Intrauterine Devices (IUDs)

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iud
  • hormonal (LNG) or nonhormonal (Cu)
  • most effective method
  • long-acting and reversible
  • must be placed by a physician
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What is an intrauterine device (IUD)?

IUDs are small, T-shaped pieces of plastic that are inserted by a physician into the vagina. There are two kinds of IUD:

  • Copper (Cu) IUD: no hormones, lasts for 10-12 years at a time.

  • Levonorgestrel (LNG) IUD: progestin hormone, lasts for 5-7 years at a time.

IUDs are just as effective as surgical sterilization, and can be removed at any time. Plus, women love them! They have some of the highest satisfaction rates of any contraceptive method.

How effective are IUDs?

IUDs have pregnancy rates of 0.3-0.5%; rates which are similar to surgical sterilization. Because IUDs only need to be replaced at 5-10 year intervals, there is no maintenance involved beyond making sure they are still in place - so these rates are the same for everyone no matter how you use them. They are not affected by medications, either!

How does it work?

Both IUDs act primarily by interfering with the normal movement of sperm. If sperm cannot move properly, they cannot meet an egg and pregnancy cannot occur. The Cu IUD is directly toxic to sperm, but also causes the lining of the uterus to react with its own chemicals and protective cells which harm the sperm.

Both IUDs may also prevent a fertilized egg from implanting in the uterus. However, more research is required in order to tell. Further, this would account for only a very small fraction of the effectiveness of the IUD.

The LNG IUD, because of its progestin hormone, may also act by:

  • thickening the cervical mucus to trap sperm outside the uterus.

  • in some women, preventing ovulation - the release of an egg by a woman's ovary. Without an egg, there can be no pregnancy.

The primary method of action, however, is still through the direct effects on sperm.

Are there any side effects?

The most common side effects for both IUDs are:

  • increased bleeding with menstruation and spotting between periods.

  • abdominal/pelvic pain and cramping.

For most women, these side effects decrease after 6 months. Further, the bleeding and sometimes the pain can be treated with NSAID medications (like ibuprofen).

The LNG IUD, after the initial increase in menstrual bleeding over the first 6 months, causes amenorrhea - no menstruation - in up to 1 in every 3 women who uses it. Up to 3 in 4 women experience a regular, but lighter period.

Because the LNG IUD uses a progestin hormone, some uncommon side effects include acne, bloating and cramping.

Because the copper IUD has no hormones, it does not affect acne, headaches or nausea.

Because they have so few side effects, more women who try IUDs stay with them, than do women who try any other method of birth control!

Are there any other benefits?

IUDs, because of how highly effective they are and the lack of maintenance involved, can help increase sexual drive and spontaneity through peace of mind.

Further, both IUDs have either no hormones or such low levels of hormones that they avoid the side effects associated with hormones.

The LNG IUD can also have several medical uses beyond contraception - birth control. If you have any of the following symptoms, the IUD might help:

  • pain due to endometriosis.

  • menorrhagia - heavy menstrual bleeding.

  • bleeding due to fibroids.

There is some evidence to show that IUDs may decrease the risk of endometrial cancer or thyroid cancer, as well.

Who can use it?

IUDs are safe and effective for women of all ages, whether or not they have already had children.

They can be placed immediately after delivering a baby, miscarrying or aborting a pregnancy. IUDs also do not interfere at all with breastfeeding, and are safe for breastfeeding infants.

They can be used safely in women with a history of blood clots, heart disease, diabetes, bone fractures, HIV and STDs. They do not interfere with medications, and are just as effective in obese women as in everyone else.

The only women who should not use an IUD are those with:

  • an active infection of the uterus, cervix or vagina.

  • an abnormally shaped uterus that will interfere with IUD placement.

  • a possible current pregnancy.

Copper IUDs should not be used by women with Wilson's disease: an inherited illness that interferes with the ability to eliminate copper from the body.

Let your doctor know, also, if you have a history of:

  • anemia, sickle cell disease, thalassemia

  • easy bruising, or if you are on aspirin or warfarin therapy

  • pelvic inflammatory disease (PID) or an STI within the last 3 months

  • a prosthetic heart valve, or endocarditis.

