IUD offers 'no-brainer' birth control

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

The intrauterine device is one of the most popular forms of contraception in America, and today we'll learn about why with Dr. Renee Mestad. She's director of the complex family planning section of the obstetrics and gynecology department at Upstate.

Welcome back to "The Informed Patient," Dr. Mestad.

Renee Mestad, MD: Thank you.

Host Amber Smith: What is the intrauterine device, or the IUD?

Renee Mestad, MD: In the United States, the IUD is a small device that has a T shape, and it fits inside the uterine cavity.

While there, it provides what we call LARC, or long-acting reversible contraception, that is as effective as being sterilized without actually being sterilized, so that, depending on the device, it provides contraception from anywhere from three years to 12 years but can be removed at any point in time if the patient wants to become pregnant.

Host Amber Smith: You said in the United States. Are IUDs different in other parts of the world?

Renee Mestad, MD: Yes. There are a wide variety of different types of IUDs throughout the world, but in the United States, the only ones that are approved by the FDA (Food and Drug Administration) are the two T-shaped IUDs.

Host Amber Smith: Now, have you seen that its popularity is on the increase in America?

Renee Mestad, MD: Yes. When I started in complex family planning, way back in 2008, the utilization was roughly about 1%. And at this time, we are up to about 14%, with the highest group being about 16%, being young women aged about 18 to 25.

Host Amber Smith: So why do you think this is becoming more popular with that segment?

Renee Mestad, MD: Part of the unpopularity was due to the Dalkon Shield scandals from the '70s that resulted in a lot of physicians not wanting to provide intrauterine devices, or IUDs, for women who had never had children, due to a concern that they might cause pelvic inflammatory disease or scarring of the Fallopian tubes, which would cause infertility to these women.

And as a result, all of the IUDs were basically taken off the market. The companies that made them determined that it wasn't profitable to provide these methods of contraception

When people interested in contraception went through the data that had been accumulated, stratified out the different IUD types, they found there was only one kind of IUD that caused the pelvic inflammatory disease. The rest of the IUDs did not increase a woman's chance of developing pelvic inflammatory disease any more than any woman who was sexually active. Period.

So, starting in the late '90s and early 2000s, two companies were willing to start making IUDs again. And the people in the family planning world began publishing a lot more data about the safety around IUDs, the efficacy around IUDs. And new physicians became very interested in IUDs. They're very popular because they are as effective as they are. And because they're what we kind of refer to as no-brainer birth control. You, don't have to remember it every day. You don't have to refill it every month.

It's expensive to start, but once it's in the uterus, the woman owns it; it's hers. If she loses her insurance, she doesn't lose access to her IUD. If she gets into a car accident and has to pay a huge deductible to repair her car and therefore doesn't have any money to pay for her copays for anything else, she still has her IUD. So they've become very popular for these reasons. And for female trainees in obstetrics and gynecology, it's the No. 1 form of birth control.

Host Amber Smith: What's the difference between hormonal IUDs and copper IUDs?

Renee Mestad, MD: The copper IUD: In the United States, we have one available, and its contraceptive effect comes from the copper ions that come from the very thin copper wire that's wrapped around the frame of the IUD -- the frame is basically of plastic -- and copper ions are very toxic to sperm. They prevent the sperm's ability to fertilize. And these ions actually act up into the Fallopian tubes, which is why this is a very good method of emergency contraception for up to five days after unprotected sex, because those ions are able to get to that sperm that's already made it into the uterus and even made up into the Fallopian tubes, and therefore it's unable to fertilize the egg that is released with ovulation.

The progestin IUDs have only one hormone, which is a synthetic version of progesterone. Progesterone helps to decrease the amount of blood that the uterine lining creates, but its primary mechanism of action is that it thickens cervical mucus, so the sperm cannot penetrate the cervix and therefore cannot get into the uterus and ever meet up with an egg to fertilize it.

