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Tuesday, January 24, 2012

Contraception: IUDs

Author : Dr Jennifer Frank University of Wisconsin School of Medicine and Public Health Appleton, Wisconsin

2010-03-12

INTRAUTERINE DEVICES: IUDs

Background Info
   If you are in your 30's or older you probably have heard about the Dalkon Shield used in the 1970s.  It was an intrauterine device (IUD) - something that stays inside the uterus to prevent a pregnancy.  Unfortunately it caused a lot of harm - infections and even a few deaths - and made IUDs an unpopular form of birth control.  I learned from yahoo.com that IUDs were actually first invented in 1909.  Those early models are not in use today, but there are two available IUDs in the U.S.  One is a copper IUD - it looks like a small T and fits easily inside the woman's uterus.  Another is the levonorgestrel (a fancy name for a hormone called progesterone) impregnated IUD called Mirena.  It also looks like a T and fits easily inside the uterus.
How IUDs work
    IUDs prevent pregnancy by preventing the sperm and egg from meeting.  Copper IUDs release copper ions (or very small particles) that harm sperm, making it difficult for the sperm to get far enough to fertilize an egg.  Levonorgestrel IUDs (LNG-IUD) release a small amount of hormone (progesterone) that makes cervical fluid thick (so sperm can't get through) and makes the uterus an unfriendly place for both sperm and fertilized eggs.  Approximately one out of every four women will also stop ovulating (not release an egg) and may not have periods at all.

    IUDs can also make the environment (fallopian tube and uterus) inhospitable (not very friendly) to a fertilized egg.  Some people think this is like an abortion because it prevents a fertilized egg from implanting.  Some people do not consider this an abortion-like effect. Whatever your view is, it is important to know that this is a possible effect of the IUD, although not the main way that it works.
Where everything is located

Copper IUDs versus hormonal IUDs (LNG-IUD)
The Copper IUD generally does not make your menstrual flow lighter or less frequent but can stay in place for up to 10 years.  The LNG-IUD often make women's periods lighter and less frequent, but only can stay in place for up to 5 years.  They are equally effective in preventing pregnancy - about 99% effective.



So, who can get an IUD? 
Well, there is a lot of misleading information out there.  Basically, you may be a good candidate for an IUD if:

-You've had a baby or you've never had a baby
-You have a normal shaped uterus
-You are not at risk for sexually transmitted infections - this usually means that you are with one sexual partner long-term
-You are not in the middle of an evaluation for abnormal uterine bleeding or an abnormal pap smear
-You smoke or you don't smoke
-You don't have a current or recent pelvic infection
-You can check for the IUD strings (you feel comfortable putting your fingers in your vagina to check the strings on a regular basis - usually about once per month)
-You are breastfeeding (or bottle feeding)
    
Why get an IUD? 
We are really lucky to live in a time when there are lots of options for birth control.  There are pluses and minuses to all forms of birth control.  IUDs have some advantages:
1.  They are fairly maintenance-free.  Once it is in place, you usually don't have to do anything other than check to make sure the strings are in place monthly. 
2.  You don't have to prepare anything in advance of intercourse (like inserting a diaphragm or spermicide or putting on a condom).  HOWEVER, YOU SHOULD ALSO USE A CONDOM IF THERE IS ANY CHANCE OF BEING EXPOSED TO A SEXUALLY TRANSMITTED INFECTION.
3.  It is effective - 99% or higher.
4.  A LNG-IUD (the one with the hormone in it) can make your periods lighter and/or less frequent.
5.  There are minimal side effects - we'll talk about some of the potential bad parts of an IUD later.
6.  It lasts a long time - 5 to 10 years.
So, if it is so great, why doesn't everyone have one? 
    This is a great question.  Part of the reason is because not everyone is a good candidate for an IUD.  If you have risky sexual behavior - any sexual activity that puts you at risk for a pelvic infection, an IUD is probably not a good choice.  Another reason is that the whole idea of something being put inside you can be kind of scary.  Some women just don't like the idea of something staying inside your uterus or having to check the IUD strings.  And finally, lots of women have heard negative things about the IUD - either the history of the Dalkon Shield or things friends have experienced. 
How do I get an IUD?
    IUDs are placed by physicians or other health care providers experienced in IUD placement.  You can either make an appointment with your primary care doctor, visit a gynecologist, or go to a Planned Parenthood Clinic (call first to make sure they do IUD placement).  You may have to have one visit to talk about the IUD and find out if it is a good choice and a second appointment to actually get it placed.

