Breakthrough birth control device linked to serious complications
Problems seen to be expected, Bayer says
When a new contraceptive implant came on the market over a decade ago, it was considered a breakthrough for women who did not want to have more children, a sterilization procedure that could be done in a doctor’s office in just 10 minutes.
Now, 13 years later, thousands of women who claim they were seriously injured by the implant are urging the Food and Drug Administration to take the device off the market and to warn the public about its complications.
Troubling long-term data on women using the device, called Essure, were published on Friday after an unusual eight-year delay. Several patients have filed lawsuits against Bayer HealthCare Pharmaceuticals, and representatives of patient groups plan to meet with officials of Bayer, the manufacturer, on today to discuss their concerns.
The device is a small metal and polyester coil placed into a woman’s fallopian tubes in order to make her permanently sterile. The FDA approved Essure after a fast-track review process that prioritized the device because it offered the first alternative to surgical sterilization and promised a quick recovery.
Since then, the agency has receivedmorethan4,000reports of serious complications related to the device, including severe back and pelvic pain, heavy prolonged menstrual periods, and coils that pierced the fallopian tubes and lodged in other organs.
According to a petition filed with the FDA, an inspector was given records of more than 16,047 complaints made to the original manufacturer, Conceptus,between2011and2013,when majority interest in the company was acquired by Bayer. Both the agency and Bayer say Essure’s benefits outweigh the risks.
Essure is sold in at least 23 countries, Bayer said, with some 750,000 devices used worldwide. Company officials declined to say how many American women use Essure but said serious complications were relatively rare.
“There are no signals, nothing that would indicate a problem with Essure,” said Dr. Edio Zampaglione, vice president for medical affairs and women’s affairs at Bayer. “The events being reported and seen are expected for this type of procedure.”
But in interviews with more than a dozen patients, many said the risks were anything but expected.
Angie Firmalino, a 42-yearold mother of four in Tannersville, N.Y., said she experienced severe pain and nonstop bleeding for two years after receiving the implant in 2009.
Eventually, doctors discovered that the coils somehow had gotten lodged in her uterus and had broken apart. She has had several operations, including a hysterectomy, to remove the fragments.
In 2011, Firmalino created a Facebook page to warn about the device. The page now has nearly 17,000 members.
“If I had any idea of the possible consequences of Essure, I would never have chosen it,” said Firmalino, who still takes ibuprofen daily to manage her pain.
In 2000, Kim Hudak was a 28-year-old mother when she volunteered to participate in an early trial of the device. But as soon as she received the implant, she said, she developed a sharp pain in her right hip that did not go away. Her menstrual periods became painful, and she developed a slew of symptoms including fatigue, migraines and joint pain that often kept her from working full time.
“It felt like I had a really severe case of the flu, and those were the good days,” said Hudak, now 43, who works in sales in Cleveland. “I had years and years of doctors telling me I was crazy.”
Hudak has filed a $1 million claim against Bayer seeking reimbursement for injuries and lost wages.
Yet, many women do well with Essure and recommend it.
“I had it done during my lunch hour, and I ran a half-marathon shortly afterward,” said Cindy Dossett, 54, of Newburgh, Ind
She required another procedure to curb menstrual bleeding after getting the implant, but overall, she said, “it’s a pretty easy process.”
Essure was the first device to offer women an alternative to tubal ligation (commonly known as having one’s “tubes tied”) and, as such, was considered a gamechanger, experts said.
The small coils are placed in the fallopian tubes vaginally, without a surgical incision and with minimal anesthesia.
Once inserted, the coils — made of a nickel titanium alloy and a polyester-like fiber called polyethylene terephthalate, or PET — trigger an inflammatory response, causing scar tissue to form and block the fallopian tubes, preventing sperm from reaching ovum. The scarring process can take three months, and women must use other contraceptives until testing confirms the tubes are blocked.
But pain and other serious side effects emerged early in clinical trials required for approval.
