By Danelle Frisbie © 2009
I realize the subject of contraception is not one you likely expected to find in this blog...but it is something I have been asked about a number of times as of late. It is also an area I used to address frequently when teaching Human Sexuality courses. I do believe it fits into the area of peaceful parenting when we make conscientious choices about child spacing - those that are in the best interest of ourselves, our marriages, our families, our individual locations in life, and those that are most favorable to the babies/children we already have.
I am fully aware that there are a number of people who choose to not use any form of contraception, and I do not condemn their choices in this matter - as long as it truly is the conscious choice of the mother. All women should have the option of making a fully informed decision as to their reproduction. That being said, the information and science we have surrounding safe contraceptive options and healthy child-spacing is indispensable and important to us today in much the same way as are the sciences/information surrounding other aspects of our modern world -- electricity, surgical procedures, pharmaceuticals, solar power, the internet, etc.
In her book, The Natural Child: Parenting From the Heart, Jan Hunt highlights four steps that developmental and attachment scientists say are important in raising emotionally healthy and securely attached children. These steps include: (1) A positive birth experience, (2) extended breastfeeding and child-led weaning, (3) the consistency of caregivers and minimal separation from mom and (4) careful child spacing. "These four steps can have a profound effect on the entire family," notes Hunt. "[T]hey establish the capacity to love and trust within the child...Unfortunately many new parents are unaware of these four critical steps, especially if they have never experienced unconditional love and trust in their childhood," (Hunt 2001).
Family and childhood psychologist, Dr. Elliott Barker, takes the matter of child-spacing one step further. Barker is the founder and director of the Canadian Society for the Prevention of Cruelty to Children (CSPCC) and has studied the roll that birth control plays in healthy family units and the secure attachment of children to their parents. A lot of parents consider the question of the perfect 'spacing' of their children. According to Barker and CSPCC research, approximately 36 months between births (or more if it suites a particular family's needs) is optimal for most family units and for the health and wellbeing of both the babies/toddlers and their parents. Barker writes, "It requires an enormous amount of time and energy on the part of both parents to adequately nurture one child under the age of three. Spacing children is one important thing that parents can do to prevent the exhaustion that occurs when well-intentioned parents take on the very difficult task of trying to meet the emotional needs of closely spaced children," (Barker 1991).
The mounting evidence that a 36 months (or more) spacing of babies is ideal under most family conditions today in the West is compelling. If we lived under more natural, age-old, physiological human conditions (apart from nipplephobia and the like) where babies nursed well into their 3rd (or 4th or 5th) years of life, slept next to mom, were worn wherever she went, and had a 'village' of mothers helping out, we would see a natural spacing of birth that more closely emulates this longer span between babies, with much less stress on mothers when babies occasionally arrived closer together. But today, when only a very small fraction of babies are exclusively breastfeeding post 6-months in North America, many sleep apart from their mothers from birth, a large number of mothers leave to go to full time jobs all day, every day, and there is very little societal support or respect of mothering in general, child spacing must rely on other outside means of control. And this is where our modern day sciences surrounding contraception come into play.
Most of the questions I have received in my inbox over the past month are those inquiring about intrauterine devices (IUDs). And so, I will highlight that which I know to be true about IUDs in this article. If you personally have experiences with IUDs that would help other women in their exploration of this subject, I invite you to leave a comment at the end. I do not advocate for or against the use of an IUD with this article. It is solely meant for neutral, evidence-based information regarding the IUDs currently available in the United States.
Let's get started...
Currently, there are two IUDs available for use in the United States. One is a copper-wrapped device and the other is a progestin-releasing (artificial hormone) device.
