IUDs : the best method of contraception that you’re not using

Grace Sheehy

Mindthis Magazine introduces a new Lifestyle Column: Sexual Health 

Sexual health brings to my mind those terrible sex-ed classes from PE, a cursory overview of anatomy and that squeamish moment of putting a condom on a banana. And while we’ve graduated from that simplistic class, we’re pretty sure that you haven’t graduated from having sex and some of the questions that go along with it. This column is a sex positive, pro choice space that offers open and non-judgmental information, opinions, and advice about all things sexual health. From conversations on personal to the global issues; should you get that IUD and what’s the latest sexual harassment prevention campaign in Thailand, to gender violence and advice on building healthy sexual confidence and self esteem, our sexual health practitioners are thinking it all through with the young professional in mind.

Let’s talk about sexual health in a substantive yet interesting way that’s relevant to modern day young professionals.

It’s about time. 

– Alexandra Emanuelli, Lifestyle Editor

What is an IUD? How does it work? Why does the word make me cringe? And how much does insertion REALLY hurt?

If you winced as you saw “IUD” in this title, you’re not alone. Like many people working in the field of sexual and reproductive health, I read, talk and think about IUDs a lot. But whenever I bring IUDs up in conversations with my non-reproductive health obsessed friends, family members, or strangers (I’m great at parties!) they almost always squirm, cringe, or find a more interesting party guest to talk to. So why all the discomfort around this method? Let’s break it down.

First things first: an intrauterine device (IUD) is the single most effective method of reversible contraception. The only better way to prevent pregnancy is by being abstinent or getting sterilized. IUDs are twenty times more effective than the pill, patch, or ring, and nearly one-quarter of all contraceptive users around the world use an IUD. IUDs are most popular in Europe and Asia, but are seeing a recent surge in popularity in North America. Young women in particular are increasingly choosing IUDs because they are super effective (you have less than a 1% chance of getting pregnant with an IUD, compared to about 8% with the pill), cost-effective over time (although can be steep upfront if you don’t have insurance), long-lasting (3 to 12 years), and totally safe.

But wait: that sounds awesome – why isn’t everyone using an IUD and why does the thought of it still make us so uncomfortable? Although intrauterine contraceptives have been safely used for decades in countries around the world, the first mass marketed IUD in North America – the Dalkon Shield – was a disaster, and its impacts have been long-lasting. The Dalkon Shield was first introduced in the 1970s and, in addition to sounding like a cool spaceship, had little “feet” sticking out of its side to keep it in place in the uterus. Unfortunately, they did their job a little too well, making the device tricky for doctors to remove. To solve this problem, a strong braided string was added to the bottom of the device, so doctors could remove it easily.

Unfortunately, the braids in that string turned out to provide a perfect superhighway for germs to travel into the uterus. Women began getting severe infections, some leading to infertility, and 18 women died. This had a devastating and long-lasting impact, and many women in North America stopped using IUDs altogether. Following the Dalkon disaster and subsequent lawsuits, IUDs largely disappeared from North American markets – by the early 2000s, only around 2% of contraceptive users in the US used an IUD. Although this number has since increased to about 10%, the number of users in Canada remains low, at about 3%. But guess who make up the biggest users of IUDs? Female gynecologists – 40% of those who use contraception choose an IUD, and clearly they know what’s up. Despite their dip in popularity in American markets, IUDs have always remained popular in Europe and Asia (where the Dalkon Shield was never mass-marketed like in the US), and researchers in these regions continued exploring new methods in the decades that followed.

The IUD also has a complicated history among marginalized communities. Coercive practices have been used by governments in North America and in the Global South to encourage women of colour, poor women, and women with disabilities to adopt long-acting contraceptive methods to control their fertility – essentially, these policies deemed these women “unfit” to be mothers by the state. Understandably, in many of these communities long-acting contraceptives like IUDs could continue to be rightfully distrusted, and acknowledging this history is important, especially when promoting the benefits of IUDs. To barely skim the surface of this history is to come across stories of long-acting reversible contraceptives (LARCs) like the IUD being marketed specifically to poor communities of colour, and American states considering legislation that would essentially pay women on public assistance to use the implant, another type of LARC. And this doesn’t even touch on the still recent histories of forcible sterilization of women deemed “unfit” to be mothers in Canada and the United States.

At the same time, the high upfront cost of IUDs can make them inaccessible to low-income women, so removing cost-related barriers is an important way to increase access. In fact, in studies where contraceptives have been offered to young women for free, the overwhelming majority chose the IUD for its long-lasting benefits. However, incentivizing these methods can be dangerous and can become coercive, which is why acknowledging this fraught legacy is imperative.