 
What happens during the IUD placement?  What can I expect? 
    You will go to the doctor's office like you do for a regular appointment.  You may be asked to take some ibuprofen (Motrin or Advil) before your appointment so that you don't experience as much cramping when the IUD is placed.  You will probably be asked to have a pregnancy test since the IUD is not inserted if you are already pregnant.  In the exam room, you will be asked to undress from the waist down, just like a pap smear appointment.  The doctor may do a pelvic exam to find out how your uterus is angled so that he or she can insert the IUD more easily. 

    Next, you are asked to lay down and put your feet into stirrups (just like for a pelvic exam).  A speculum is inserted into your vagina so that the doctor can see your cervix (this is the opening to your uterus).  The doctor will clean the cervix with a special soap called betadine - this is to make sure that you don't get an infection when the IUD is put in.  Next, the doctor will sound your uterus.  This means that he or she will place a very thin metal or plastic rod inside your cervix into the uterus.  This allows the doctor to find out how large your uterus is (usually will be 6-8 centimeters deep).  Next, the doctor will prepare the IUD and get it ready for insertion. The doctor will place a marker at the same depth as your uterus was measured.  This makes sure that the IUD is put in far enough.


Sometimes the cervix can be floppy or move around a lot.  If this happens, the doctor may need to use something called a tenaculum.  This is an instrument that holds the cervix in place (by grasping it) so that the IUD can be put in.  Next, the IUD is inserted.  You may feel some cramping (like menstrual cramps) when the IUD is put in.  After the IUD is placed, the doctor will cut the IUD strings to about 2 centimeters long.  This will be long enough so that you can still feel the strings, but not so long as to bother you or your sexual partner.

You may have some mild cramping or bleeding after the IUD is placed.  It is pretty common to have irregular vaginal bleeding right away and also to have some irregular bleeding for a few months after the IUD is put in.  This should go away.

What could go wrong? 
    Generally, IUDs are very safe.  Occasionally, a woman may experience more bleeding than normal. This is more common with a Copper IUD.  Since something is being inserted into your body, it is possible to get an infection.  The risk of infection is highest right after the IUD is placed and for about 20 days afterwards.  Like all birth control measures, IUDs can fail and you can get pregnant.  IUDs are very effective (99%) but no method (except abstinence) is 100% effective.  The IUD can fall out or move further inside your uterus.  Finally, very rarely an IUD can go through the wall of the uterus (uterine perforation).  This is very serious and usually requires surgery to take out the IUD and sew up the wall of the uterus.  While this is rare, it may be more likely to happen if you have any history of problems with your uterus or if you recently (within the past 3 months) had a baby and are breastfeeding.  It is generally safe to have an IUD after you have had a baby, even if you are breastfeeding.

CALL YOUR DOCTOR RIGHT AWAY IF YOU EXPERIENCE:
-Heavy bleeding
-Severe cramping or abdominal pain
-Strings are no longer there
-Yucky smelling vagina discharge or fever
-Positive pregnancy test

What will sex be like after the IUD? 
    IUDs should not affect your sex life (except to make you less worried about getting pregnant).  Sometimes the male partner can feel the string with deep penetration, but this often goes away as the strings get "stuck" in the cervical mucus and become more difficult to feel.  Also, your doctor can cut the strings shorter if this is a problem.

    In summary, IUDs are a good birth control option for a lot of women.  If you think that an IUD could be a good choice for you, talk to your doctor about it.