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Abstract
Copper-bearing intrauterine contraceptive devices (IUCD) are commonly associated with menorrhagia. They cause certain morphological changes in the endometrium. These have been extensively reported and the mechanisms of menorrhagia have been investigated in a number of studies.
In a study done by Wang et al, they examined the endometria1 morphometry in a group of women using IUCD, a group of women with ovulatory dysfunctional bleeding and a control group of women with entirely normal cycles. There was increased leukocytic infiltration of the endometrium in both groups of women with menorrhagia compared to contro1 cases. In addition, IUCD use was associated with greater luteal phase glandular epithelial height, supporting the concept of a secretory function defect in glandular epithelium.
The morphology of IUCD-exposed endometrium has been widely studied. The effects are seen mostly in the endometrial functional layer and in immediate proximity to the device, even though endometrium away from the IUCD can also be affected ( Sheppard , 1980; El-Badrawi, 1981 ). Effects of the copper-bearing IUCD include denudation of the surface epithelium, stromal leucocyte infiltration and increased vascular density in the functional layer, especially adjacent to the IUCD sites. Associated with these defects are the presence of more contracted and degenerative endothelial cells and microthrombosis in capillary vessels ( Sheppard, 1987; Wang, 1989 ). Ultrastructurally, there is poor microvillus growth of the glandular epithelium, a lack of secretory cytoplasmic protrusions and an abundance of apocrine and glycogen
material within the cytoplasm suggesting defective cellular secretion.
Copper-IUCDs can cause increased menstrual bleeding ( Mishell, 1984 ) the exact mechanism is not completely understood. It has been postulated that vascular defects are partly responsible. In addition, IUCD activation of plasminogen and the fibrinolytic system or activation of lysosomal hydrolytic enzymes ( Wang et al, 1989 ) may also be involved. In this study, both infiltrating leucocytes and vasculature of the endometrial stroma were slightly more abundant in IUCD users than normal subjects, but not significantly so. Histologically identifiable endometrial stromal vessels were concentrated mainly in the superficial layers for all three groups. Their dimensions and density (the number of vessels per field) were similar.
Endometrial stroma of IUCD users contained significantly more plasma cells than that of normal subjects. This is not surprising considering the reported occurrence of “sterile endometritis” in IUCD users due to a foreign body reaction ( Johannisson et al, 1991 ). It should be noted, however, this was not found in all endometria from IUCD users and there was a wide variation in the number of plasma cells per 1000 stromal cells (range 0-8.3) indicating a widely variable host response. While glandular external and luminal diameters remained unchanged, the height of glandular epithelial cells in IUCD-exposed endometrium was significantly greater (26.9u) than in the normal endometriurn (20.3u). This was accounted for by unusually tall columnar epithelial cells in the secretory phase. This phenomenon could not be explained by epithelial height variation which normally occurred throughout the secretory phase as the secretory endometrial biopsies were taken from comparable cycle days in both groups (day 22+/- O.6 in the normal subjects vs. Day 20+/- 1.4 in users of IUCD). In ultrastructural studies, glandular epithelium has