Lately IUDs (intrauterine devices) are making as many headlines as Beyoncé. One woman live-tweeted her insertion earlier this year and another wrote how she is “completely and totally obsessed with” hers. Yet despite all the attention (and at times praise), the little T-shaped device isn't an especially popular form of contraception, except with the women who may know the female reproductive system best: gynecologists.
While IUDs are GYNs’ contraceptive of choice (with 40 percent reporting using one), only 11 percent of women ages 25 to 44 have an IUD Differences in contraceptive use between family planning providers and the U.S. population: results of a nationwide survey. Stern LF, Simons HR, Kohn JE. Contraception, 2015, Feb.;():1879-0518. . “They’re safe, they’re effective, and they’re pretty much foolproof,” says Lauren Streicher, M.D., associate clinical professor of gynecology at Northwestern University’s Feinberg School of Medicine and author of Sex Rx: Hormones, Health, and Your Best Sex Ever.
IUDs are appealing because there’s no worrying about missing a dose, your period may lighten or even disappear, and it can save money in the long run. But outdated beliefs about safety and fear about a painful insertion process keeps more women from getting them. While they’re not for everyone, we set out to get all of the facts about this option.
What Is an IUD?
First introduced in the 1960s, IUDs are two-inch T-shaped plastic or metal devices that release either copper ions or the hormone levonorgestrel, depending on the type. Both of these cause the cervical mucus to thicken, which prevents sperm from entering and makes implantation difficult Copper-T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action. Ortiz ME, Croxatto HB. Contraception, 2007, Mar.;75(6 Suppl):0010-7824. . And that means no pregnancy worries (IUDs are 99 percent effective) for at least three years (and many last up to 10!).
It takes about 10 minutes for a healthcare practitioner to insert an IUD through the cervical opening into the uterus, and then you should be good to go. “I recommend that a woman assures herself that the IUD is where it needs to be monthly by inserting a finger into her vagina and feeling for a string that hangs out from the IUD,” Streicher says. “If she can’t feel that string, it’s critical that she come back for a follow up appointment.”
And if you decide you want your IUD removed, no worries: There are no added risks if you do this, and fertility returns quickly after removal, says Alyssa Dweck, M.D., a gynecologist in Westchester, NY, and co-author of V is for Vagina.
The Pros: No Increased Risks, No Pills, No Problem
Compared to IUDs of the '70s (such as the Dalkon Shield, which increased the risk of infections, complicated pregnancies, infertility, injuries, and death), today’s IUDs are widely revered as one of the safest birth control options Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United States. Yoost J. Patient preference and adherence, 2014, Jul.;8():1177-889X. . Once inserted, there’s no increased risk of infection, and the American College of Obstetrics and Gynecologists even encourages IUDs as a first-line approach for preventing pregnancy, stating that they are safe and appropriate for most women, including those who haven’t given birth and adolescents Neisseria gonorrhea and Chlamydia trachomatis screening at intrauterine device insertion and pelvic inflammatory disease. Sufrin CB, Postlethwaite D, Armstrong MA. Obstetrics and gynecology, 2013, Feb.;120(6):1873-233X. .
With perfect use (in which the user reaches into her vagina to make sure the strings of the IUD are still there regularly), the probability of pregnancy is 0.8 percent in the first year with ParaGard and 0.2 percent with Mirena or Skyla—comparable to sterilization procedures. In contrast, birth control pills and vaginal rings have failure rates of 9 percent, and for condoms it's a whopping 18 percent. Plus, you won’t have to worry about popping pills every day, or having vaginal rings or condoms messing with your sex life. Though keep in mind that, unlike condoms, IUDs don’t protect against STDs.
Another benefit is the cost. An IUD will set you back up to $1,000 for the product and insertion. That sounds like a lot, but birth control pills can cost up to $50 a month, so after 20 months, you’re saving moolah. “Patients tell me their IUD is the best contraception bargain ever,” Streicher says.
For many women, the biggest upside of hormonal IUDs is that periods often get lighter and lighter and may eventually disappear altogether ACOG committee opinion. No. 337: Noncontraceptive uses of the levonorgestrel intrauterine system. . Obstetrics and gynecology, 2006, Jul.;107(6):0029-7844. . So long tampons, hello white pants!
The Cons: Heavy Bleeding, Cramps, and Pain (Oh My!)
As with all things, this seemingly miraculous pregnancy preventer isn’t without downsides. The most common side effect of any IUD is a change in bleeding pattern. While hormonal IUDs bring a welcome lighter flow (or none at all), with the copper version, periods often get heavier and are accompanied by more painful cramps, especially at first. “Hormonal IUDs cause the lining of the uterus to be very thin, which decreases bleeding, but the copper IUD doesn’t have that effect,” Streicher says.
