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Postmenopausal Bleeding in a Woman with an IUD Retained for 42 Years
Dyer, RA, OMSIII, Guay, N, DO
Central Maine Medical Center, Family Medicine Residency, Lewiston, ME
Introduction: The intrauterine device (IUD) is a widely utilized method of contraception
that was first popularized in the 1950s. The first modern IUD was available in the 1920s
and by the early 1970s, a variety of devices were available to women in the US,
including the Lippes Loop. The Lippes Loop was removed from the market in 1985 due
to a decline in IUD use and a new FDA rule that would require further clinical studies to
obtain premarketing approval. The clinical studies included an investigation of the safety
of leaving the IUD in situ when contraception is no longer indicated.
Case: A 69 year old gravida six, para four, abortus two female with a past medical
history of hypertension and morbid obesity presented to a family medicine clinic with of
post-menopausal bleeding. She described a three month history of three episodes of
vaginal bleeding, each lasting less than two days. The patient denied prior episodes,
pain with bleeding, or abdominal pain. Physical examinations of the cardiac, respiratory,
and abdominal systems were benign. The gynecologic speculum exam revealed strings
emerging from the cervical os, but no evidence of bleeding. The bimanual exam
demonstrated no palpable uterine masses or adnexal tenderness. When asked about an
IUD, she recounted that she had one placed 42 years ago, following the birth of her
fourth child. She reported that she had not had it removed because, although she no
longer needed contraception, the device was not causing any discomfort. To assess for
endometrial hyperplasia, an ultrasound was ordered which revealed a homogenous
5mm endometrial thickness. At that time, the patient was referred to the gynecologist for
removal of the IUD (suspected of having become imbedded in the uterine wall) and an
endometrial biopsy. At this visit, a Lippes Loop IUD was removed without complications
and an endometrial biopsy was obtained. The biopsy revealed FIGO Grade 1
endometrial carcinoma and the patient was referred to a gynecologic oncologist for
treatment.
Discussion: This case is amongst only two published cases of endometrial pathology
discovered in the presence of a retained Lippes Loop and postmenopausal bleeding. It
demonstrates that an IUD may be retained for decades before a patient manifests
symptoms to alert a provider. The widespread use of IUDs for the past 50 years and
unknown prevalence of prolonged retention merits increased screening by primary care
physicians. If an examination reveals the presence of an IUD retained after menopause,
it is best for the IUD to be removed. Although there are no studies clearly demonstrating
risk of prolonged retention, the presence of an IUD may delay necessary diagnostic
testing for endometrial pathology. Moreover, this serves as a reminder to all providers
that even when a patient presents in the post-menopausal period, a thorough
gynecologic history and exam is warranted.