IUD. Effective, Reversible, Long Acting!

Birth control methods have always intrigued people, and the ability to control one’s fertility has been the desire of different populations. Some old civilizations used honey, stones, acacia leaves and lint to be inserted in the vaginas to prevent sperm migration into the uterine cavity, while others relied on prayers and more spiritual methods to prevent unwanted pregnancies. Many ancient documents talk about birth control methods, including the Ebers Papyrus and Kahun Papyrus. 

In this article, I will be focusing on one form of contraception known as the intrauterine contraceptive method. Intrauterine devices (IUD) are considered one of the most effective contraceptive methods we have nowadays. They belong to a group of contraceptives called LARCs or long acting reversible contraceptives.
Generally speaking, IUDs are considered to be safe, cost effective, reversible and easily accessible, however, what is the actual effectiveness and safety of these devices? And are there any non-contraceptive benefits?

Prevalence of use

Intrauterine devices are the most commonly used reversible contraceptive methods with more than 20% of female contraceptive users relying on them worldwide. The use of these devices increased with time secondary to the people’s understanding of their efficacy and safety profiles.

There are 2 broad categories of IUDs; the copper and the hormonal devices.

Copper IUD (ParaGard)

This is a T-shaped ~4 cm long device with copper wires looped around its arms. It acts by causing a local inflammatory reaction disabling sperm migration and viability, preventing fertilization, and averting implantation. Keep in mind that this device does not inhibit ovulation as it contains no exogenous hormones.

As previously mentioned, the copper IUD is one of the most effective reversible contraceptive methods with a failure rate of less than 1%. Actually, with typical use, the reported first year unwanted pregnancy rate is 0.5-0.8%. Younger women (age < 25) are expected to experience higher failure rates as they are naturally more fertile than their older counterparts.

This device is approved for use for 10-12 years, however it is advisable to renew it every 10 years especially in younger women, to minimize unwanted pregnancy rates.

Copper IUD can also be used as an emergency contraceptive method after unprotected intercourse: check my article “Plan B. Is it Guaranteed?” on https://onlinewomenhealth1.blogspot.com/2020/07/plan-b-is-it-guaranteed.html).

Non-contraceptive benefits of Copper IUD

Since copper intrauterine devices do not contain hormones, women benefit from keeping their natural menstrual cyclicity. Moreover, this device was associated with a lower rate of cervical and endometrial cancers, and this observation can be physiologically explained by the local inflammatory state provoked by the device.

Hormonal IUD

There are many hormonal intrauterine devices differing in their sizes and concentrations, nevertheless they all contain the hormone Levonorgestrel (LNG) (the most famous one is sold under the brand name Mirena). Depending on the concentration of LNG, the device can last from 3 to 7 years. Kyleena and Liletta can be used for up to 5 years, and Skyla can stay in place for up to 3 years. The Mirena IUD is approved for 5-7 years of use.

Just like the copper IUD, the overall efficacy of the hormonal IUD is more than 99%. Actually, studies have shown that the LNG releasing IUDs are more effective than copper IUDs with a failure rate of 0.1-0.2% for the first year of use.

The mechanism of action is related to the local release of levonorgestrel hormone which causes endometrial atrophy (rendering it less receptive to implantation), cervical mucosal thickening (making it less permeable to sperm penetration) and in some women ovulation inhibition (however the latter is NOT the major mode of action of the hormonal IUD as most cycles remain to be ovulatory in LNG IUD users)

Non-contraceptive benefits of hormonal IUD

The progesterone in the hormonal intrauterine device causes endometrial atrophy, and this in turn lessens the severity of menstrual bleeding, and thus this device is used in the management of menorrhagia (heavy/prolonged cycles) and anemia (check with your physician)

Also, the use of the hormonal IUD is associated with less painful periods, hence it can be used in the management of different forms of dysmenorrhea (painful periods) including endometriosis-related pains.

In addition, hormonal intrauterine contraception can be used in the management of endometrial hyperplasia (a condition of endometrial thickness that predisposes women to endometrial cancer) in the right population.

