IUDs are a great birth control option. Why aren’t they more common?

Few things are more complex than choosing birth control. There are so many options, and each has its own pros and cons. One option that has many advantages but isn’t used much in the United States is the IUD, or intrauterine device. This post describes what an IUD is, how they work, iud safety, and some reasons they might not be as widely used as they could be.

Note: None of the SciMoms are medical doctors, so please consult with your healthcare provider before making any decisions about birth control or any other medical topic.

Looking for better birth control

After my daughter was born, my spouse and I knew we were done having children. More so, I knew I was done having periods, if I could avoid it. I had used Nuvaring (a flexible plastic ring infused with hormones that is placed in the vagina) with success for years before we started trying to conceive, and I tried to replace each ring without a withdrawal period. Still, I kept having breakthrough bleeding with cramps and emotional swings. I knew there had to be something better!

My problem with Nuvaring was that sometimes I changed it a day or two late, leading to spotting. I wasn’t sure what to do, so I removed the ring to start my period. My healthcare provider, Nicole Meyer, PA-C at the Iowa Clinic, says this is a fairly common problem with Nuvaring. Instead of removing the ring, I should have replaced it right away. Frustrated, I started wondering, what about an IUD?

SciMom Anastasia Bodnar holding an anatomical model of a uterus and vagina with a Mirena IUD (intrauterine device) inside.
Anastasia is getting to know the Mirena!

Of course, I started by asking my fellow SciMoms what they did. I was surprised that I was the only one who did not have an IUD yet! Next, I asked my provider Nicole, and she said every female employee in their clinic has an IUD. They’re in good company: 40% of all female healthcare providers who assist with family planning decisions have personally chosen the IUD for themselves.

Next, I checked with gynecologist Dr. Jen Gunter. She said, “Of all the forms of contraception, an IUD is the one a woman is most likely to be using after two years. They have the highest user satisfaction rate and the lowest pregnancy rates. They are not for everyone, but they are a wonderful choice for many women.”

Five of the smartest women I’ve ever met, my personal healthcare provider, Twitter’s star gynecologist, as well as many other experts all have come to the same conclusion about reproductive health. Clearly IUDs have a lot of support, yet much the information that I found online was negative. Why the vast difference in experiences? I wanted to get to the bottom of this question, so I researched the topic to provide an evidence-based answer to SciMoms readers.

Hormonal birth control basics

There are six hormone-containing birth control options described in the infographic below. Hormonal birth control does not protect against sexually transmitted infections (STIs), so all of these options should be used with a condom to reduce risk of transmitting STIs. You can find a table from the CDC comparing hormonal and non-hormonal birth control options at the end of this post and learn more about them at the Department of Health and Human Services and Planned Parenthood websites.

How do they work? Some hormonal birth control options contain a hormone that keeps ovaries from releasing eggs. All of them contain a hormone that thickens cervical mucus and thins the lining of the uterus, which keeps sperm from reaching and fertilizing an egg. No fertilization means no embryo and, obviously, no pregnancy. Hormonal birth control does not cause abortion.

As an added benefit, if the uterine lining doesn’t have a chance to thicken, regular use of hormonal birth control can make your period becomes lighter over time. In some cases, it can even go away entirely. That said, some period-associated symptoms can remain, such as cramping or irritability.

As Kate Mooney describes in My IUD Ghosted My Period But Not My PMS, “it’s much harder to follow your cycle when you don’t get a period” but it might be worth keeping an eye on the calendar. That way, if you start to get symptoms similar to premenstrual syndrome, you’ll know why.

IUD specifics

The American College of Obstetricians and Gynecologists recommends that IUDs and implants be offered as “first-line contraceptive methods” over other birth control options. That’s because both IUDs and implants are more than 99% effective in preventing pregnancy. Of all birth control options, satisfaction rates are highest for the IUD.

A hormonal IUD is a T-shaped piece of plastic infused with hormones. It’s inserted through the cervix and sits in the uterus. Thin strings attached to the bottom of the IUD hang out of the cervix so the IUD can be easily checked and removed by your healthcare provider. The strings are firm initially, but soften over time, and are typically undetectable during intercourse.

The IUD Mirena is the longest lasting, effective for 7 years. It releases slightly more hormone than other hormonal IUDs, so it is more likely to reduce periods, yet because the hormone is localized to the uterus, the total amount of hormone released into the body overall is still low. This combination of attributes makes IUDs a potential choice for transgender men.

It’s important to have reasonable expectations about what will happen once the IUD is inserted. About 50% of people who get a Mirena will have some initial bleeding which will stop within 30 days. That leaves 50% who will bleed irregularly for longer, some up to 50 or 60 days. I was not in the lucky half, and it’s easy to get frustrated. Still, it’s worth it to be patient. Over the next year, my periods will become lighter and lighter, and will hopefully disappear. I’ll have the IUD strings checked at my annual check-ups, and check the strings myself each month. I won’t have to worry about birth control again for 7 years, and can continue using an IUD right into menopause.

While the IUD’s pregnancy-preventing effects last a long time, rest assured it can also be easily removed by your healthcare provider. Your ability to get pregnant will quickly go back to whatever is normal for you. Whatever you do, do not try to remove the IUD by yourself.

Despite the effectiveness of the hormonal IUD at preventing pregnancy, and the high level of satisfaction in IUD users, the total percentage of people using IUDs in the US remains very low. From 2011-2015, Centers for Disease Control surveys found that just 6.8% of women aged 15-44 were using IUDs at the time they were interviewed, and only 15% had ever tried an IUD. This may be due to concerns about pain during insertion, cost of the IUD, and a few persistent myths about this form of birth control.