If you have any of these conditions, you will still be able to use an IUD, but your doctor may want to monitor you more closely at first.

How do I get it?

Planning:

Your IUD can be placed at any point in your menstrual cycle, and the copper IUD can even be used as emergency contraception within 7 days of unprotected sexual intercourse. However, with the LNG IUD, you will only have immediate protection if it is placed within 7 days after the start of your last period. If you miss this window, you will need to use back-up contraception (condoms) for 7 days.

Your IUD can be safely placed within 10 minutes following vaginal or c-section delivery, as well, which can minimize the discomfort of placing the IUD. However, there may be a slightly higher expulsion rate - risk of the IUD coming out - right after delivery.

If your doctor has an IUD in the office, you may be able to have it placed the same day you go in if you do not have a sexually transmitted infection and have not had unprotected sex since your last period. Your doctor will test you for gonorrhea and Chlamydia, and may want to test for pregnancy. If you have symptoms of an STI (infection), including itching, burning, unusual discharge or abdominal pain, your doctor may wait for your test results before placing the IUD, or may give you antibiotics.

 

Insertion:

The whole process takes minutes. Your doctor will examine the vagina and cervix before placing the IUD to check for signs of infection. The cervix will then be widened just enough to let the IUD through into the uterus.

When the IUD is in place, a 1-2 inch string, like a tampon string, will hang down out of the cervix. Check for it in the doctor's office to make sure you know what it feels like.

 

What to expect:

There is likely to be some abdominal cramping during the procedure, and anesthetics do not seem to help. 2 in 3 women report that there is minimal to no pain, but others can experience moderate to severe pain. It is temporary discomfort, however, which is significantly less than that of delivering a baby! This cramping and a little spotting should resolve over 1-2 days. Try taking ibuprofen or Aleve to help with persistent cramping.

Few women (2%) faint or become dizzy. You may also experience some nausea. Consider having someone drive you to and from your appointment if this is a concern.

How much does it cost?

IUDs involve a much higher cost up-front, when you first get the IUD, ranging from $500 to $1000. This cost includes the IUD, placement and follow-up appointments with your doctor. Given that IUDs last for 5-10 years at a time, and this is a one-time cost, they end up costing less than most other birth control methods.

Further, some family planning clinics including Adagio and Planned Parenthood, may be able to adjust the price based on income. Not all of these locations offer IUDs, however. Medicaid may be able to help, as well, if you qualify, and other insurance may lower the cost.

What do I do after my IUD is placed?

At home:

There is a risk that the IUD will be expelled - come out of place. This risk ranges widely; between 8-22% of IUDs come out of place. This risk is higher in women who have never been pregnant, or who are immediately post-partum (after childbirth) or post-abortion. If an IUD comes out of place, a pregnancy can occur.

For the first few months, check that your IUD is still in place every week. The risk of expulsion is highest in these first few months, but it can happen at any time.

There is also a risk that the IUD will perforate - poke a small hole in the uterus. This is very rare, and only happens in 1 out of 1000 women. When it occurs, it is usually during insertion. It does not usually hurt and does not usually cause any other health problems if removed. It can theoretically cause problems if it stays in, however, so your doctor will want to remove the IUD if perforation occurs.

To check your IUD:

  • wash your hands,

  • squat down or sit,

  • insert your fingers into your vagina until you feel the rubbery, firm cervix,

  • feel to make sure the string coming through the cervix is the same length as when it was inserted,

  • do not pull.

If you cannot feel the string or the string is shorter than usual, contact your doctor. This does not necessarily mean that your IUD is out of place, since the string can sometimes be hard to find. However, you should use back-up contraception (condoms) until your doctor can check.

 

With your doctor:

Try to follow-up with your physician within 6 weeks in most cases, or 3-4 weeks if the IUD is placed immediately post-partum (after childbirth). Your doctor will check to make sure the IUD is in the right place, will go over your gonorrhea and Chlamydia test results with you and may draw some blood for testing if necessary.

This follow-up appointment would also be a good time to discuss any discomfort or symptoms you may be having, as your physician can check for a cause and prescribe a pain reliever if necessary.

After this first follow-up appointment, unless there is a problem, you need only schedule your annual gynecologic exam.