The IUD is inserted into the uterus by a health care provider. A good time for insertion is during menstruation because the cervix is dilated at this time and it will cause the least amount of discomfort. However, insertion can take place at any time during a woman's cycle. This should be done after a complete evaluation is done to ensure this is the optimal method of birth control for any individual woman and her current needs and location in life. This is not, however, frequently the case. Because women's gynecological concerns are a billion dollar business, many clinics are willing to hand out IUDs like candy to anyone who walks through the door. So it is up to YOU to do the research ahead of time and decide what is best for you at this point in life. My mother (a pediatrician) has come under fire many times because of hospital pressure to give very young teen and preteen girls IUDs before she (my mother) knows 100% for certain that they are not already pregnant. If a woman is already pregnant and has a progesterone IUD implanted, the hormones can interfere with or end the pregnancy. If she has a copper IUD inserted, the uterus may start contracting to try and push out the foreign invader. In cases where neither of these things happen, babies have been born with an IUD inserted into their skull or other body organ. To avoid all these things, women should know for sure that they are NOT pregnant before getting an IUD.
When it is inserted, the uterus responds to an IUD by producing inflammatory cells and white blood cells in the uterine lining. The body is responding to the IUD as an invader and the uterine climate changes as a result. For a few minutes upon insertion the uterus may contract strongly and there may be significant discomfort. It is advised to take a pain-reliever (such as ibuprofen) before having an IUD inserted. Cramping may last a few minutes to a few hours.The body's natural inflammation response works in a contraceptive manner by preventing sperm from surviving in the uterus, and by preventing them from reaching the fallopian tubes. Sperm are actually pretty fragile creatures and die easily and quickly when conditions for their survival are not optimal. Male sperm die easier/faster than female sperm, so in the very, very small number of cases where impregnation does occur even with an IUD, the baby is often female. [For more on different internal climates leading to male or female offspring, see this book.]
The difference between the copper and progestin IUD:
Copper IUDs have fewer than 1 case of pregnancy per 100 women per year with typical use, and fewer than 1 case of pregnancy per 100 women per year with perfect use. The average cost is $200-$300 and it lasts 10-12 years (or until a woman has the IUD removed).
A copper IUD is immediately effective as long as a woman is not already pregnant, did not ovulate in the past 24 hours, and has not had unprotected intercourse within the past 72 hours. [If this were the case, pregnancy could have resulted, and the IUD may or may not act to stop the pregnancy.] A copper IUD does not interfere with breastfeeding or a woman's natural hormones (Stoppard 2001). It is also thee most effective means of birth control, with the same rate of efficiency as tubal sterilization (Boston Women's Health 2005). Copper IUDs have the added benefit of not changing a woman's natural cycle (hormonally) so she will still ovulate and menstruate naturally. As a result, women with a copper IUD can continue to track their cycle (days of menses, number of days in cycle, and counting back 11-14 days to determine approximate time of ovulation). During the week she will likely ovulate, a women with an IUD can use the additional backup method of a condom, diaphragm, or other barrier method to ensure 100% pregnancy does not occur.
For the Paragard brand copper IUD, see their website here.
Hormonal (progesterone) IUDs:
Progestin IUDs have 2 cases of pregnancy per 100 women with typical use per year, and 1.5 cases of pregnancy per 100 women per year with perfect use. The average cost is $395 and it lasts 5 years (or until a woman has the IUD removed).
The progestin IUD is also immediately effective with the same stipulations as the copper IUD listed above. However, unlike the copper IUD, the hormonal IUD does impact a woman's natural hormone flow and suppresses ovulation in some women. The progestin IUD is a progesterone-only hormonal birth control method. Progesterone is in the same family of hormones as testosterone and it is NOT an estrogen or estrogenic hormone. As such, complications that apply to drugs acting in an estrogenic manner, do not apply to the progestin IUD. The specific artificial version of progesterone used in the progestin IUD (brand name, Mirena) is levonorgestrel. It is very similar in nature to other sythetic progestin-only contraception methods (the 'mini-pill', Depo-Provera, Norplant).
As with our intake of all artificial hormones (ubiquitous today in most of our food, drinks, pharmaceuticals, and environment) the progestin IUD does shift normal hormone flux in woman. This may be desired in some women (to regulate heavy blood flow or cramping) and it may not be desired in other woman (who experience migraines, have had breast cancer, or cervical cell change). The FDA issues this precaution about all artificial hormone contraceptives (including the progestin IUD): Women who currently have or have had breast cancer, or have a suspicion of breast cancer, should not use hormonal contraception because breast cancer is a hormone sensitive tumor.
