.
Despite these foundations, there are few Egyptian studies that
have evaluated the suitability of IUDs for adolescents. Moreover, the
majority of studies concerned with IUDs and adolescents conducted
worldwide were either retrospective, which may have the shortcoming of missed or under-reported data [1719], or had a small sample
size [20,21]. More importantly, all studies that have addressed this
issue dealt with adolescence as a continuous period of time, although
the size, growth, development, and maturation of the uterus and
cervix may differ from year to year [10,11].
The present study was a prospective comparative study that was
designed to evaluate the rate and pattern of IUD-associated complications among adolescents, according to individual age. The study
showed that the rates of pain, bleeding, displacement, expulsion, and
IUD removal were higher in adolescents than adults throughout the
6-month follow-up period. In addition, the rates of these complications
were high in women younger than 16 years of age, then decreased
progressively and became comparable with the adult rate only at
18 years of age.
Previous studies reported that the rates of pain and bleeding
associated with IUDs were inuenced by the uterine cavity/IUD
surface area [22,23]. Moreover, many investigators concluded that the
uterus of a pubertal girl continues to grow and may reach full size and
maturity only many years after menarche [9,10]. One of the plausible
explanations for the high rate of IUD-associated complications in
adolescents is the relatively small-sized uterus in relation to the size
of the IUD. This explanation is supported by two observations derived
from the present study: rstly, the reported high expulsion and
displacement rates of IUDs in adolescents, particularly in those
younger than 16 yearsa nding that may suggest the tendency of
the small-sized uterus to get rid of the large-sized IUD; and secondly,
the tendency of IUD-associated complications to stabilize at the age of
18 yearsa time at which the uterus may have attained its full size
and maturity.
The theory of biologic immaturity of the uterus was postulated as
a cause for poor pregnancy outcome in gravid adolescents [24]. The
present study not only showed that IUD-associated complications
were higher in adolescents, it also provided a preliminary postulation
that may extrapolate this theory as the reason behind the high rate of
IUD-associated complications among adolescents.

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S.M. Rasheed, A.M. Abdelmonem / International Journal of Gynecology and Obstetrics 115 (2011) 269272

The present study showed that the pattern of IUD-associated

complications varied according to the period of time after IUD insertion.
Pain was the most dominant complication during the rst month in
both adults and adolescents, while bleeding was the most frequently
reported complication thereafter. The high rate of IUD-associated
bleeding, particularly after the sixth month of insertion, may be related
to the gradual fading away of the effect of lactation, which was reported
to ameliorate the problem of IUD-associated bleeding [25,26].
Again, the high rate of pain in adolescents during the rst month of
IUD insertion could be explained by the theory of biologic immaturity
of the uterus. The high rate of pain in adults during that time
compared with the subsequent visits may seem to question this
explanation. However, not only was the rate of pain at that time
signicantly higher in adolescents than in adults, pain was a much
more common cause of IUD removal in adolescents than adults (34.7%
vs 8.7%, respectively). This high rate of pain-attributed IUD removal in
adolescents may reect a much more severe degree of pain as a result
of more intense uterine contractility induced by the relatively largesized IUD [18]. On the other hand, the lower rate of pain in adolescents
during subsequent visits may reect an inherent capability of the
uterus to accommodate this foreign body.
The most evident limitation of the present study was that it did not
test the inuence of parity, particularly nulliparity, on the rates of
IUD-associated complications. However, inserting IUDs in nulliparous
patients was not possible owing to the general tendency of women in
this society to have had at least 1 child before seeking contraception.
Moreover, many studies concluded that the complications of IUDs
were higher in adolescents regardless of parity [26,27]. Lack of
information about the duration of lactation and the use of nonsteroidal drugs that have been reported to alleviate the problems of pain
and bleeding associated with IUDs [28] was another shortcoming.
Although the use of these medications may lessen the IUD removal
rate, the design of the present study did not allow testing the benet
of these medications. A third limitation was the short follow-up
period, which was attributed to the high rate of drop-out during the
follow-up period.
In conclusion, IUDs were associated with higher rates of pain,
bleeding, displacement, expulsion, and removal in adolescents
compared with adults. These rates were high in girls younger than
16 years of age, then decreased progressively and stabilized only at
the age of 18 years. The copper IUD is a suitable option for adolescents
after the age of 17 years. Adolescents younger than 18 years of age
should be counseled carefully before IUD insertion for the possibility
of high complication rates and examined more frequently to detect
displacement and expulsion of the device.
The question remains whether our recommendations are applicable
to other populations with different sexual practices and differences in
the prevalence of sexually transmitted diseases.
Conict of interest
The authors have no conicts of interest.
References
[1] d'Arcangues C. Worldwide use of intrauterine devices for contraception.
Contraception 2007;75(6 Suppl):S27.

