09 Dec Contraceptive – IUD
Ask the Lady Doctor – Which contraceptive should I use?
Part 3 – IUD’s
The IUD (intrauterine device) is an attractive method of birth control for many women because it is highly effective (99% efficacy), has few associated side effects and is “no nonsense” – meaning once it is in you can forget about it and don’t have to do anything else. You don’t have to remember to take a pill or interrupt the “moment” to put a condom on correctly. And, an IUD does not affect your future fertility – as soon as it is removed you can get pregnant. You may hear the term “long-acting, reversible contraception” or LARC. That is exactly what an IUD is.
How does an IUD work?
An IUD is a small, T-shaped device no bigger than a quarter. Your physician inserts it up into the uterus during an office visit. The IUD strings are soft and pliable and will protrude from the opening to the uterus so that the IUD may be removed when desired. The strings are not felt by the woman’s partner and do not interfere with intercourse or the use of tampons.
There are two types of IUDs: hormonal and non-hormonal (copper).
The copper IUD functions to irritate the endometrial lining of the uterus – a foreign body is present and the body reacts. The addition of copper to the IUD increases this inflammatory reaction producing an environment that is inhospitable to sperm. This inflammatory reaction rapidly disappears with removal of the IUD and fertility is restored.
The pregnancy rate among users of the IUD is 2 to 3 per 100 woman years of use. If pregnancy does occur while using the IUD, it should be removed promptly as there is an increased rate of spontaneous abortion (miscarriage), ectopic pregnancy (pregnancy located outside the uterus), and prematurity.
The copper IUD is generally left in place for 5 – 10 years. In Canada, there are a variety of brand name copper IUDs available:
- Liberte
- Flexi T
- Mona Lisa
- Nova T
A copper IUD will cost between $80 and $160 depending on the brand and the length of time it can be used for. The biggest side effect associated with a copper IUD is bleeding and cramping. Copper IUDs may make periods heavier and are generally contraindicated for women with menorrhagia (heavy, crampy periods).
Copper IUDs may be used for emergency contraception within 120 hours (5 days) of intercourse. They are 99% effective for this purpose.
Hormonal IUDs release progesterone – one of the two hormones found in birth control pills (the other being estrogen). Progesterone prevents fertilization by damaging or killing sperm and making the mucus in the cervix thick and sticky, so sperm can’t get through to the uterus. It also helps to keep the endometrial lining of the uterus thinner which makes it a poor place for a fertilized egg to implant and grow.
Progesterone IUDs are known to reduce menstrual bleeding and cramping and for this reason many older women who may not require contraception but are not yet menopausal, choose to use the Mirena therapeutically to reduce excessive bleeding.
The two hormonal IUDs now available in Canada are Mirena and Kyleena.
The Mirena IUD:
- Reduces heavy menstrual bleeding by an average of 90% after the first few months of use, (making it the therapeutic choice for menorrhagia)
- Reduces menstrual bleeding and cramps
- May cause amenorrhea (cessation of menses altogether)
- May prevent endometrial hyperplasia or endometrial cancer.
- May effectively relieve endometriosis and is less likely to cause side effects than high-dose oral progestin.
- Reduces the risk of ectopic pregnancy.
- Does not cause weight gain.
- Can be left in for up to 5 years.
Kyleena IUD (New in 2017)
- This IUD is designed for nulliparous (never pregnant) women who would like contraception for up to 5 years.
- It has less progesterone (19 mcg as opposed to 52 mcg in Mirena)
- It is more slender for ease of insertion (for women who have not have had children)
- Generally causes menses to be shorter and lighter
- May cause periods to cease in some women
- Associated with fewer side effects
- Often a better choice for women under 30
Both progesterone IUDs are offered at the same price point – just a little under $400. This may same like a lot of money for contraception, however, when you compare it to the cost of 5 years worth of oral contraceptive pills, for example, an IUD is much more economical.
The IUD does not protect against STI’s (sexually transmitted diseases) and condoms should be used for this purpose.
Complications associated with IUD insertion
There are very few problems associated with insertion of an IUD but they can occur. Your doctor will review the following possibilities with you while assuring you that these occurrences are extremely uncommon.
