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BACKGROUND: The objective of this study was to evaluate obstetrician/gynecologist (OB/GYN) protocols regarding single-visit intrauterine device (IUD) insertion in Rhode Island. STUDY DESIGN AND METHODS: We conducted an online cross-sectional study of OB/GYNs in Rhode Island regarding TUD insertion protocols. The primary outcome was the proportion of respondents who provided single-visit TUDs. RESULTS: The response rate was 70% (80/114). Fortytwo percent (42%) (95% CI, 30.3-55.2) of OB/GYNs reported they would provide an TUD with one clinical visit for counseling and insertion. However, only 22% (95% CI, 12.5-34.0%) reported that patients in their practice typically have a single visit for TUD placement. More OB/GYNs would add an IUD to an annual visit if they were presented with a Black patient vignette compared to a White patient vignette (58% vs 24%, p = 0.01). Barriers to single-visit TUD insertion included scheduling constraints and insurance and billing concerns. CONCLUSION: In Rhode Island, access to OB/GYNs willing to provide IUDs in a single visit as part of usual practice is low.

Background Though safe in most circumstances, intrauterine device (IUD) has some rare serious complications such as missing IUD, uterine perforation, missing strings, and pregnancy with IUD in situ (failed IUD). This study reviewed IUD complications and management techniques utilized at a national complex family planning center in Ethiopia. Methods This was a retrospective study of women who had an IUD complication and were managed at St. Paul's Hospital Millennium Medical College in Addis Ababa, Ethiopia between May 2017 and April 2024. Data were collected retrospectively by reviewing the medical records of patients. Data were analyzed using SPSS version 23. Simple descriptive statistics were employed. Frequency and proportions were used to present the results. Results Thirteen cases were excluded due to incomplete data. Out of the 27 women included in the final analysis, 12/27 (44.4%) had a missing IUD, followed by 7/27 (25.4%) who had missing strings. There were two cases of pregnancy with IUD in situ. Among those with a missing IUD, 10 were diagnosed with uterine perforation and were managed surgically (9 managed laparoscopically and one managed with an open laparotomy). Both women with a pregnancy and IUD in situ chose to continue the pregnancy after removing the IUD. Conclusion In this study, missing IUD (with uterine perforation diagnosed in 10 out of 12 patients) was the most common complication, occurring in close to half of the study participants. Ultrasound should be routine in evaluation of missing IUDs, and laparoscopy should be considered the gold standard for extrauterine removal, even in low‐resource settings (patients with such serious complication should be referred to centers that have this capacity). Missing IUDs should be carefully evaluated with ultrasound, as uterine perforation is a common finding. We support laparoscopic removal of IUD as the standard for management for extrauterine IUDs.

Malpositioned intrauterine devices (IUDs) are not yet a well recognized cause of acute pelvic pain. Correct identification relies on recognizing key imaging findings such as low-lying or endocervical positioning, and an understanding that acute pelvic pain may be the result of a malpositioned IUD. We report the case of a 28-year-old sexually active female (she/her/hers) with a history of a malpositioned IUD, who presented with sudden onset, unprovoked, right sided pelvic pain. She denied hematuria, dysuria, vaginal discharge, or vaginal bleeding. On physical examination she noted right-sided pelvic tenderness below McBurney's point; however, a pelvic examination was deferred. Ultrasound revealed an IUD in the endocervical canal. A CT confirmed a low-lying IUD. These findings were initially interpreted as normal. Only after follow-up with primary care, the IUD was removed and the patient reported complete resolution of her symptoms. This case highlights the importance of recognizing malpositioned IUDs on imaging. As in this case, misdiagnosis can result in overtesting and delays in patient care. Emergency providers should be familiar with radiographic findings and include malpositioned IUDs on their differential diagnosis.

INTRODUCTION:The use of intrauterine devices are a core of contraception practiced globally. There are several different types and brands that are FDA Approved for use in the United States. The advantages include their length of efficacy, one cost, and safe for breastfeeding. The risks of using IUDs include infection and migration. These risks have been as high as 3% but more consistently at one to two percent. Usual mechanisms for migration include erosion through uterine tissue or expulsion from vaginal canal. Once migrated the device is removed and another is placed as efficacy drops.CASE DESCRIPTION/METHODS:Patient is a 43-year-old female Hispanic American who presented to the hospital with complaints of generalized abdominal pain and low back pain for one year. The patient has no past medical history and does not take any medication besides ibuprophen for minor aches and pains. The patient has a surgical history of copper IUD placed five years prior. The patient mentions at a recent appointment with her primary care doctor her “liver tests” were “a tad elevated.” The patient has no family history of cancer or gastrointestinal history. Labs were performed and were WNL other than moderately elevated transaminases. Imaging demonstrating the patient’s intrauterine device had migrated to the anterior portion of the liver.DISCUSSION:There have been less than three cases including this one where an IUD migrated to the liver. The migration of the copper IUD was causing the transaminitis and general abdominal pain. This Case was chosen because it demonstrates a complication that is less than one percent. There have been very limited cases of an IUD migrating to the liver and even lower causing transaminitis. The mechanism of the migration in this case is unknown and thus makes this case very unusual. The proposed mechanism is erosion through the uterus and migration to the anterior portion of the liver.