In a safety trial that enrolled involving 269 women ages 23-45, the device was successfully inserted into 200 patients. In nine of them, a coil perforated the fallopian tube, was expelled or lodged elsewhere in the body, according to a 2003 report in the journal Human Reproduction.
Trial participants were asked to keep diaries, and nearly 1 in 10 participants recorded painful intercourse, while 1 in 8 had painful menstrual periods during the first three months.
In a subsequent trial of 518 women, only 449 were able to rely on the device. On 21 occasions, the implant perforated the fallopian tubes, was expelled or ended up in the wrong place in the body. At least eight women had surgery to be sterilized or to remove a misplaced coil.
Participants again reported back pain, abdominal pain and pain with intercourse.
At the time, FDA officials were concerned that the trials had followed women only for a year or two, while the implant was meant to last a lifetime. The agency approved Essure in 2002 on condition that investigators continue to monitor the women who participated in the trials for four more years.
The FDA said only 171 women in the smaller trial were followed for five years. A heavily redacted report, posted on the FDA web- site, shows that five women had hysterectomies and at least one became pregnant.
Participants reported 270 adverse events, including dozens involving pain and heavy menstrual periods. Investigators determined only 17 of these were caused by Essure and attributed the rest to other factors. They concluded that pain and bleeding were rare among users.
Although the monitoring period ended in 2007, long-term data on women in the larger trial were published only last week in the journal Minimally Invasive Gynecology.
Of the original 518 participants, whose average age was 31 at the start, only 366 — about 70 percent — were followed for the full five years.
Fifteen women had hysterectomies. The investigators concluded that only two of these major operations were “possibly” related to Essure.
Some 37.5 percent experienced unusually heavy periods on a recurring basis. One in 20 patients had recurrent pelvic pain, 1 in 15 had recurrent painful periods and nearly 1 in 25 had recurring pain with intercourse. Investigators said just one had persistent pain, however.
Because there is no other device like Essure on the market, and because Bayer will not say how many American women have it, experts find it difficult to judge whether the risks are disproportionate. Manufacturers are not required to include control groups in clinical trials, as is standard in drug trials, so there is no comparison group.
FDA officials say they are concerned about the coils moving outside the fallopian tubes but do not believe the device is flawed.
“The agency believes the benefits outweigh the risks in appropriately selected patients who are adequately informed,” Dr. William Maisel, deputy director for science and chief scientist in the FDA’s Center for Devices and Radiological Health, said.
Complications linked to Essure are comparable to those seen following surgical sterilization, said Zampaglione, of Bayer. A 1998 study of women undergoing surgical sterilization in the ’70s and ’80s also found high rates of subsequent hysterectomies, he said.
The slowly accumulating data and patient reports, however, have made other experts uneasy.
The National Center for Health Research, a nonprofit group, has begun analyzing adverse event reports related to Essure, looking for patterns of complications.
“The fact that 16,000 women with children and a lot of things to do are willing to take the time to talk about this is very, very unusual,”saidDianaZuckerman, president of the group, referring to Firmalino’s Facebook page. “I can’t think of another device like this.”
Dr. Aileen Gariepy, an assistant professor of obstetrics, gynecology and reproductive sciences at Yale School of Medicine, has calculated nearly 1 in 10 women with Essure would get pregnant over a 10-year period, a higher rate than that among women who undergo tubal ligation.
She finds it troubling that the long-term study published last week did not include data on 30 percent of the trial participants.
In clinical trials, she said, “the most common reason patients are lost like this is because they had a problem.”
Physicians familiar with Essure are divided. Many use it regularly and say they have had tremendous success.
“It’s the best thing out there,” said Dr. Jeffrey Bittner, a gynecologist in Ottumwa, Iowa. Others are disillusioned. “When Essure came out I was very enamored by it and did a lot of Essures all the time, until I started seeing patients come back with problems and referred to me with complications,” said Dr. Mitchell Creinin, professor of obstetrics and gynecology at UC Davis Health System in Sacramento, Calif. “It’s a great technology. I’m just not sure it’s ready for prime time.”