The added benefit by thinning the lining of the uterus is that it can also help with women who have heavy periods. It can help with women who have problems with abnormal bleeding, women who have things like polycystic ovarian syndrome, or PCOS, where they bleed only every few months, because it can help, therefore, to prevent endometrial hyperplasia, or development of precancer cells. And it can definitely help with preventing endometrial cancer for women who are at high risk of that.

Host Amber Smith: And it's pretty effective at preventing pregnancy?

Renee Mestad, MD: Yes. The risk of pregnancy for both the hormonal and the copper IUDs is less than 1%.

Host Amber Smith: What about sexually transmitted infections?

Does it guard against any of those?

Renee Mestad, MD: Not officially. It, first of all, does not increase the risk of sexually transmitted infections. The progestin, by thickening cervical mucus, can make it more difficult for bacteria to also work its way up into the uterus. So observational studies have demonstrated that any kind of progestational (preceding pregnancy) contraceptive can decrease the chance of developing pelvic inflammatory disease. It will not prevent a woman from getting gonorrhea or chlamydia of the cervix. It will not prevent HIV (human immunodeficiency virus). It will not prevent herpes. It will not prevent HPV (human papillomavirus), but it can possibly help decrease the risk of pelvic inflammatory disease.

Because these are just observational studies, we don't promote this as a benefit of utilizing the methods. If sexually transmitted infections are a concern, then condoms need to be used.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Renee Mestad from the obstetrics and gynecology department at Upstate.

Now, let's talk about who is a good candidate for this. I know the younger women seem to be interested in this, but is it for any age woman?

Renee Mestad, MD: It is for any age woman who can tolerate having a pelvic exam. It requires the provider to place a speculum so that they can see the cervix, so that they can insert the device through the cervix.

So if a patient can tolerate a pelvic exam, and the whole process is usually about five minutes, then it's a good method, good option, for this woman.

Host Amber Smith: What if the woman has never had a vaginal birth before getting the IUD? Does that matter?

Renee Mestad, MD: It does not. Once upon a time, that was a reason to not be able to get an IUD, because it can be a little bit harder to insert the IUD through the cervix, because the cervix has never been stretched open, but it is not a hard and fast rule of why a woman cannot receive an IUD.

Host Amber Smith: Are there any medical conditions that would prevent, assuming that you can undergo a pelvic exam, are there any things other than that, that would disqualify?

Renee Mestad, MD: For the copper IUD, if a woman has something called Wilson's disease, or basically an allergy to copper, she clearly should not. Women who have heavy periods, where they bleed for many days and have developed anemia as a result, should probably not get the copper IUD, theoretically. And there have been complaints that it causes more bleeding, but it's more a matter of it won't really help the bleeding at all.

Any abnormal bleeding should be worked up before either IUD is provided. Cancer often will bleed in advance of being diagnosed. It's not usually the reason a woman, particularly a young woman, has abnormal bleeding, but it needs to be ruled out first.

And then, anybody with a current pelvic inflammatory disease infection should not get an IUD. It needs to be treated first, and then they can get an IUD. Women who have fibroids or scarring of the inside of the uterus or have something that we call didelphic or bicornuate uterus, uteruses that are not the normal light-bulb shape but are actually like two horns. They're not a hard and fast rule, but it could be much more difficult to place or keep the IUD. It may wind up being ejected by the uterus if the shape of the uterus is not standard.

Host Amber Smith: So are these inserted in an office procedure?

Renee Mestad, MD: The vast majority of the time, yes.

Host Amber Smith: And does it hurt?

Renee Mestad, MD: Yes. And it varies woman to woman. I'll have some patients who I go through the process, and I place the IUD, and the response is, "Oh, you started?" And I have other patients who just ... it's just excruciating.

And I can't speak to why it varies. It can be the same person inserting the exact same device or from the same company, and the response is just different. But it does merit that providers be honest with the patients that yes, this is definitely going to be uncomfortable, it might be painful, that the patient makes sure that she takes some ibuprofen before she comes in. It won't necessarily help with the immediate pain of the insertion, but it can help with the cramping that's going to happen afterwards, so it's important that the provider not brush off the potential for pain or significant discomfort by saying, "Oh, it's just a couple little cramps."

