As promised: IUD's
- Jeanette Thomas
- Jun 7, 2024
- 8 min read
The Essential IUD spiel:
We have options for treating period cramping, heavy bleeding, and preventing pregnancy. One of these is a hormonal intrauterine device (IUD). Below describes how I would talk to patients about an IUD, and insert it. There isn’t any one right way to do those things, and your provider may or may not say or do things exactly as I did.
IUD, not actual size.
Image via Yahoo and all over the internet.
IUD 101:
In the US, the IUD comes in 2 types: a copper one and a hormonal one which contains progesterone.
https://www.plannedparenthood.org/learn/birth-control/iud is a great primer and resource.
Ways that IUDs are different:
Copper IUD (brand name Paraguard):
creates a hostile environment for sperm and eggs, preventing fertilization and implantation.
can be used as emergency birth control up to 5 days after unprotected sex
good for 12 years.
It won’t change the timing of your periods, but can cause slightly heavier periods. If you miss a period with a copper IUD, you should do a pregnancy test.
We don’t use the copper IUD to treat heavy or irregular periods, only to prevent pregnancy.
Hormonal IUD (brand names include Mirena or Kyleena, Skyla and Liletta, depending on the size and amount of hormone released):
Slows the movement of the eggs in the tubes, so that if the sperm and egg meet, they aren’t in the right place at the right time for implantation. It also irritates the lining of the uterus to prevent implantation
Can also be used as emergency birth control
Good for 3 to 8 years in young women, depending on the type of IUD.
Great for the perimenopausal transition for many women.
Most common side effect of a hormonal IUD is irregular bleeding and spotting. Let me say that again: THE MOST COMMON SIDE EFFECT IS IRREGULAR BLEEDING AND SPOTTING. This is most frequent complaint right after a hormonal IUD is placed. It almost always gets better after a couple months, up to three months. After that, periods are generally much lighter, with less cramping. Some women have no periods at all. Irregular bleeding after the first 3 months should be evaluated for infection or movement of the IUD.
Ways that IUDs are alike:
More than 99% effective at preventing pregnancy (remember, no birth control is 100% effective)
Once they are in place, you don’t have to think about them. No pill to remember or miss, no shot to schedule. The less you have to think about your birth control, the more effective it is.
You are less likely to get pregnant with an IUD, however, if you are in the less than 1% that does get pregnant, the risk for ectopic pregnancy is increased. Ectopic pregnancy is when the tissue implants outside the uterus, sometimes just placental tissue, sometimes an embryo. This is life-threatening for women, and there is no way to transplant the pregnancy (!! Policymakers, please note). Ectopic pregnancy needs to be treated with medical or surgical removal.
IUD's go inside the uterus, hence the name. Yes, a pelvic exam.
They do not cause abortions.
There is a slight risk of infection in the first month after insertion, but after that they do not increase the risk of getting a pelvic infection or sexually transmitted disease (STD). If you get one with an IUD, it can be more serious.
They don’t cause infertility later in life. Any woman who has a STD or an ectopic pregnancy, related to an IUD or not, may have difficulty getting pregnant when she wants to.
Even if everything goes perfectly with an IUD, it can move after it has been placed. The chance of this happening is <1-3% in women who can/should use an IUD.
It can work its way into or through the muscle wall of the uterus, or it can fall out. Either way, it isn’t going to work once it moves. If it’s going to move, it is usually in the first few months after insertion.
If it goes into or through the uterine muscle, it has to be removed. Sometimes this requires a minor surgery to see it and take it out. While this is a bummer, it shouldn’t impact your ability to get pregnant in the future.
IUD’s are less effective if the uterus is too big, and more likely to move or cause problems if the uterus is too small.
Image not meant to scare you, but what pops up in an internet search. Copyright Dittrick Medical History Center.
IUD's currently in use in the US pictured below.
“I read on the internet...” Ask your doctor about whatever hideous story you read. Nothing is risk free, but most people will have a better experience than what you read. People who have a horrific experience are more likely to write about it than women who loved it.
There were some IUD’s that caused bad pelvic infections. These haven’t been used since the 1970’s.
Copper IUD. Image copyright NHS
Hormonal IUD. Image
copyright University of Michigan
You can always have the IUD checked with a pelvic exam, and should have it checked if you have severe pain, heavy or unusual bleeding, feel part of it where you shouldn’t, or have a positive pregnancy test at home.
“Sign me up—”
placement and removal happens in a clinic, you can’t do it at home
(in the you cannot make this up category, I once had a patient whose scumball "boyfriend" made it his mission to remove the IUD's of his many partners by feeling the strings with his fingers and pulling them out. Ick. She deserves better. You deserve better.)
It is safest and easiest to insert during your period. For real. It is also less crampy to do it then, because the cervix is open a little bit. During your period is also the time when we can best confirm that you aren’t pregnant when we put it in.
You might find the idea of having a vaginal exam while you’re bleeding gross. Trust me, your gyno has no issues with this.
Your doctor will usually do a pregnancy test and talk to you first. If the timing is right, the pregnancy test is negative, and you want to go ahead, then an IUD may be placed that day. Your doctor may not place it if there’s concern for a pelvic infection or STD already, or if we can’t confirm that you’re not pregnant.