In addition to making the uterine lining inhospitable for sperm, the progestin IUD also alters the cervical mucus so that sperm cannot easily penetrate through the cervix and into the uterus. There are still rumors that IUDs allow fertilization to take place (but prevent the fertilized egg from implanting into the uterus). However recent studies indicate that modern IUDs (they have changed in design since the 1980s) prevent pregnancy by preconception mechanisms - especially by thickening the cervical mucus to be impenetrable to sperm (Foley, Kope & Sugrue 2002; Stoppard 2001). In this manner, the hormonal IUD is, again, much like Norplant or Depo-Provera in its contraceptive properties. If a woman already plans to use a hormonal method of birth control, the progestin IUD has the added benefit of being one that she does not need to think about every day for use, and one that acts directly within and on her reproductive organs (not throughout her entire body). In fact, she can have one inserted, and other than checking the strings, not have to worry about it for 5 years.
Studies also show that the progestin IUD decreases menstrual bleeding and cramping over time. We see a typical 85% decrease in blood loss within the first 3 months after insertion, and a 97% decrease by 12 months (Boston Women's Health 2005). 30% of users of the hormonal IUD stop having menstrual periods altogether. These results are not usually the case during the first couple months when periods may be longer, heavier, and more erratic. Because of the change in hormones and cycle (number of days, menses, and ovulation) it is not possible for a woman with a progestin IUD to accurately chart her cycle.
For the Mirena brand progesterone IUD, see their site here.
IUDs do not cause infections themselves (another myth that stems in part from the 70s' Dalkon Shield discussed below) but they do enable sexually transmitted infections (STIs) to enter the fallopian tubes more easily (Haas 1998). Having multiple sex partners with an IUD increases the risk of contracting an STI (unless condoms are also used), and increases the risk of pelvic inflammatory disease - more bacteria from a wider assortment of people is introduced into the body with multiple sex partners (Foley, Kope & Sugrue 2002; Stoppard 2001). If a woman contracts an STI, it is wise to have the IUD taken out so that bacteria do not cling to and grow on the IUD, and so that it does not irritate her body while it is trying to heal itself.
Most clinicians believe that IUDs are not typically a smart choice for young women who have not had children. They have, on occasion, caused a perforation of the uterus (1 in 1,000 cases), pelvic inflammatory disease (PID) usually from an STI that spreads, and an increase in cases of ectopic pregnancies. We find sociologically that the younger a sexually active girl is, the less likely she is to use another form of protection against STIs if she has an IUD in place. Ectopic pregnancies are also more common in first pregnancies, and while IUDs decrease the rate of ALL pregnancies (ectopic included), IF a pregnancy does occur with an IUD in place, it is more likely to be an ectopic pregnancy. [Ectopic pregnancies occur in about 1 of every 100 pregnancies, but are more common in 1st pregnancies.]
For these reasons, most clinicians also agree that an IUD is not a good choice for women with compromised sensation (i.e. not able to feel sensation in their pelvic area) because perforation of the uterus and/or the pain that accompanies a PID or ectopic pregnancy would not be noticed (Boston Women's Health 2005; Hakim-elahi 1991).
IUDs may also increase bleeding and pain during menstruation (as the uterus is irritated by the IUD and attempts to push it out). This is usually more true with the copper than the progestin IUD. About 1 in 10 women has her IUD removed due to excessive bleeding and/or cramping (Condon 2004). Expulsion of the IUD (having it pushed out with a woman's period) is not uncommon, so women need to check the strings to make sure it is still in place. Usually, if an IUD is going to be pushed out by the body, it will happen within the first 3 months. After that time, it seems to be more stable. In one study 1.2 - 7.2 On occasion an IUD is painful to insert (this, again depends on each individual woman). The progesterone IUD also includes the possible side effect of ovarian cysts (already common in many women and frequently painful) because it is interfering with hormones. It should be noted that at times heavy bleeding (and cramping) with an IUD only occurs during the first several months, and then subsides as a woman's body grows accustomed to the 'invader' within.
