IUDs: A deep dive into long-term contraception

This post was written by Lindsay Roose, APRN, CNM, Parkview Bryan Hospital.

Choosing a birth control method is a deeply personal decision that begins with understanding your options and how they fit into your lifestyle. Among the numerous contraceptives available, intrauterine devices (IUDs) offer a safe and effective method for managing your reproductive well-being. In this post, we'll explore all you need to know about IUDs, including the different types, what to expect during insertion and practical tips on caring for yourself afterward.
 

What are the primary benefits of choosing an IUD?

IUDs are one of the most reliable and convenient forms of contraceptive available, offering long-acting protection that is immediately reversible if the patient decides to discontinue use.

After placement, IUDs provide continuous pregnancy prevention without ongoing effort. Unlike other methods, their effectiveness isn't reliant on strict dosing schedules, they do not require repeated use, and they are not coitus dependent.

Additionally, for patients who experience menorrhagia, over time, some IUDs can aid in the reduction of heavy menstrual bleeding.
 

Can you explain the different types of IUDs that are available?

When selecting an IUD, patients can choose between a non-hormonal device or several hormonal options. Both forms provide long-term birth control but work in different ways.

ParaGard®, commonly referred to as the copper IUD, is the only hormone-free device available in the United States. ParaGard prevents pregnancy by making the uterine environment inhospitable to sperm and egg fertilization. I usually suggest this option if a patient wants a hormone-free contraception that is long-acting for up to 10 years and is immediately reversible.

Alternatively, hormonal IUDs, also known as levonorgestrel (LNG) or progestin-only devices, work by releasing small amounts of the hormone into the uterus each day. This process thickens the cervical mucus and prevents ovulation. The levonorgestrel IUDs are Mirena®, Kyleena® and Skyla®, each offering a slightly different dosage, size, and length of effectiveness. Depending on my patients' goals, I typically suggest the following:

• Mirena (52 mg LNg) - If looking for long-acting, immediately reversible contraception lasting up to 8 years that will help reduce menstrual bleeding or stop menstrual cycles.

• Kyleena (19.5 mg LNg) - If she is looking for long acting, immediately reversible contraception lasting up to 5 years that may reduce menstrual bleeding but prefers a smaller IUD.

• Skyla (13.5 mg LNg) - If she is looking for long acting, immediately reversible contraception lasting up to 3 years and is smaller in size but may not reduce bleeding.

Just as each patient is unique, so are their reproductive needs. The size and hormone dosage of an IUD are significant factors to consider and should be discussed with your provider to determine the best fit for your body and health goals.
 

How do you prepare a patient for an IUD insertion?

I think it is vital for every patient to come in and discuss all birth control methods to ensure they can make an informed decision before beginning treatment or placement. When someone chooses an IUD, I review the entire insertion process and show them the tools used for the procedure if they wish to see them. Some patients experience significant pain during the procedure; however, we try to make it as comfortable as possible. While patients can expect to feel some discomfort, we discuss breathing exercises and distraction techniques that can help during the process. I also offer premedications and advise them to visit bedsider.org to review nonbiased information about birth control and watch other women's accounts of IUD placements.

On the day of the procedure, I advise the patients to take 800 mg of ibuprofen approximately one hour before their appointment. Although it is not a powerful painkiller, the uterus responds well to ibuprofen at that dose. It diminishes cramping by inhibiting prostaglandin production, which helps reduce uterine contractility. 
 

What is the actual process like?

Upon arrival, patients provide a urine sample to confirm they are not pregnant, and then the nurse brings them into the procedure room to take their blood pressure. Once settled, I review the risks, benefits and details of the procedure before we sign the consent form. When they're ready, I assist the patient into the lithotomy position and explain each step of the procedure before I do it so there are no surprises.

First, I perform a pelvic exam to assess the position of the uterus in the pelvis, then place a speculum in the vagina to collect a sample for the gonorrhea and chlamydia test. Completing an STI test before the procedure ensures there are no chances for pelvic inflammatory disease.