So don’t have unprotected sex for at least 2 weeks before your appointment. If you’re already using something reliable, like the pill, time your visit for when you’re on your period/your sugar pills.
“Isn’t it going to hurt?”
It is a pelvic exam, so that’s always a little uncomfortable. Putting it in will be crampy, but that usually gets better by the time you leave the clinic. Taking ibuprofen (600 mg, or 3 of the over the counter pills) about an hour before your appointment helps. Eat something before you take the ibuprofen. You can also take this again 4 hours later if you’re still cramping. If you can’t take ibuprofen, you can take two extra strength Tylenol.
If you tend to get light-headed or dizzy, you can take this with something with sugar and caffeine, like a coffee or regular pop. My personal preference is a diet Coke and dark chocolate.
Most women who have had vaginal sex and/or use tampons don’t have an issue with the exam or IUD placement.
It isn’t going to be pain free, but the pain should be improving by the time you leave the clinic.
See “Not your mom’s Gyno visit” from February 13 and/or 22 for relaxation tips for pelvic exams.
Music, deep breathing, essential oils, visualization, etc.
I say cramping instead of pain because it’s from the uterine muscle, like bad period cramps. Some women have very little pain. Some have a lot.
The clamp on the cervix or a numbing shot will be a sharp pain.
There’s a lot of buzz right now about doctors diminishing women’s pain with office procedures. Yes, you could get a numbing shot in the cervix for this procedure. I guarantee the shot will hurt more than the IUD insertion.
In addition, the worst pain with an IUD isn’t usually at the cervix. It’s the muscle cramping above, in the uterus. A numbing block on the cervix isn’t going to help this.
“How do you place it?”
Your doctor will feel the size and shape of your uterus with her hand. This is so she knows if it tilts forward or backward, or if the shape is abnormal.
Then she’ll put in a speculum or duckbill. Do all the relaxing things that work for you.
She may collect a sample from the vagina or cervix to look for an infection that is already there, and treat it as needed. Sometimes, the concern for infection is high enough that the IUD can’t safely be placed until we have those results.
The cervix is cleaned with a cold solution. This may give you a funny brown discharge that can stain your clothes. Plan to wear a pad or liner. It is also normal to have light bleeding the day of placement.
Not the day to wear a thong or go commando.
A small clamp will be used to hold the cervix in place. This is sharp pain /crampy.
The size of the uterus is confirmed with a tube or rod that goes inside, through the cervix. This is removed, and used to gauge how far the IUD should be inserted. This is more crampy.
The IUD is set to the length of the uterus, and inserted through the cervix. This is big time crampy.
The strings are trimmed, and the clamp and speculum are removed. The cramping should start to get better.
If you are lightheaded or dizzy after this, tell your doctor. They will have you lay down on your side for a few minutes until this gets better. Don’t try to get dressed until it improves.
“What about those strings?”
They do stick through the cervix, so that the IUD can be removed when needed.
They get softer with time. Most partners don’t feel them, or if they do, they aren’t painful or bothersome. Yes, there are studies to support this.
Like a tampon, if they are in the right place, you shouldn’t feel them unless you go looking for them.
They are also used to check the position of the IUD, either by a provider or yourself at home. Most women never check them at home.
If you want to check the strings, you put your finger inside the vagina, way up by where the top of a tampon goes. The cervix feels firmer than the vagina, like the tip of your nose compared to your cheek. Move your finger around the cervix, like a clock, until you feel something that feels like fishing line. This is the string. It’s ok if you only feel one.
If you don’t feel them, they are usually up inside the uterus, wrapped around the IUD. As long as we know that the IUD is in the right place, this isn’t a big deal.
If you have felt them in the past, and can’t now, your provider can always check for them with a pelvic exam. Sometimes an ultrasound or x-ray is needed. Definitely have it checked if you have severe pain, heavy bleeding, or other concerning symptoms.
"I'm done with it"
To take it out, we basically reverse those steps. Speculum, grasp strings, remove. Sometimes we have to use a special tool or trick if the strings are hiding. If you’re taking it out because the time is up, and you want another IUD, we can generally place a new one at the same time. When you need a pap smear, or testing for infection, this can be done with the IUD in place.
Again, from our friends at the Cleveland Clinic.
Questions? Absolutely ask your doctor.
For real world, boots on the ground, what do women do when their reproductive choices are threatened: They seek control of their own bodies via sterilization or LARC--Long Acting Reversible Contraception--IUD's and the implant rod. We put in more IUD's and implants in the Trump Era and after the takedown of Roe v Wade than ever before.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9341462/#:~:text=LARC%20use%20among%20U.S.%20women,2011).
Sterilization is meant to be permanent, and is clearly not a great choice for young women--the biggest risk for women under 30 is that they will regret having their tubes tied or removed.
In the clinic we heard stories of women who feared that their access to LARC would be cut off; from middle aged moms to those moving to more restrictive states OR middle aged moms whose daughters were moving out of state for college. Women want bodily autonomy.
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