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Should you set it and forget it?

Safe, effective and long-lasting, the IUD is the gold standard of birth control among gynecologists. Strange, then, that only about 3 percent of Canadian women use one

For women frustrated with their birth control choices (the pill is a hassle to remember, the effectiveness and ease of condoms and diaphragms can be iffy, and tubal ligation is permanent), the very best option, the one that fans rave about and gynecologists swear by, is the intrauterine device (IUD). It’s also one of the least popular methods of contraception; in Canada, only about 3 percent of women who use birth control opt to use one, compared with about 44 percent who take the pill.

Inserted by a doctor into the uterus, the small T-shaped plastic frame comes in two forms: One is wrapped in copper, which causes an inflammation in the lining of the uterus that’s toxic to sperm; the other version, called Mirena, releases a type of progestin that thickens cervical mucus to stop sperm from reaching an egg, while it thins the uterine lining and partially suppresses ovulation. IUDs and implants (small hormone releasing rods inserted under the skin of the upper arm) are referred to collectively as LARCs — long-acting reversible contraception — and once they’re in place, they are 99 percent effective and last for anywhere from three to 10 years. After they are removed, your body returns immediately to its baseline level of fertility. Of the two, IUDs have the advantage of lasting longer (up to 10 years for the copper version); in addition, Mirena reduces menstrual bleeding and cramping. Implants often lead to heavier bleeding and cramping, as well as mood swings and acne.

Dr. Erika Feuerstein of the Bay Centre for Birth Control at Women’s College Hospital in Toronto says IUDs are “brilliant.” It’s the only form of contraception she’s used, and she says, “It’s my favourite form of birth control to suggest to patients.” The big advantage is that IUDs are “forgettable contraception.” The pill is equally effective at preventing pregnancy, but it works only if women take it at the same time every day. IUDs remove the need to remember, therefore removing one of the reasons why birth control can fail.

Two recent large-scale U.S. studies back this up. The Contraceptive Choice Project in St. Louis, Missouri, and a statewide program in Colorado provided adolescent and adult women with free LARCs in an effort to reduce unwanted pregnancies and abortions. The results were staggering: In Colorado, the adolescent birthrate fell by 40 percent and the rate of abortions by 42 percent. For teenaged girls enrolled in the St. Louis study, pregnancy and abortion rates plunged to less than a quarter of the national level. Researchers there also reported that after three years, 70 percent of women with IUDs and 56 percent with implants still had them; meanwhile, only 31 percent of the women in the study who had opted for short-term contraception had continued to use it.

Given these kinds of results, why are IUDs so unpopular? One reason is money. Mirena costs $325 and up, while copper IUDs are about $80 to $150. Over time, they turn out to be cheaper than the pill. Some insurers cover the cost, but the upfront fee can be prohibitive.

Then there’s the IUD’s history. An early model used in the 1970s, called the Dalkon Shield, was “a disaster,” according to Feuerstein. “It looked like a crab and if it imbedded itself in the uterus, a woman had to have a hysterectomy to get it out.” As if that weren’t bad enough, the Dalkon Shield had a long, braided tail made of multifilament string that allowed bacteria to travel into the uterus, causing infections. This creepy image continues its hold on the imagination of plenty of women, she says. “There are patients who are just freaked out by the idea of having something inserted into their body.” She adds that widespread use of IUDs in the 1970s coincided with the sexual revolution — and as people began to have more partners, sexually transmitted infections (STIs) became more common. Many of the infections attributed to IUDs were actually contracted by having sex without condoms.

Today, aside from a slight chance of infection from the insertion procedure, IUDs are not associated with higher risks for infection or pelvic inflammatory disease. There is discomfort during insertion, and with the copper version, some women experience heavier and crampier periods. More significantly, there is a risk (one in 1,000) of perforation of the uterus, which has led to a series of lawsuits against Mirena’s manufacturer, Bayer, in the U.S. and Canada. And, like the birth control pill, LARCs don’t protect against STIs.

These issues have made some doctors leery of prescribing IUDs — particularly to teenagers and to women who haven’t had children — because of those old fears that IUDs could cause infections that lead to infertility. A 2008 study published in the journal Canadian Family Physician found that general practitioners unfamiliar with the latest research had misconceptions about safety and effectiveness.

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Perceptions are changing, though, due to research that underscores the advantages of IUDs and implants. A 2011 analysis published in the medical journal the Lancet Oncology followed 20,000 women from more than a dozen countries for 10 years. It found that women who used IUDs as briefly as for one year had half the risk of developing cervical cancer of women who never used IUDs; one theory is that the insertion and removal procedure may destroy precancerous lesions or cause a long-term immune reaction that prevents human papilloma virus from developing into cancer. Other studies have noted an association between IUD use and a reduced risk for endometrial cancer. Last year, the American Academy of Pediatrics recommended LARCs as “the first-line contraceptive choice for adolescents who choose not to be abstinent.” A 2015 U.S. study published in the reproductive health journal Contraception surveyed 488 women who worked in the field of family planning; it found that they were far more likely to use LARCs than the general population: 42 percent compared with 12 percent.

Feuerstein says that effective contraception should provide a sense of freedom and control over your own body. IUDs come out on top on these counts, as well as offering nearly 100 percent effectiveness and no impact on fertility. One of her patients was previously refused an IUD by three separate physicians but kept persisting. “Counselling is key,” Feuerstein says. “I would encourage any woman interested in an IUD to talk to her family physician first because many of them are supportive. If that doesn’t work out, then try a centre that specializes in birth control.”

IUDs through the ages

THE DALKON SHIELD

This early-model IUD was released in 1971. Its crablike shape made it difficult to remove, and its multifilament tail string inadvertently acted as a delivery device for bacteria. With its use came reports of septic abortions and other pelvic infections, and in 1983 the FDA ordered all women using the device to have it removed. The manufacturer, drowning in litigation, filed for bankruptcy in 1985.

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COPPER IUDs

These first came on the market in the U.S. in the mid-1970s, when it was discovered that copper turned the uterus into a hostile environment for sperm. Even with its T-shape design, smaller size and monofilament string, it had trouble taking off because of the negative publicity from the Dalkon Shield. Today, copper IUDs have proven to be safe and highly effective, but they can result in heavier periods and cramping.

MIRENA

This hormonal IUD is made of plastic and releases a type of progestin that thickens cervical mucus to stop sperm from reaching an egg. It also reduces menstrual bleeding. The rare (one in 1,000) but serious risk of uterine perforation has led to a series of lawsuits that are ongoing against Mirena’s manufacturer, Bayer.

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