Since the IUD has to go up through your cervix, insertion isn’t going to be the most pleasurable experience of your life. But for many women, it’s not so terrible either. “I always recommend women take a Motrin or Advil before coming in,” Dweck says. She recommends scheduling your appointment at the tail end of your period so you know you’re not pregnant, and try to relax. “If you’re too anxious and tense, insertion may be more challenging,” she adds. And for the rare woman, gynecologists will have to utilize a tiny dilator to open the cervix enough to admit the IUD—a process that may make the experience a little more painful.
“While it's hard to predict what each woman’s experience with insertion will be, it’s usually mild to moderate cramping, no worse than a bad menstrual period,” Streicher says. "But if you have a uterus that tips back a little, it’s not a 'straight shot,' so it may be a little harder to place the IUD." Your doc will let you know if you’re like this, and while insertion may be more uncomfortable for you, you can certainly still get an IUD, she adds. In fact, there are very few women who are not good candidates for IUDs.
Afterward, women often experience cramping for up to a couple hours and should wear a pad to account for extra bleeding for up to 30 minutes after insertion, Dweck recommends. If the cramps are I-can’t-move severe or your bleeding is very heavy, go back to your doc to be sure the IUD is positioned correctly, she adds.
Other risks are perforation of the uterine wall during insertion (though that only happens during insertion in about 0.1 percent of cases) and the IUD falling out, which occurs 3 to 6 percent of the time and of course means you’re no longer protected against pregnancy Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the European Active Surveillance Study on Intrauterine Devices. Heinemann K, Reed S, Moehner S. Contraception, 2015, Jan.;91(4):1879-0518. Effects of age, parity, and device type on complications and discontinuation of intrauterine devices. Aoun J, Dines VA, Stovall DW. Obstetrics and gynecology, 2014, Apr.;123(3):1873-233X. . If the IUD falls out, you may also notice an increase in bleeding or pain, especially if it's only partially out (which you should be able to feel with a finger). This is why doctors recommend checking once a month with your finger that the IUD string is hanging about a half inch out of the cervix, Streicher says.
Find the Right IUD for You
Picking the contraception that’s best for you, your body, and your plans for the future should involve a talk with your gynecologist. If you’re considering an IUD, keep these things in mind.
1. Copper IUD: ParaGard
How it works: The copper in Paragard interferes with sperm movement and egg fertilization, preventing implantation.
How long it lasts: 10 years
Cost: $0 to $932 (depending on insurance coverage), plus cost of insertion
Side effects: ParaGard is the only IUD that doesn’t decrease menstruation, and it may make periods heavier. Although no adverse reactions related to copper allergy or Wilson's disease (a rare disorder that causes too much copper to accumulate in vital organs) have ever been reported, hormone-releasing IUDs are still preferred for use in women with these conditions.
Added bonus: Paraguard can be used as emergency contraception and then left in place to provide ongoing contraception. “Like the morning-after pill, copper IUDs can be used as emergency contraception since you have five to seven day before a fertilized egg travels from the fallopian tube to the uterus, and IUDs prevent this,” Streicher explains. This option is great if you’re not only worried about one slip up but also want to avoid the anxiety of potential future mishaps.
2. Hormonal (levonorgestrol) IUD: Mirena, Skyla, and Liletta
How it works: “Levonorgestrol IUDs prevent pregnancy by making the mucus in the cervical opening so thick that even the most motivated sperm can’t get through,” Streicher says. “If one strong sperm does manage to get past that cervical barrier, implantation is unlikely since the hormone progestin makes the uterine lining thin and inactive.”
Cost: $0 to $1000 (depending on insurance coverage; Mirena is the most expensive of the bunch), plus cost of insertion
Side effects: These IUDs decrease—and often completely diminish—menstrual bleeding. In one study, after 24 months of use, 50 percent of users didn’t experience a monthly period, 25 percent had occasional and very light periods, 11 percent reported spotting, and the rest experienced normal or heavy bleeding Bleeding patterns and clinical performance of the levonorgestrel-releasing intrauterine system (Mirena) up to two years. Hidalgo M, Bahamondes L, Perrotti M. Contraception, 2002, Apr.;65(2):0010-7824. . Hormonal IUDs have also been shown to decrease pain from endometriosis An overview of treatments for endometriosis. Brown J, Farquhar C. JAMA, 2015, Feb.;313(3):1538-3598. .
Other side effects are similar to those you’d see on low-dose birth control pills—breast tenderness, mood changes, or acne. “While strictly speaking these are hormonal contraceptives, it’s important that women realize that they’re not in the same category as other hormonal options like the pill or patch since the hormone is released in the uterus instead of in the bloodstream, so there are minimal systemic effects,” Streicher says. “Often, people who are told they can’t use hormonal birth control actually can use hormonal IUDs, so check with your doctor before ruling them out.”
Added bonus: Skyla is smaller than the other two, making it easier to insert and good for women who have never been pregnant and may have a tighter cervical opening, Streicher says.
Still confused? While a talk with your gynecologist is a must, this simple quiz can help you narrow down your options.