National figures show more women are using intrauterine devices, though there are still lingering myths and stigma. (Photo by Getty Images)
By Kirstin Fawcett for US News & World Report
While earning her master’s degree in architecture, Emilie Schmitz barely had time to sleep, let alone remember to take a birth control pill every day. She’d already tried the contraceptive patch – a thin plastic strip that sticks to the body and delivers hormones through the skin – but it had given her a rash. She didn’t like needles and had no desire to choose Depo-Provera, the pregnancy-preventing shot. And in the past, she’d used the NuvaRing – a flexible plastic ring that’s placed inside the vagina and releases progestin and estrogen – but for her, its side effects included “extreme mood swings, to the point where I was crying and then I was laughing.”
During a break from school, Schmitz – now a 28-year-old architectural intern who lives in Atlanta – visited a trusted primary care physician, a female doctor whose husband was an architect. She listened closely to Schmitz’s concerns, and then suggested the student try a form of contraceptive she’d never used before: an intrauterine device, more commonly referred to as an IUD.
IUDs, the doctor explained, are small, T-shaped plastic devices that are either wrapped in copper – a metal that’s toxic to sperm – or release a hormone called levonorgestrel. They’re inserted into the uterus by a health care professional, and depending on the type, can be left inside the body for time periods ranging from three to 10 years. And perhaps most importantly, they’re nearly 100 percent effective in preventing pregnancy. An IUD, Schmitz’s doctor said, would free her from worrying about birth control so she could focus on her budding career.
After weighing her options, Schmitz decided to opt for Mirena, a levonorgestrel-releasing IUD that releases hormones into the uterus instead of the entire body. It’s known to lighten cramps and menstrual flows, and is approved by the Food and Drug Administration for five years of use. Four years later, Schmitz says, it’s almost time to get a new one – and depending on life circumstances such as marriage and pregnancy, she wouldn’t hesitate to choose the method again.
“It was a godsend,” she says. “I didn’t have mood swings, I had very few periods or they were light, and I didn’t have to worry about [pregnancy] anymore. I didn’t have to think.”
Both Schmitz and medical experts stress that there are many different forms of birth control. Some might work better than others for certain women’s bodies and lifestyles, be it condoms, a patch or a pill. But according to recent national figures, more and more women, just like Schmitz, are opting to choose the IUD – once viewed as a contraceptive method best suited for busy mothers – as a first-line method of birth control.
The Guttmacher Institute, a nonprofit organization that works to advance reproductive health, reports that women using long-acting reversible contraceptives, or LARCs – which primarily consist of IUDs, but can also include hormone-releasing implants – have increased among all women, regardless of age, race, education or income. Only 2.4 percent of women used LARCs in 2002. By 2007, that figure had risen to 3.7, and by 2009 it was 8.5 percent.
Similarly, Planned Parenthood reports that it’s seen the total number of patients using IUDs increase 75 percent from 2008 to 2012. In just one year, between 2011 and 2012, the organization says it saw a 19 percent rise in patients with IUDs. And because the data was compiled before the Affordable Care Act’s no-copay birth control benefit took effect, Planned Parenthood says they expect the numbers to keep rising.
Meanwhile, both the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics recently recommended long-acting contraceptive devices as the first choice of birth control for sexually active teenage girls – outweighing conventional views that IUDs and implants were better suited for older women.
But are IUDs the right option for you? Here are a few common questions answered – and a few longstanding myths debunked:
How Do IUDs Work?
At first glance, IUDs look alike – they’re small, plastic, T-shaped devices that are several centimeters high and wide. Thin strings that resemble fishing line dangle from the bottom and are primarily used so the doctor can remove the device and women can manually check to make sure it’s still in place.
However, there are differences between various types of IUDs. Although many kinds are used across the world, the U.S. currently offers three on the market: ParaGard, which is covered in tiny copper coils; Mirena; and Skyla, a new IUD that also releases levonorgestrel but is slightly tinier than Mirena or ParaGard and designed for women who have a smaller uterus.