I mean, for some women it is, but for some women, it is very significant.

Host Amber Smith: So once it's in place, can the woman feel it?

Renee Mestad, MD: She will have an awareness of her uterus, which is how I describe it. Most of us go through the month without really thinking about most of our organs, until you bruise your arm, and now, every time you wave it, it hurts a little bit.

But when it comes time for our periods every month, then we're very aware of our uteruses, down there in our pelvis. So there might be some cramping; well, there will be some cramping upon insertion and the rest of the day. It should ease up, and it could be a couple of hours up to a couple of weeks and even maybe a month or two, before a woman stops being aware of her uterus.

But like I said, it's just kind of an awareness. It might be a dull ache, or it might just be, "I have a uterus," and you know it's there. And eventually, though, that goes away.

There are strings that hang down from the IUD through the cervix and into the vagina. They should not hang out outside of the vagina like a tampon string. But a lot of times women can feel that. Occasionally a male partner might complain about IUD strings, so we usually try to tuck them behind the cervix if that becomes an issue.

Host Amber Smith: How hard is this to remove?

Renee Mestad, MD: Most of the time, not very.

It's often easier coming out than it was going in because we just grab the strings and pull. sometimes it can get flipped around in the uterus. I don't know how that happens, but it does, so it may be difficult getting it unflipped.

Rarely, but not impossibly, one of the arms can wind up kind of embedding in the muscle of the uterus itself, which can make it difficult to get out. And we've had a few cases where an "L" of the IUD comes out with one of the arms breaking off and being stuck inside the uterus, whether it's in the uterus itself or in the muscle of the uterus.

And very rarely, like, at this point, about less than one in a thousand times, you can get an IUD that goes all the way through the uterus and into the woman's abdomen, into her belly. In that case, then, she would need a laparoscopic surgery through her belly button to find and remove that IUD.

Host Amber Smith: So those, I assume, are some of the risks of using an IUD.

Renee Mestad, MD: Yes.

Host Amber Smith: But for most women, that doesn't happen.

Renee Mestad, MD: Correct. It's generally pretty straightforward.

Host Amber Smith: Will use of an IUD make it difficult to become pregnant when they're ready to start a family?

Renee Mestad, MD: Return to fertility is pretty immediate. The copper IUD does not affect the function of the ovaries, so a woman continues to ovulate every month. So basically whenever she would ovulate next would be the next time she'd be able to get pregnant.

The progestin IUD, or hormonal IUD, sometimes might affect ovulation, but it's really not reliable in that respect. So once it's removed and that progestin is removed, then the ovaries should start ovulating again, and her fertility comes back fairly quickly.

The thinning of the lining of the uterus, that recovers fairly quickly once the progestin is removed, as well.

Now, the thing to keep in mind is because these are long-acting devices, say that the woman gets one that lasts for eight years, so she has it placed at 24 years of age. She has it removed at 32 years of age. She will have a more difficult time getting pregnant, not because she uses contraception for a long period of time, but because she's now 32 years old. Eight years have passed. Her ovaries are eight years older. Pregnancy after the age of 30 does become more difficult, so that is the only reason why getting pregnant after removal might be more difficult. You simply aged.

Host Amber Smith: Now, we talk about the hormonal IUDs. Do they have the same sort of emotional effects that the pill might have, the hormonal pill?

Renee Mestad, MD: Intuitively, they should not. The amount of hormone in the progestin IUDs is very, very low. It's not zero, as far as getting into the bloodstream and affecting the brain and the emotion centers. But it is significantly lower than that of systemic hormones like birth control pills or the shot, the patch or the ring.

They don't stop ovulation. So if a woman is ... say her PMS (premenstrual syndrome) is well managed with systemic hormones like the patch or the ring or the pills, that might stop, and she may find that she has more significant PMS or mood swings again. All that said, we have had women who have had mood disturbances after having an IUD placed.

Like I said, intuitively, it doesn't make sense, but it happens, and we just don't necessarily know why at this point, but it has the potential to happen.

