Let’s talk about IUDs!

Written By Lawren Honken

First, let me tell you why I love IUDs -

  1. Set it and forget it: once it’s in place, you don’t have to remember to do anything else for pregnancy prevention, and it’s more effective than having your tubes tied. You can remove it whenever you’re ready!

  2. Amenorrhea rates: with the progestin IUD (Mirena is my fave), about 20% of users have NO PERIOD, and almost 30% experience less periods. It actually is used a lot to treat heavy periods.

  3. Low risk of side effects: because the progestin is released inside the uterus, it usually only acts locally.

Skyla IUD size compared to AirPods

There are types of IUDs: the copper IUD and the progestin IUDs. 

IUDs compared on https://providers.bedsider.org

  • There is only 1 copper IUD (Paragard). It is non hormonal but can cause heavier periods because of the way it works, and it’s less effective (although not by much) than the progestin IUDs. 

  • There are 4 FDA approved progestin IUDs: Mirena, Kyleena, Liletta, and Skyla. Mirena and Liletta both have 52mg of levonorgestrel (progestin) in them that is slowly released over time and are approved for prevention of pregnancy up to 8 years. Kyleena has 19.5mg of LNG (levonorgestrel) and prevents pregnancy up to 5 years. Skyla has 13.5mg of LNG and prevents pregnancy up to 3 years. Kyleena and Skyla are both a little smaller - 28mm x 30mm as opposed to Mirena and Liletta, which are 32mm x 32mm. Paragard is the largest at 32mm x 36mm.

BUT HOW DO THEY WORK?!

  • Both copper & LNG IUDs work by changing the way sperm moves so that it can’t reach the egg to fertilize it.

  • LNG IUDs also thicken cervical mucus to keep sperm from coming in and they can also stop ovulation (so your ovary doesn’t release an egg). 

  • Paragard, Mirena, and Liletta can be used as emergency contraception and are 99% effective if placed within 120 hours/5 days of unprotected intercourse. They are the most effective ways to prevent pregnancy after sex.

Ok now let’s talk downsides, or potential risks -

  1. The placement can be hard, especially if you’ve never had a child. Ask your gynecologist what to expect and how they will manage your pain. I usually give a medication called Valium to help decrease anxiety and I use a topical spray to help with numbing the cervix. You can also opt for a paracervical block (injections to numb the cervix). Playing your own music in headphones can help too!

  2. You can’t use a menstrual cup. This may pull out the IUD.

  3. You could have irregular spotting. Most common right after placement but could last the whole time the IUD is in place.

  4. Difficult removals are rare, but can happen if the strings can’t be found when it’s time to remove. I usually attempt removal in the office under ultrasound guidance and a paracervical block if needed. Another in office option is a hysteroscopy (or a camera inside the uterus). Finally, you may have to go to the operating room for removal.

  5. Pelvic inflammatory disease is not caused by IUDs but if you have an STI can increase the risk.

  6. Uterine perforation is when a hole is poked through the uterine wall during placement and can be very painful. It usually heals on its own. This is why it’s important to have an experienced clinician place your IUD!

Here are my general recommendations if you’re planning to have an IUD placed (especially if you’ve never had a baby) -

  1. I usually prescribe Valium or a benzodiazepine which is a controlled medication that a patient takes one time about 30 minutes prior to the procedure. This helps decrease anxiety related pain.

  2. Sometimes misoprostol is sent, which is a medication to make the insertion easier or to make it less likely to have to dilate your cervix. There is not good evidence for this - evidence actually shows that it may make cramping worse prior to insertion and does not help with insertional pain or ease of inserting. However, there was one trial that showed nulliparous patients (who had never had a baby) in the misoprostol group did not need their cervix dilated.

  3. Take Motrin 800mg 30 minutes prior to insertion, usually when you arrive in the waiting room.

  4. Don’t make any big plans for the day besides Netflix and chill.

  5. Expect cramping and spotting for a few days after the placement, and up to 6 months before you know what your bleeding will look like.





References:

Zapata LB, Jatlaoui TC, Marchbanks PA, Curtis KM. Medications to ease intrauterine device insertion: a systematic review. Contraception. 2016;94(6):739-759.

Lathrop E, Haddad L, McWhorter CP, Goedken P. Self-administration of misoprostol prior to intrauterine device insertion among nulliparous women: a randomized controlled trial. Contraception. 2013;88(6):725-729.

Edelman AB, Schaefer E, Olson A, et al. Effects of prophylactic misoprostol administration prior to intrauterine device insertion in nulliparous women. Contraception. 2011;84(3):234-239.

Lesavre M, Legendre G, Fernandez H. [Use of misoprostol in gynaecology]. J Gynecol Obstet Biol Reprod (Paris). 2014;43(2):190-194.

Waddington A, Reid R. More harm than good: the lack of evidence for administering misoprostol prior to IUD insertion. J Obstet Gynaecol Can. 2012;34(12):1177-1179.

Turok DK, Gero A, Simmons RG, et al. Levonorgestrel vs. Copper intrauterine devices for emergency contraception. N Engl J Med. 2021;384(4):335-344.

Simmons RG, Baayd J, Elliott S, Cohen SR, Turok DK. Improving access to highly effective emergency contraception: an assessment of barriers and facilitators to integrating the levonorgestrel IUD as emergency contraception using two applications of the Consolidated Framework for Implementation Research. Implement Sci Commun. 2022;3(1):129.

Salcedo J, Cleland K, Bartz D, Thompson I. Society of family planning clinical recommendation: emergency contraception. Contraception. 2023;121:109958.

Lawren Honken