The basic science of how they work differs as well, according to Anne Burke, an assistant professor of obstetrics and gynecology and director of the Family Planning Fellowship Program at the Johns Hopkins University School of Medicine. For Mirena and Skyla, “The progesterone – which is the kind of hormone that levonorgestrel is – has several contraceptive effects,” she says. “One is that it helps thicken the cervical mucus, which creates a more impenetrable barrier for sperm. It also suppresses the growth of the lining of the uterus, which also probably impacts fertilization and enhances the contraceptive effect. There’s also some evidence that it may impede some of the function of sperm.”
Meanwhile, she says, ParaGard – the copper IUD – creates a mild inflammatory reaction inside the uterus, which primarily helps prevent the sperm from fertilizing the egg.
ParaGard can be left inside a women’s uterus for 10 years, whereas Mirena only prevents pregnancy for five years, and Skyla for three. Upon insertion, ParaGard works to prevent pregnancy immediately; Mirena and Skyla are fully effective after a week. According to the U.S. Centers for Disease Control and Prevention, between 0.2 and 0.8 percent of women who use an IUD will have an unplanned pregnancy within a year.
What’s the Insertion and Removal Process Like?
Before getting an IUD, you’ll usually need to take three things: a pregnancy test if you’re sexually active,an STD test (the insertion process could potentially carry any infections through the cervix into the uterus) and a pain reliever like ibuprofen to alleviate the procedure’s potentially painful aspects. Before actual insertion, the doctor will also perform a quick pelvic exam and check the position of the uterus.
According to Burke, the insertion process itself is done by a medical provider, be it a primary care physician who’s trained in IUD insertion, a gynecologist or another clinician. After explaining any risks and benefits, the procedure begins similar to a Pap smear: The doctor inserts a speculum into the vagina, dilates the cervix and occasionally provides numbing medicine to remove some discomfort. Then, the physician uses forceps to hold the cervix still, and a tool called a sound to measure the uterus to make sure it’s large enough for the IUD to fit inside.
Finally, the IUD is placed into the uterus through an insertion tube, which flattens the IUD’s “T” and pushes the IUD through the cervix into the uterus before it’s taken out. Once the IUD is inside the uterus, the doctor trims the strings so they poke out only slightly beyond the cervix and then removes the speculum. The entire process takes 5 to 10 minutes.
Although IUDs can be left in for years, Burke says a woman can have her IUD taken out anytime she wants. Removal is a no-fuss procedure; a medical provider grabs hold of the strings with forceps and simply pulls the IUD out of the vagina.
As for a women’s return to fertility, it’s “fairly immediate,” Burke notes. “There’s been some studies showing that out of the women who have their IUDs removed and are trying to get pregnant, about 85 to 89 percent … will be pregnant by the end of [a] year,” she says.
Side Effects, Risks and Non-Contraceptive Benefits
Irregular bleeding or spotting is common after the levonorgestrel IUD is inserted, as is cramping, Burke says. Often a woman will continue to get her period for several months after, although half of women don’t experience any form of menstrual flow after about a year. Other than preventing pregnancy, the levonorgestrel IUD can also help reduce cramping, regulate periods and even help prevent fibroids or uterine cancer. And ParaGard can be used as a form of emergency contraception for up to five days after unprotected sex.
The copper IUD carries no hormonal side effects, although some women also report a heavier flow,increased cramping and irregular periods or spotting in between their periods for the first few months.
Rare – but real – risks of IUDs include both potential infections and pelvic inflammatory disease. There’s also a very small chance of uterine perforation, which is when the IUD works its way through the uterus and ends up in a women’s abdomen. Perforation is extremely rare, says Burke; it only occurs in about 1 in 1,000 insertions. But if it does happen, a woman might need laparoscopic surgery – a camera inserted into the body so doctors can locate and remove the IUD.