 

At any time:

There is a slight risk that during the insertion, a vaginal infection can be spread to the uterus. This type of infection is called pelvic inflammatory disease (PID), which is a very serious complication that can lead to infertility. In 1% of women, symptoms may appear within the first month after IUD placement. After one month, however, the risk of infection returns to normal (0.1%).

Although it is normal to have some pain and bleeding for a few days after placement, tell your doctor if:

  • severe pain continues.

  • you develop a fever or chills.

  • you notice unusual vaginal discharge.

  • you have vaginal discomfort.

These could be signs of PID. PID can be treated with antibiotics, but should be caught as early as possible.

 

Pregnancy:

If you become pregnant with an IUD in place, have it removed as soon as possible. The IUD will not cause any birth defects. However, if left in, it can lead to preterm birth and other complications later in the pregnancy.

An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, which can cause severe abdominal or pelvic pain and may require surgery. If you experience this pain or other signs of pregnancy including unusual nausea, breast tenderness or fainting, let your doctor know immediately.

Although the overall risk of pregnancy is lower with an IUD, and therefore the overall risk of ectopic pregnancy is lower with an IUD, if you become pregnant with IUD there is a higher chance that it will be ectopic.

How long will my IUD last?

Copper IUDs are approved for 10 years at a time, though some studies show that they can work for 12 years. That means you go to your doctor once, have the IUD placed, and do not have to change it for 10 years! And, they are effective right away!

The LNG IUD is approved for 5 years at a time, though it has been shown to be effective for up to 7 years. If this is placed within 7 days of the start of your period, it is effective right away. If it has been longer than 7 days since the start of your last period, use back-up contraception (condoms) for 7 days after the IUD is inserted.

Although there is a 5-10% risk that the IUD will be expelled and need to be replaced, both of these IUDs mean you don't have to remember a daily or even monthly pill, ring or injection. Plus, the IUD can be removed at any time if you want to become pregnant or to switch methods.

Myth #1 - Do IUDs increase the risk of infection?

NO! Despite being one of the most popular birth control methods worldwide, many women in the US have never even tried an IUD. This is because of some outdated, faulty information from the 1970s and 1980s about an IUD that is not even on the market anymore; the Dalkon Shield. That IUD did cause increased rates of infection. IUDs that are currently on the market are very safe and very effective.

With current IUDs, if there is already a vaginal infection, insertion of the IUD may spread the infection to the uterus. This means there is a slightly increased risk of pelvic inflammatory disease in the first month after insertion (1%). After that, there is no increased risk of infection. Your doctor will try to minimize the risk of infection by asking you about symptoms of a vaginal infection and testing for gonorrhea and Chlamydia. Your physician may also give you antibiotics if you show signs of infection.

Myth #2 - Do IUDs prevent pregnancy after they are removed?

NO! This myth stems from when IUDs were associated with pelvic inflammatory disease (PID) - an infection of the uterus. PID can cause infertility if it is not treated immediately.

However, modern IUDs are not associated with an increased risk of PID. After removing an IUD, fertility returns immediately, and pregnancy rates return to the same rates as women who did not use IUDs. There is no delay in being able to conceive children after removing an IUD.

Myth #3 - Am I more likely to have an ectopic pregnancy with an IUD?

NO! Because the IUD makes it a lot less likely that you will get pregnant at all, ectopic pregnancies are less common in women who use IUDs.

However, if you do become pregnant, the IUD makes it more likely that the pregnancy will be ectopic, so let your doctor know immediately if you become pregnant with an IUD, or if you experience severe abdominal or pelvic pain.

Myth #4 - Is it unhealthy not to have my period?

NO! Your period occurs when your body needs to shed the lining of the uterus. This lining builds up in response to the estrogen and progesterone hormones released by your body. When these hormone levels drop, the lining becomes unstable and sheds - your period. The progestin hormone in the LNG IUD prevents this lining from building up in the first place.

Therefore, when it becomes time for your period, there is simply less of the lining to shed until in some women, the lining stops building up at all. Therefore, it is perfectly healthy not to have your period with the LNG IUD and can be a lot more convenient for you!

Myth #5 - Do IUDs protect against sexually transmitted infections?

NO! Condoms are the only method currently available to prevent transmission of sexually transmitted infections.