Today, there are two types of IUD: copper and hormonal. The small, plastic T-shaped devices are inserted in the uterus, and work by making it hard for sperm to reach and fertilize an egg. Both types of IUD are more than 99% effective. For the non-hormonal fans, the copper IUD is an amazing contraceptive option. Completely hormone-free, a copper wire is wrapped around the plastic T and slowly releases copper ions, which are toxic to sperm; this type of IUD lasts up to 12 years.

For those who don’t mind or prefer hormones, there are several types of IUDs that release low doses of hormones (and do not contain copper): Mirena and Jaydess (known as Skyla in the US) are both available in Canada and the United States. They release small doses of the hormone progestin (with Skyla releasing slightly less), and last for five and three years, respectively. In both devices, the amount of hormones released is tiny, and very safe (more great information on hormones in birth control can be found here). In terms of side effects, copper IUDs may increase the intensity of cramps and menstrual flow, but this often returns to normal after a few months. Hormonal IUDs, meanwhile, actually reduce menstrual flow significantly, and stop it altogether for about 20% of users – a major perk for some people.

So, are they safe now? All of the most recent research on IUDs has overwhelmingly pointed to their safety – the risk of serious side effects is basically at zero. Meanwhile, the advantages of IUDs are huge: they involve no maintenance, are cheap over time when the upfront cost is adjusted for their duration (for instance, $400 up front over five years is less than $7 a month), and they’re long-lasting but can be taken out at any time with fertility returning to normal almost immediately. And, in the past few years, IUDs have been recommended for adolescents and young adults specifically as a great first contraceptive, so there’s no reason you need to have already had children or used another method of contraception before grabbing an IUD.

Some people might be surprised to know that copper IUDs are also the most effective form of emergency contraception, and can be inserted 5-7 days after sex to reduce the risk of pregnancy. While the more commonly used emergency contraceptive pills (ECPs, often know as Plan B or the morning after pill) are about 89% effective in protecting pregnancy for up to 5 days after sex, the copper IUD is amazing in that it’s 99-100% effective even five days after unprotected sex, and can continue providing you protection for up to 12 years afterwards. Essentially, if a woman hasn’t ovulated yet, the copper prevents an egg from being fertilized by destroying sperm, and if a woman has ovulated, the IUD prevents implantation of a fertilized egg by irritating the uterine lining. It won’t mess with an established pregnancy, but it can prevent one very effectively. If you do want an IUD as an emergency contraceptive, be sure to emphasize this when you call your local sexual health clinic or family doctor for an appointment, so they can try to get you in quickly.

Alright, but on to the real issue: how awful is getting an IUD inserted? Is it even worth it? Real talk: getting an IUD inserted is not fun – it’s uncomfortable. While some users report little to no pain, others experience intense pain and discomfort. Fortunately, the actual insertion process is quick and straightforward, meaning a few minutes of discomfort for up to a decade of worry-free contraception. If you’ve ever had a pelvic exam or Pap smear, think something similar. Let’s walk through it:

First, you’ll likely have a consultation with your doctor, where they’ll explain how the IUD and the insertion process works. Use this opportunity to ask any and all questions you might have, so you can make an informed decision. They may recommend you take pain medicine like ibuprofen before insertion, or a drug like misoprostol to dilate your cervix (although evidence now suggests that this doesn’t actually help with pain). Similar to a gynecological exam, you’ll lay on your back with your feet up on the examining table. They will then do a pelvic exam, and measure the depth of your uterus using a small instrument to ensure the IUD will fit properly. Following this, a small plastic tube with the IUD inside will be inserted and the IUD will be pushed into place (imagine a tampon being pushed from the applicator). The doctor will then cut the strings, so they protrude slightly from the cervix (not from the vagina, so you’ll probably never notice them), and that’s it! Some people are good to get up and go immediately after. While others (including yours truly) writhe around in pain and almost pass out – it really varies by person. But the good news is – you’re done! You don’t have to think about your birth control up to 12 years, and for a lot of users, a bit of pain is more than worth that kind of gain. Now take the rest of the day off, curl up with a movie and ice cream, and congratulate yourself on making a smart decision for your reproductive health.

You might have some cramping, pain, or irregular bleeding in the first few months after insertion – talk to your doctor if you are concerned about any side effects. Not all doctors are well-trained on insertion of IUDs, and many still have biases against younger women using them. If you decide to get an IUD, be prepared to advocate for yourself and push for a referral if your doctor is hesitant to insert one (unless you have a history of pelvic inflammatory disease, in which case you may not be a good candidate). If you’re interested in reading more about IUDs, or are ever looking for credible information on side effects (beware of internet forums!), here are a few awesome sources of information:

And don’t forget! IUDs do not protect against sexually transmitted infections, so it’s important to also use a condom if you and/or your partner have not been tested. Mindthis Magazine is not your source for definitive health advice, you should always consult your own doctor.