Perforation of the uterus
This complication of IUD use is associated with 1 in 1000 insertions. The IUD should be removed if the uterus has been perforated. Fortunately, this is a very rare occurrence even though it is a potentially serious complication. Excessive pain (cramping) is the main symptom. Your doctor would send you for either an x-ray or an ultrasound test to locate the device. If it is outside the uterus (i.e. in the abdominal cavity) it must be surgically removed to prevent adhesions and bowel obstruction. A perforated uterus will heal up nicely on its own and does not affect your ability to have a child.
Infection
When the IUD is inserted into the sterile uterine cavity, bacteria are inadvertently introduced – no matter how careful the physician. Your immune system usually has no problem arresting any developing infection. Nevertheless, occasionally pelvic infections may occur following IUD insertion. Infection rates are highest in the first 2 weeks following insertion. Your risk for developing a pelvic infection with IUD insertion increases if:
- You have a prior history of PID (pelvic inflammatory disease)
- You are younger than 25 and have not had children
- You have multiple sex partners
Expulsion
Another complication of IUD usage can be spontaneous expulsion. About 2 to 10 out of 100 IUDs are pushed out (expelled) from the uterus into the vagina during the first year. This usually happens in the first few months of use.
Expulsion is more likely when the IUD is inserted right after childbirth or in a woman who has not carried a pregnancy. When an IUD has been expelled, you are no longer protected against pregnancy. If the Mirena or Kyleena is expelled within the first few weeks of insertion, the manufacturer will replace it free of charge. Again, the risk of a second expulsion is very low.
What are the side effects of having an IUD in place?
Copper IUDs have few side effects beyond bleeding and cramping. Progesterone IUD’s can cause hormonal side effects similar to those caused by oral contraceptives. These include:
- Abnormal bleeding (spotting or heavier bleeding)
- Acne
- Worsening migraine headaches
- Worsening depression
- Decreased libido
- Benign ovarian cysts (that resolve spontaneously)
If you suffer with any of these conditions it does not mean that a hormonal IUD is not an option. It does mean, however, that your physician should weigh the pros and cons of copper versus progesterone IUDs and select the one that is best for you. Often, the medicated IUD with less progesterone (Kyleena) can still be a good choice for women who are being treated for depression or suffer with migraines from time to time.
The majority of side effects cause by the IUD will resolve within a few months. Remember that by far the most common side effect of having any IUD in place is bleeding.
What is it like to have an IUD inserted?
It is about a 20-30 minute office procedure to have an IUD inserted. Your doctor may suggest that you take a mild analgesic prior to the procedure to help with any cramping. You will provide a urine sample to make sure you aren’t pregnant.
A doctor or nurse may put in your IUD. You will be asked to put your legs up into stirrups (the lithotomy position), the same as for a PAP smear or pelvic exam. A sterile speculum is inserted into the vagina so that the doctor can visualize your cervix. An instrument is used to open the cervix and the IUD is placed up inside the uterus. Some people feel a bit light-headed or faint for a few minutes following the procedure. Any cramping during the insertion usually subsides as soon as the IUD is in place. You are likely to experience some bleeding immediately afterwards.
Most physicians will ask you to return in 6-8 weeks for follow-up. Having an IUD in place doesn’t change your need for PAP smears. Remember that many IUD’s will stop your period but you needn’t worry about pregnancy just because you don’t have a period. Should you desire to have the IUD removed, your doctor will simply insert a speculum and grab onto the strings in one swift move that is mildly uncomfortable.
The Bottom Line
An IUD is a no-nonsense, effective and reliable form of contraception preferred by many. However, there are a few issues to consider in determining if this form of contraception is right for you. Your doctor will explore the various options, discuss the side effects and explain the insertion process.
For a thorough review of this subject, I recommend the following on-line resources:
HealthLink BC
Planned Parenthood
The Mayo Clinic – Mirena IUD
Kyleena
Healthline
More :
Part-1 : Natural Family Planning
Part-2 : Barrier Methods of Contraception
Part-4 : Oral Contraceptive Pill (OCP)
Part-5 : Which contraceptive should I choose?
Reference:
Beck, William. Obstetrics and Gynecology. 4th Edition. Williams & Wilkins. 1997.
© November 2020, Ask The Lady Doctor – Dr Shannon Lee Dutchyn, MD, CCFP FCFP