Host Amber Smith: Do IUDs affect a woman's cancer risk for uterine or ovarian cancers or breast cancers?

Renee Mestad, MD: The progestin IUDs definitively decrease the risk of what we call endometrial cancers, which are the most common uterine cancers.

So if a patient is at risk of developing something like that, then it can definitely decrease her chances of getting endometrial cancer. The copper IUD may or may not decrease the chances of endometrial cancer, due to the inflammatory process that happens within the uterus. It doesn't increase, but it may actually help to decrease the chance.

Neither will have any effect on ovarian cancer, as far as we know at this point in time.

Breast cancer, the copper IUD will not affect breast cancer risk. The progestin IUD, if a woman has an estrogen or receptor positive breast cancer, she really should not use a progestin IUD.

Will it increase the risk?

I just looked at a study last week, and they did find a small increased risk of breast cancer. But you're looking at about eight per 10,000 women higher. Interestingly, pregnancy also increases your risk of breast cancer in the first few years after delivery.

And then, as time goes on, that risk goes back down to what your normal risk would've been. And the risk of developing breast cancer after being pregnant, for a few years afterwards, is actually higher than of using this IUD. So if your biggest, absolute biggest fear in life is getting breast cancer, maybe it might not be your best choice.

The likelihood that you're going to get breast cancer, though, like I said, the absolute numbers are like eight per 10,000 women. So your risk really is not that much higher than the average woman's. And again, the risks of pregnancy across the board in all causes, mortality, morbidity (deaths, illnesses) is significantly higher, particularly in the United States, than the risk of developing breast cancer using an IUD.

So what providers and women need to keep in mind is, when you're comparing the risks of using an IUD or any method of contraception, if they're sexually active, then they need to compare the risk with the contraceptive against her risks of becoming pregnant. If this is a woman who is not having sex, will never have sex and is not at risk of ever becoming pregnant, then her comparison is different. But women and providers need to remember that the risk of pregnancy is not "none." And it's actually fairly significant, particularly in the United States.

Host Amber Smith: What are the other birth control methods you counsel women to consider if they're just not sure about whether the IUD is a good option for them?

Renee Mestad, MD: We run the gamut. It starts with what the patient's goals are. So if this is a patient who has no desire to get pregnant in the next four or five years, then we lean towards either the IUDs or the Nexplanon, which is the only subdural contraceptive implant that's available in the United States. That is a device that fits in the upper arm, just under the skin, and that is effective officially for three years, but post-marketing research outside of the pharmaceutical company has found it to be effective for four and five years.

So those two methods, again, once they're in the body, they're owned by the patient, and they're both extremely effective in preventing pregnancy for many years.

Now if this patient is interested, she just got engaged, and they're getting married, and a few months after they get married, so in about six months, they're thinking they want to try and get pregnant, I'm not going to recommend an IUD or a Nexplanon. They're both very expensive devices. And to place them and then remove them in five or six months is, unnecessary expense and it's unnecessary anything for the woman to go through for insertion. So in those cases, I would lean towards birth control pills or the patch or the ring, or, if they're really good at using their condoms or their spermicide gels, then I recommend in that direction.

The shot, the birth control shot, which in the States is Depo-Provera, that's very effective, and it's good for three months at a time, but the return to fertility can be anywhere from the week after you missed your dose to 18 months. So I'm not particularly fond of recommending that for women who are of an age, in their 20s and early 30s, where when they decide they want to get pregnant, they want to get pregnant right now, they don't want to wait up to 18 months before they can get pregnant.

So it's good for teenagers who are definitely not getting pregnant anytime in the next six or seven or eight years. And it's good for women who are done with childbearing, and they're just kind of waiting for menopause. But for women of that age group where when they decide they want to get pregnant, they want to get pregnant right now, I don't recommend Depo for them.

Host Amber Smith: Well, Dr. Mestad, thank you so much for making time for this interview. I appreciate it.

Renee Mestad, MD: Thank you.

Host Amber Smith: My guest has been Dr. Renee Mestad. She's the director of the complex family planning section of the obstetrics and gynecology department at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.

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