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Doctors also warn women about expulsion, Burke says, which is what happens when an IUD falls out of the vagina. It’s not dangerous, per se, she notes – but it does mean a woman might be at risk for pregnancy and not realize it. According to Burke, expulsion can occur in 2 to 10 percent of women in the first year of IUD use.
And of course, physicians say, IUDs prevent pregnancy but don’t protect against sexually transmitted diseases or infections. A barrier method of disease protection, they say, should always be used by someone who’s not in a monogamous relationship.
In the 1970s, there was a public and medical backlash against IUDs after a form of the device called the Dalkon Shield resulted in injury, infections, miscarriages, hysterectomies – and in occasional cases, death – in some 200,000 women. The design, which contained a string that wicked bacteria into the uterus, caused pelvic inflammatory disease and blood poisoning that led to infertility. The design was eventually pulled off the market, and thousands of lawsuits resulted in multimillion dollar settlements. The A.H. Robins Company, which manufactured and marketed the Dalkon Shield, eventually went bankrupt in the mid-1980s.
Today’s IUDs are safe, says Megan Kavanaugh, a senior research associate at the Guttmacher Institute. But falsehoods still exist among the general public and medical professionals alike. One, she says, is that doctors worry about fertility and recommend them only to women who’ve already had children.
“The most common misconception about IUDs is that only women who have had at least one child are appropriate candidates for the method,” Kavanaugh says. In reality, more doctors now recognize that IUDs are appropriate for women during all stages of their reproductive careers.
Another concern is the risk of uterine perforation in women who’ve never had children and therefore have a smaller uterus. However, Kavanaugh says, most women have a large enough uterus to fit an IUD, and improved insertion training among physicians has helped dispel this belief.
Other common misconceptions are that IUDs cause ectopic – out-of-uterus – pregnancies, and that a woman can only get an IUD during her period. In fact, she can have it inserted at any time during her cycle.
Which Kind of IUD Would Work Best For Me?
It comes down to personal preference and what you’re most concerned about – lighter periods, say, or avoiding hormones. Burke says women who feel more comfortable about getting an IUD for a shorter duration, for example – be it for family planning reasons or personal preferences – or younger women with a smaller uterus might want to opt for Skyla.
However, she continues, IUDs are generally safe for most women, with exceptions for those who might be pregnant, are allergic to copper or have certain kinds of cancer, such as breast or cervical.
Why Don’t More Women Get IUDs?
IUDs are a fairly common method of birth control in other countries, but data suggests only 8.5 percent of American women use them. Of course, physicians note, there’s still lingering stigma from the Dalkon Shield debacle. But there are myriad other reasons why many women don’t choose IUDs.
One is a steep price tag: Upfront costs for IUDs can add up to several hundred dollars, although over time they prove to be cost-effective. According to Kavanagh, however, the Affordable Care Act will soon diminish costs by allowing all methods of contraception to be covered equally for women who have health insurance from the exchange.
Meanwhile, younger women often aren’t educated about IUDs and are instead taught about the pill and condoms. According to Vanessa Cullins, vice president of external medical affairs for Planned Parenthood, IUDs aren’t marketed to the public as much as birth control pills are – nor have they been available for as many years.
Cullins says that when cost isn’t an issue and misinformation is dispelled, women are more likely to opt for an IUD as their primary form of birth control. She cites the Contraceptive CHOICE Project, a study of 9,256 women conducted by researchers at Washington University in St. Louis. For two to three years, the project educated participants about the safety and efficacy of various forms of birth control, including IUDs. It also provided contraceptives free of cost. Researchers found that when given the choice, 67 percent of participants chose IUDs.
However, Burke stresses, it’s important to note that despite their benefits, an IUD is only right for a woman if it works with both her physical needs and lifestyle choices. “The IUD is one of the most effective forms of birth control,” she says. “And a lot of women who choose it are very happy with it. But it’s really important for women to feel empowered – and to choose any birth control that really makes sense for them.”