Afterward, I clean the cervix with betadine (an antiseptic) and tell the patient to cough deep from the belly, which lessens discomfort while placing the tenaculum to stabilize the cervix. I also suggest they raise both hands in the air, open and close their hands like they are waving, and take deep breaths in through their nose and out their mouth. This technique helps with cramping.

Next, I use a plastic uterine sound to measure from the outer cervical os to the top of the uterus. This step can be very crampy. Once this is complete, I remove the device from its packaging and set the phalange (device placement guide) according to the measurement.

I then instruct the patient to breathe deeply again and open and close their hands while I place the device through their cervix until the phalange is at the cervical os. Once it's in position, I count to 3 and warn the patient that there may be a sharp cramp when the device deploys. Counting to 10, I gently move the IUD upwards before slowly pulling the applicator through the cervix.

With the IUD in place, I trim the strings until they are 2 cm from the cervical os and then remove the tenaculum. Usually, the cervix does not bleed from where the tenaculum was, but if it does, I apply gentle pressure with a cotton swab to help stop the bleeding quickly.

Once the procedure is complete, I instruct patients to lie flat, give them a bottle of water and turn the lights low. We let them rest for about 10 minutes, and they are usually good to go from there.
 

How long does the discomfort typically last after an insertion, and what are some ways to manage it?

The level of discomfort after an IUD can vary from woman to woman. Some do not have any pain, others report period-like cramps, and some may experience more intense discomfort and significant cramping. This can last for a week or two after placement.

Ibuprofen is the best treatment for managing pain because of its prostaglandin inhibition effect. Applying heat can also provide relief, and in some cases, I have also given low-dose muscle relaxers to help ease the symptoms. For first-time IUD users, I recommend scheduling placement on a day when they can rest at home for a day or two afterward just in case they have cramping or bleeding. 
 

Are there any side effects or risks associated with IUDs that patients should be aware of?

While IUDs are generally safe, there are some side effects and risks to keep in mind. Before making a decision, patients should consider these potential complications:

Pelvic inflammatory disease (PID): IUDs can increase the risk of PID if a patient contracts gonorrhea or chlamydia before or shortly after placement.

Uterine perforation: In rare cases, the device may puncture the uterine muscle layer, potentially damaging tissue, vessels and organs under the uterus.

• If the IUD seems out of place, or you can no longer feel the strings, contact your healthcare provider immediately.

Irregular bleeding: With hormonal IUDs, some women experience irregular bleeding for 3-6 months after placement.

• There are options to help manage this side effect, so it's important to discuss any concerns with your healthcare providers.

Heavier menstruation: With ParaGard, periods can become heavier and longer for some women. Pain and cramping are also common side effects, especially during the first couple of weeks after placement.

• If this occurs, let your healthcare provider know. We can prescribe analgesia and provide tips to relieve cramping.
   

How often should someone with an IUD visit a doctor for check-ups?

I ask my patients to come to the clinic for a follow-up appointment a month after insertion. At this appointment, we'll discuss how they are feeling and check the string length to ensure the IUD placement is correct. Subsequent follow-ups typically occur every year during their well-woman exam. However, I always encourage patients to make an appointment if they have any concerns or notice anything unusual.
 

What advice do you have for people who may feel anxious about the procedure?

I recommend making an appointment for a consultation with your provider first. Have them walk you through the procedure and show you the tools involved. Ask a million questions and discuss all your options. Make sure you feel comfortable before you start. If you still have doubts, postpone placement until another day. 
 

Final thoughts

IUDs are an effective birth control for many people, but not every method is suitable for everyone. Make sure you explore all of your options as well as the risks, side effects and benefits so you can choose the contraception that best supports your reproductive health.

For more information about women’s health services or to schedule an appointment with one of our specialists, please call 1-877-PPG-TODAY or visit our Women’s Health page.