Finally, the use of this device was associated with lower rates of pelvic inflammatory diseases/infections, cervical, endometrial and ovarian cancers.

Painful Insertions?

Many women report anxiety and fear of pain from the insertion process, but keep in mind that in the right hands, the IUD (both copper and hormonal) insertion should take no longer than few minutes. The pain attributed to the device introduction is described as period like crampy pain, so I advise you to take a non-steroidal anti-inflammatory medicine 20 to 30 minutes prior to your appointment to minimize pain.
Moreover, you can ask your provider about the possibility of cervical block (local anesthesia around your cervix) in case of prior bad painful experience with IUD use (to note that this option is rarely if ever needed). 

Changes in bleeding patterns

Both intrauterine devices, hormonal and non-hormonal, are associated with irregular menstrual spotting for the first few months of use. This irregular pattern is expected to improve after 3-6 months of insertion, however copper IUD users should be educated about the possibility of developing heavier, longer or more painful periods particularly in the first cycles of use. 

In Levonorgestrel IUD users, the most commonly reported changes in bleeding patters are prolonged bleeding (60%), unscheduled spotting (up to 52%) and absent periods (up to 20%), however these changes are not dangerous and are expected to improve within 6 months of the device’s use.

Risk of device expulsion and perforation

The reported rates of expulsions of the copper and hormonal intrauterine devices are 3-10% and 3-6% respectively, in the first year of use.
The risk of device perforation is reported to be around 1 in 1000 equivalent to 0.1%!

Risk of Ectopic pregnancy

Ectopic pregnancy is any pregnancy occurring outside the uterine cavity. A big percentage of women assume that the risk of such pregnancy increases with IUD use, however this assumption is wrong!
With the use of an IUD, the absolute risk of any pregnancy (including ectopic) is very low (less than 1%), nevertheless in the setting of a pregnancy, the risk for it to be ectopic is as high as 53%. So, if you get pregnant with your IUD in place seek immediate medical attention to rule out ectopic pregnancy.

Sexually transmitted infections

Intrauterine devices are NOT protective against sexually transmitted infections, so I would always recommend condom use in case of a non-monogamous relationship.
You should not get an IUD if you have a recent sexually transmitted or uterine infection.

The overall risk of pelvic inflammatory disease (PID) in IUD users is low and similar to its risk among other birth control methods users, however some studies reported a mild increase risk of PID during the first week to month of IUD insertion.

Another misconception is linked to the risk of HIV in the setting of IUD. Concerns have been raised about the risk of HIV acquisition in IUD users, but studies have shown that both LNG and Copper IUD users have a lower risk of HIV infection.

Contraindications for IUD use

Finally, what are the contraindications for intrauterine devices use?

Anatomic abnormalities in the uterine cavity (including multiple fibroids) can hinder the use of IUD as expulsion and failure rates are much higher than what is acceptable.

Active pelvic or cervical infection is also considered to be an absolute contraindication for IUD insertion as the latter can worsen and impede the resolution of the infection.  

In the setting of a known or suspected pregnancy an IUD should not be inserted as it can lead to miscarriage and increase the risk of infections.

Allergy to copper is not considered to be a contraindication to copper IUD use as the concentration of copper released by the device is minimal, however in these patients the LNG system is preferred over the copper IUD.

In the setting of abnormal uterine bleeding intrauterine devices should NOT be inserted without proper investigation first.

Current or a history of breast cancer are contraindications for LNG IUD use as per the Centers for Disease Control and Prevention (CDC).

Women with active liver disease or allergy to levonorgestrel should avoid hormonal IUD and rely on copper IUD instead.

 

In conclusion, it is evident that intrauterine devices are highly effective, reversible and long acting contraceptives. They have limited and well tolerated side effects and few contraindications for use.
Keep in mind that even though myths and misconceptions revolving around contraceptive methods (including IUDs) are common and easy to believe, always look for the best evidence in order to have an informed decision about your health.

Karam