Introduction/BackgroundComplex atypical endometrial hyperplasia suggests a pre-malignant state of endometrial cancer which tends to occur in women of reproductive age. Oral progestins have been used as conservative treatment in young women with atypical endometrial hyperplasia who want to preserve their fertility. This treatment can be used alone or combined with Levonorgestrel-releasing intrauterine system (Mirena). LNG-IUD could be also used alone. The aim of our study was to evaluate the response of treatment in women who received oral progestins as monotherapy and others who were treated with LNG-IUD.MethodologyWe conducted a randomized prospective study, at the gynecological department of the Naval Hospital of Athens since 2019. We included women, 32–38 years old, with complex atypical endometrial hyperplasia, treated with oral progestins alone, compared to Levonorgestrel-releasing intrauterine device. The histology of the patients was reevaluated every 6 months by hysteroscopy and curettage.ResultsSo far, 12 women wishing to preserve fertility, have been included in the study. Five patients received oral progestins alone and 4 out of 5 achieved disease regression. Five patients were treated only with LNG-IUD and are free of disease. Two quite obese patients were treated with a combination of LNG-IUD and oral progestins and are also free of disease.ConclusionAlthough a larger sample is needed, the preliminary results are encouraging. Both oral progestins and LNG-IUD are effective in women who undergo fertility sparing treatment. Megestrol acetate had higher and quicker remission rates than medroxyprogesterone acetate. Regarding disease regression, the LNG-IUD proved to be more effective. Furthermore, there were no side effects associated with the use of LNG-IUD, whereas one woman who received megestrol acetate experienced secondary adrenal insufficiency. After complete response, conception should be recommended. Maintenance therapy with strict follow-up can also be proposed to decrease recurrence, along with proper counseling over the safety of this approach.DisclosuresNo conflict of interest

Intrauterine devices (IUDs) are effective and safe long-acting reversible contraceptive methods for preventing unplanned pregnancies. While extensive studies were conducted to evaluate return to fertility after removal of IUDs, majority of them were focused on multiparous women using copper IUDs. Current trends indicate increased use of levonorgestrel (LNG) IUDs in nulliparous women for very long periods of time, with both nulliparity and long duration of LNG-IUD use being potentially associated with trends towards longer time to conception post removal. Understanding the effects that LNG-IUDs may have on endometrial morphology and gene expression has important implications to further understanding their mechanism of action. Studies examining endometrial gene expression show persistent changes in receptivity markers up to 1 year after removal of an inert IUD, and no similar studies have been performed after removal of LNG-IUDs. Given the current gap in the literature and trends in LNG-IUD use in nulliparous young women, studies are needed that specifically look at the interaction of nulliparity, long-term use of LNG-IUD, and return to normal fertility. Herein, we review the available literature on the mechanism of action of IUDs with a specific focus on the effect on endometrial gene expression profile changes associated with IUDs.

Fibroids, which are common in women of reproductive age, may cause heavy menstrual bleeding and symptoms related to leiomyoma bulk. Hysterectomy is an effective treatment, but many uterine-sparing options are available and should be discussed with patients. Foreword This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations. Stage A 47-year-old black woman has heavy menstrual bleeding and iron-deficiency anemia. She reports nocturia and urinary frequency. A colonoscopy is negative. Ultrasonography shows a modestly enlarged uterus with three uterine fibroids. She is not planning to become pregnant. How should this case be evaluated and managed? The Clinical Problem Uterine fibroids (leiomyomas or myomas) are extremely common benign neoplasms of the uterus. 1 The lifetime prevalence of fibroids exceeds 80% among black women and approaches 70% among white women. 2 In a study using ultrasonographic screening, 51% of premenopausal women received a new diagnosis of fibroids. 2 Fibroids can cause heavy or . . .