[2] Fleming KL, Sokoloff A, Raine TR. Attitudes and beliefs about the intrauterine
device among teenagers and young women. Contraception 2010;82(2):17882.
[3] Mosher WD, Martinez GM, Chandra A, Abma JC, Willson SJ. Use of contraception
and use of family planning services in the United States: 19822002. Adv Data
2004;350:136.
[4] Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet
2000;356(9234):10139.
[5] Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra-Infante F, Guzmn-Rodrguez R. Use
of copper intrauterine devices and the risk of tubal infertility among nulligravid
women. N Engl J Med 2001;345(8):5617.
[6] Harper CC, Blum M, de Bocanegra HT, Darney PD, Speidel JJ, Policar M, et al.
Challenges in translating evidence to practice: the provision of intrauterine
contraception. Obstet Gynecol 2008;111(6):135969.
[7] World Health Organization. Intrauterine devices. Medical eligibility criteria for
contraceptive use. www.who.int. http://whqlibdoc.who.int/publications/2004/
9241562668.pdf. Published 2004.
[8] American College of Obstetricians and Gynecologists. ACOG Committee Opinion
No. 392, December 2007. Intrauterine device and adolescents. Obstet Gynecol
2007;110(6):14935.
[9] Deans EI, Grimes DA. Intrauterine devices for adolescents: a systematic review.
Contraception 2009;79(6):41823.
[10] Holm K, Laursen EM, Brocks V, Mller J. Pubertal maturation of the internal
genitalia: an ultrasound evaluation of 166 healthy girls. Ultrasound Obstet
Gynecol 1995;6(3):17581.
[11] Ivarsson SA, Nilsson KO, Persson PH. Ultrasonography of the pelvic organs in
prepubertal and postpubertal girls. Arch Dis Child 1983;58(5):3524.
[12] Chua S, Arulkumaran S, Lim I, Selamat N, Ratnam SS. Inuence of breastfeeding
and nipple stimulation on postpartum uterine activity. Br J Obstet Gynaecol
1994;101(9):8045.
[13] VanRees D, Bernstine RL, Crawford W. Involution of the postpartum uterus: an
ultrasonic study. J Clin Ultrasound 1981;9(2):557.
[14] Fandes D, Bahamondes L, Fandes A, Petta C, Daz J, Marchi N. No relationship
between the IUD position evaluated by ultrasound and complaints of bleeding and
pain. Contraception 1997;56(1):437.
[15] United Nations. World Contraceptive Use 2005. www.un.org. http://www.un.org/
esa/population/publications/contraceptive2005/WCU2005.htm. Published 2006.
[16] El Zanaty F, Way A. Egypt Demographic and Health Survey 2008. www.measuredhs.
com. http://www.measuredhs.com/pubs/pdf/FR220/FR220.pdf. Published 2009.
[17] Zhang J. Factors associated with copper T IUD removal for bleeding/pain: a
multivariate analysis. Contraception 1993;48(1):1321.
[18] Farley TM, Rosenberg MJ, Rowe PJ, Chen JH, Meirik O. Intrauterine devices and
pelvic inammatory disease: an international perspective. Lancet 1992;339
(8796):7858.
[19] Merki-Feld GS, Schwarz D, Imthurn B, Keller PJ. Partial and complete expulsion of
the Multiload 375 IUD and the levonorgestrel-releasing IUD after correct
insertion. Eur J Obstet Gynecol Reprod Biol 2008;137(1):926.
[20] Lara-Torre E, Spotswood L, Correia N, Weiss PM. Intrauterine contraception in
adolescents and young women: a descriptive study of use, side effects, and
compliance. J Pediatr Adolesc Gynecol 2011;24(1):3941.
[21] Toma A, Jamieson MA. Revisiting the intrauterine contraceptive device in
adolescents. J Pediatr Adolesc Gynecol 2006;19(4):2916.
[22] Anteby E, Revel A, Ben-Chetrit A, Rosen B, Tadmor O, Yagel S. Intrauterine device
failure: relation to its location within the uterine cavity. Obstet Gynecol 1993;81(1):
1124.
[23] Castro A, Abarca L, Rios M. The clinical performance of the Multiload IUD. I.
The inuence of the endometrial cavity length. Adv Contracept 1993;9(4):
28590.
[24] Stevens-Simon C, Beach RK, McGregor JA. Does incomplete growth and
development predispose teenagers to preterm delivery? A template for research.
A template for research. J Perinatol 2002;22(4):31523.
[25] Stanback J, Grimes D. Can intrauterine device removals for bleeding or pain be
predicted at a one-month follow-up visit? A multivariate analysis. Contraception
1998;58(6):35760.
[26] Stanwood NL, Garrett JM, Konrad TR. Obstetrician-gynecologists and the
intrauterine device: a survey of attitudes and practice. Obstet Gynecol 2002;99
(2):27580.
[27] Rivera R, Chen-Mok M, McMullen S. Analysis of client characteristics that may
affect early discontinuation of the TCu-380A IUD. Contraception 1999;60(3):
15560.
[28] Grimes DA, Hubacher D, Lopez LM, Schulz KF. Non-steroidal anti-inammatory
drugs for heavy bleeding or pain associated with intrauterine-device use.
Cochrane Database Syst Rev 2006;4:CD006034.