When it comes to discussing birth control options with a patient,
Sheila Mody, MD, MPH, director of the Division of Family Planning, in the Department of Obstetrics, Gynecology and Reproductive Sciences at UC San Diego Health, starts with one simple question:
“What’s most important to you?”
Even for intrauterine devices (IUDs) alone, there are a growing number of options, and Mody can usually find one that’s a good fit for each patient. (This information may also apply to transgender or gender non-conforming/non-binary people, but for simplicity’s sake, we’ll just use “woman” and “she/her” in this article.)
Narrowing the choices
There are four leading types of IUDs that use the progesterone-like hormone progestin — they go by the brand names Mirena, Kyleena, Skyla and Liletta. There is also one non-hormonal IUD (brand name ParaGard), which uses copper to promote an environment not suitable for sperm.
All IUDs on the market are highly safe and effective — the chance of getting pregnant with an IUD in place is less than one percent and the chance of uterine perforation is approximately one in 1,000.
The biggest differences between them, Mody says, are their impacts on menstruation and length of time they can be used.
“So if a patient says it’s really important to her to minimize menstruation and associated symptoms, I might recommend the Mirena or Liletta, with which a patient has the highest chances of not having a period,” she said. “If my patient says it’s important to leave it in as long as possible, I might recommend the copper IUD, which can be placed for up to 10 years, but which may be associated with longer, heavier periods.”
All progestin IUDs can be placed in women whether or not they’ve previously given birth, Mody said. They’re also safe for most people with complex medical conditions, such as cancer, and in people taking other medications that may have interactions with oral contraceptives.
“Even for breast cancer survivors who can’t use hormonal contraception, the copper IUD may be a good option,” Mody said. “With an IUD, there’s one less thing to worry about, and that can be huge when you’re managing a medical condition and lots of other medications.”
She also recommends IUDs for women who can’t tolerate oral contraceptives.
“The biggest myth I hear is that if you couldn’t tolerate the pill, you’ll have similar experience with progestin IUD,” Mody said. “But it’s one-tenth the amount of progestin you’d get in a pill and no estrogen. Usually when people have problems with the pill, it’s due to estrogen. Before they skip right to non-hormonal contraceptives, such as condoms, I want my patients to know that there are non-hormonal and low-dose hormone IUD options that might be right for them.”
Overcoming fears
As of 2014, the Guttmacher Institute estimated that 11.8 percent of contraceptive users chose IUDs, compared to 25.3 percent on the pill and 14.6 percent using condoms.
One possible barrier to IUD adoption is fear of pain associated with the IUD placement procedure.
Mody recently led a randomized controlled trial to test options for pain control during IUD placement. She and her team found that 20 cubic centimeters (a little over half an ounce) of buffered 1 percent lidocaine paracervical block (an injectable analgesic) decreased pain during placement, five minutes afterward and overall for women who had not previously given birth, compared to no block. The findings were published September 2018 in Obstetrics & Gynecology. In contrast, Mody said, ibuprofen has not been shown to ease pain during IUD placement, but it can be helpful after the procedure.
Getting through the cervix to place an IUD for a woman who has not given birth can be a bit more difficult. When that happens, Mody said she might dilate with ultrasound guidance or, if that doesn’t work, apply misoprostol before the procedure to soften the cervix. Misoprostol, a drug used in a variety of obstetric and gynecologic procedures, isn’t her immediate go-to, though, as it can increase the pain associated with IUD placement.
While all IUDs are T-shaped at the moment, Mody said, efforts are underway at several companies to develop different frames, which might make placement easier on patients in the future.
Setting expectations
There may be pain during IUD placement, but “realistic expectations mean greater overall patient satisfaction,” Mody said.
To do that, she advises patients to avoid making big plans for immediately after IUD placement. She also recommends they bring along a friend or family member to drive, in case they feel light-headed after the procedure. It also reduces dissatisfaction if patients are aware that they will likely experience spotting for three months after placement, even if they might later have lighter or no periods.
“For all birth control methods, it’s important to let your patients know that you have an open door if that initial method doesn’t work out for them,” Mody said. “Some people like more control and may not choose an IUD and that’s okay. They can always come back, have their IUD removed, and find another method that works for them. We’re focusing more on patient-centered counseling, making sure an IUD is something the patient decides will work best, not just what the doctor thinks is best.”
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