Six weeks after having an IUD inserted, a woman should return to her care provider to check the IUD strings and make sure there are no signs of infection. In any cases of unusual vaginal bleeding, lower abdominal pain, abnormal discharge, or unexplained fever (possible signs of PID) a health care provider should be seen immediately.
The well-respected Brigham and Woman's Hospital in Boston gives these instructions on checking an IUD:
To check the strings of an IUD, reach a finger into your vagina and feel for your cervix. You should be able to feel the strings against your cervix. If you cannot feel your IUD strings, or you can feel the hard plastic of the IUD at the opening of your cervix, you should abstain from sex or use another contraceptive method until you see your provider to determine whether the IUD is still in place.
Women who have a long vagina, or a high set or tipped cervix, may have difficulty in reaching the cervical area to check the strings. I have known women who could not reach their cervix with their fingers no matter what 'fun' position they got themselves into. Each woman's body is unique unto herself, so again, this is something each individual should consider when exploring their birth control options.
Considerations when an IUD may not be the best option:
-current, recent (past 3 months), or repeated pelvic infection
-known or suspected pregnancy
-severe infection of the cervix
-malignant lesions in the genitals (cancers)
-unexplained vaginal bleeding
-Paralysis (because of the inability to feel a problem)
-Physical inability to check the IUD strings (as mentioned above)
-Women with Wilson's disease (copper IUD)
-Women allergic to copper (copper IUD)
-Women with heavy bleeding/cramping (copper IUD)
-Women with hormonal complications (progestin IUD)
-Women with cervical problems (progestin IUD)
-Women with breast cancer, history of breast cancers (progestin IUD)
IUDs are still not that popular among women in the United States. While more are choosing them, they received bad press in the 70s/80s when one type of IUD (the Dalkon Shield) was found to be unsafe, causing a greater than typical number of pelvic infections. 20 women died as a result, and many more filed suit against the company. The maker declared bankruptcy in 1985 and all IUDs were pulled from the market in the late 1980s. As a result, the reputation of IUDs was damaged for a couple decades. In 1998 only 2% of women using contraception choose the IUD (Condon 2004; Haas 1998). Only today is the IUD becoming popular again. The IUDs made today are safer and have not been found to increase the risk of any infections for women who are not already at risk of contracting a sexually transmitted infection (as discussed above).
There is no known connection between the use of an IUD and any future problems becoming pregnant again (Boston Women's Health 2005). As soon as the IUD is removed, pregnancy can once again occur. However, this may take a few months longer after the use of a hormonal IUD than the copper IUD because of the body's need to shift gears and get back into ovulation mode. However, IF a woman contracts an STI while an IUD is in place, the complications from the STI can cause infertility.
I hope this answers some of the questions surrounding IUDs as an option for birth control, and again, I would encourage those of you with personal experience using IUDs to leave a comment below and let others know what you liked or did not like about this particular birth control method.
Barker, Elliott. (1991). Film Guide to CSPCC Video: When You Can't Feel No Love. Canadian Society for the Prevention of Cruelty to Children.
Boston Women's Health Collective. (2005). Our Bodies, Ourselves: A New Edition for a New Era. New York: Touchstone.
Condon, Marian. (2004). Women's Health: An Integrated Approach to Wellness and Illness. York, PA: Prentice Hall.
FDA - Food & Drug Administration. (2008). Levonorgestrel-releasing Intrauterine System Warnings, Contraindications, Precautions, Adverse Reactions and Medical Guide. Washington D.C.: US Department of Health and Human Services.
Foley, Sallie, Kope, Sally, & Sugrue, Dennis. (2002). Sex Matters For Women: A Complete Guide to Taking Care of Your Sexual Self. New York: Guilford Press.
Hass Sheila. (1998). The intrauterine device: Dispelling the myths. The Nurse Practitioner, 23 (11).
Hunt, Jan. (2001). The Natural Child: Parenting From the Heart. Gabriola Island, BC: New Society Publishers.
Stewart, Elizabeth. (2002). The V Book: A Doctor's Guide to Complete Vulvovaginal Health. New York: Bantom Books.
Stoppard, Miriam. (2001). Women's Health Handbook: What Every Woman Needs to Know About Her Body. New York: Dorling Kindersley Publishing.