Diagram of the female reproductive system, showing how the Mirena IUD sits in the uterus, not the vagina. The Mirena inhibits sperm from reaching/fertilizing egg, thins uterine lining, and thickens cervical mucus to prevent sperm from entering uterus.

IUD concerns

If IUDs are so great, why do so many scary stories come up in Google searches? My healthcare provider Nicole has a hypothesis. In women who have already had a baby, the cervical opening is slightly larger and the IUD goes in fairly easily — for me it felt like a strong period cramp that quickly subsided (I’ve had two vaginal deliveries).

For women who have never had a baby, their cervical opening is smaller and insertion can be a bit more painful, especially since they don’t have the experience of labor and childbirth with which to compare it. These women tend to be younger and may be more likely to share their experiences on social media. People are also more likely to share negative experiences in general. For both of these reasons, we tend to see fewer positive affirmations online.

For most patients, IUD insertion is not painful. In one study, just 33% of women reported a pain score of 5 or more out of 10. Dr Gunter says, “if a woman has very painful periods or typically has pain with pelvic exams she is more likely to have pain with insertion, and there are definitely ways to manage that.” Dr. Gunter reviewed studies of pain-relief methods for IUD insertion. She recommends mind-body techniques to reduce anxiety about the procedure, with pain medication if needed. You can also use typical menstrual pain relief strategies such as rest and a heating pad after the procedure, if needed. Of course, if the pain is too much, contact your healthcare provider.

One drawback of IUDs is they can be expensive, up to $1300 without insurance. Mirena is effective for 7 years, so even at full price, that’s only $15.50 per month for the most effective reversible birth control available, one which also happens to come with the major benefit of reduced periods. Still, that can be a lot of money to save up. Check with your health insurance or local clinic to see what options are available to you. I was able to get the IUD for just the price of an office visit, while another of the SciMoms had to pay $800 out of pocket.

IUD myths dispelled

Many people, including healthcare providers, think that only women who have had a baby can get an IUD. The reality is that almost all people with a vagina can safely get an IUD, including teenagers and people who have never had children. In fact, providing teenagers access to IUDs at low or no cost can dramatically reduce the rate of unwanted pregnancies and abortions. People with multiple sexual partners can also use an IUD, though additional protection is needed to prevent STIs.

Another myth is that IUDs can cause infections. Nicole said that older versions of IUDs had a braided string that could allow bacteria to travel up into the uterus, but current IUDs have a monofilament string that prevents movement of bacteria. Hormonal IUDs can even reduce risk of infection in the uterus by thickening cervical mucus and preventing bacteria from entering. Less than 0.05% of people who get an IUD will get an infection, and many of those already had a bacterial infection present but undetected in the uterus. Because of these very low rates, prophylactic antibiotic use before IUD insertion is not recommended. However, Dr. Gunter recommends that you get tested before insertion if you are at risk for STDs.

Yet another myth is that the IUD can cause infertility. In fact, once the IUD is removed, your fertility quickly returns to whatever it would have been had you never gotten the IUD. This hold true for all hormonal birth control; once the hormone is out of your system, you will get pregnant at the same rates as women of the same age. There is also a myth that IUDs can cause scarring of the fallopian tubes, but a large study found such scarring is due to chlamydia, not IUDs. An older type of IUD was associated with infections and infertility, but it was pulled from the market over 30 years ago. Modern IUDs are very different.

There is also a persistent myth that IUDs can cause heavy, painful periods. For the reasons discussed above, the opposite is true for hormonal IUDs, which result in lighter periods. Heavier, more painful periods can result from copper IUDs, though the pain decreases with continued use.

Lastly, three concerns are real but often exaggerated. First, in rare cases (perhaps 3-5% of all IUDs), the uterus can push the IUD out of the cervix either partially or completely. This is called an expulsion. It does not have any lasting effects, but can be frustrating because you’d have to either try another IUD or get a different form of birth control. Second, in about 2% of all pregnancies, the fertilized egg starts to develop outside of the uterus. This is called an ectopic pregnancy, and can present a major health risk to the mother. While the likelihood of becoming pregnant with an IUD is very low (0.2%), the risk of an ectopic pregnancy is increased if you do become pregnant with an IUD. And third, very rarely (0.1% of all IUDs), the IUD can perforate the uterus, typically during insertion. Nicole says perforation during insertion is very unlikely with an experienced practitioner. “If I feel resistance, I stop pushing,” she says.

Many contraception options

There are many birth control options in addition to the hormonal birth control options. A comparison of options is presented in the infographic below from the Centers for Disease Control. All methods, including outercourse that might be practiced as part of abstinence, should be combined with male condoms for STD protection. Learn more information about these methods at the Department of Health and Human Services and Planned Parenthood websites.

No matter what your contraceptive needs are, there is an option that will work for you. While an IUD is a good choice for many, it won’t be the best choice for everyone. Consider your needs carefully and speak with your healthcare provider.

Infographic from the Centers for Disease Control showing effectiveness of birth control methods.
Infographic from the Centers for Disease Control showing effectiveness of birth control methods. Click here to download a full page PDF.

Note: Reference to any specific product is for general informational purposes only and does not constitute an endorsement by SciMoms. Information presented is generally US specific. Consult with your healthcare provider before making any decisions about birth control or any other medical topic.

Note: This post was originally published on 24 Mar 2018 and has been updated to add information about “ghost periods”.