Are you using a LARC?

Are you using a LARC? Maybe you should be. LARCs, otherwise known as long-acting reversible contraception, include IUDs and the contraceptive implant. The American College of Obstetrician and Gynecologists just released an updated opinion on LARCs which is that everyone who is at risk for pregnancy should be offered a LARC as a first choice, including adolescents. Because of the way LARCs work, which does not depend on the user, that’s you, by the way, they have a very low failure rate.

The implant has the lowest failure rate of all reversible contraceptives at 0.05 percent/year, but it can be hard to remove and bleeding is unpredictable making it less appealing. The IUD also has a very low failure rate at 0.2- 0.8% depending on the type of IUD. These rates are equivalent to sterilization. IUDs only require a minor procedure to insert, instead of surgery like sterilization; additionally, an IUD is effective immediately after insertion and fertility rapidly returns after removal making them an excellent choice for all women.

IUDs have been around for over 100 years. Early IUDs were made of inflexible metal, making them difficult to insert. Ouch. It wasn’t until the 1950s and 60s, with the advent of bendable plastics and a much easier insertion, that IUDs increased in popularity. In the early 1970s, almost 10% of women using contraception were using an IUD. Several different IUDs were available at that time, including the now infamous Dalkon Shield.

The Dalkon Shield Debacle

The Dalkon Shield was released in 1968 and marketed particularly to younger women. It is unclear precisely what, both a poorly designed shape and a braided string have been implicated, but the Dalkon Shield was associated with serious pelvic infections leading to infertility and even death. By 1974 with exploding safety concerns, the Dalkon Shield was removed from the market.

Thousands of lawsuits by users of the Dalkon Shield who suffered complications resulted in payouts reaching almost 3 billion dollars and the makers of the Dalkon Shield filed for bankruptcy. In addition to the liability disaster for the manufacturer, the Dalkon Shield debacle affected attitudes and availability of all IUDs for decades to come. With ongoing safety and liability concerns, over the next ten years, the other available IUDs were also removed from the market. No pharmaceutical company wanted to take on that kind of risk. As it turns out, the issues were specific to the Dalkon Shield. Other IUDs were and still are very safe, but by the mid-1980s not a single IUD was available in the US. Interestingly, IUD popularity continued to grow in other developed countries around the world.

Fortunately, as the memory of the Dalkon Shield fiasco fades, IUDs are making a comeback. Currently, there are two types of IUDs available. A copper one and a hormonal one. There are several different hormonal IUDs, each one releasing a slightly different amount of hormone.

Hormonal vs. Nonhormonal

A nonhormonal, incredibly effective method of contraception sounds awesome, doesn’t it? The problem with the copper IUD is that women can have significantly, unsustainably, heavier, crampier periods. The hormonal IUD was created to address this issue, and it does, usually quite well. Most women with a hormonal IUD have incredibly light periods lasting 1-2 days or no period at all. It’s totally forgettable, unlike the pill which you have to remember every day or the copper IUD which reminds you during your period.

The nonhormonal, copper IUD may be appealing to you, especially if you have tried and not liked being on the pill or just like the possibility of managing fertility without interrupting normal hormone production. In my experience most (not all) women who try the copper IUD end up taking it out because their periods are so bad.

On the other hand, one of the excellent benefits of the hormonal IUD is that it also doesn’t interfere with your normal, natural hormone production. It works by changing the environment around the uterus so that conception never occurs. This is different from other hormonal methods. Most pills suppress ovulation. With the hormonal IUD, you still ovulate. You still make estrogen and progesterone.

Every month during a normal cycle the uterine lining or endometrium proliferates to prepare for a potential pregnancy. When conception does not occur the lining breaks off; this is your period. The hormonal IUD secretes a small amount of progestin every day, which prevents the uterine lining, or endometrium, from proliferating. This means that there isn’t much tissue present to bleed. Because the hormone in the IUD is not taken orally and instead works locally on the uterus, you don’t have the same kind of side effects as you do on the pill like weight gain, bloating, mood changes or headaches.

Forgettable

If you have tried the pill and have experienced side effects, just don’t like that way you feel, or you would like a method of birth control that is totally forgettable the hormonal IUD may be the right choice for you. Here is an excellent article on the non-contraceptive benefits of the hormonal IUD.

Because the hormonal IUD is so effective while being so forgettable, it is an excellent method for teenagers and young women who historically have trouble a remembering to take a pill every day. And because women who use it have very light periods it is good for anyone who has heavy periods, especially women nearing menopause who may have both heavy and unpredictable periods.

It is not a magic bullet, however. Occasionally women do have side effects, they continue to cramp long past the insertion, it doesn’t help improve their periods or various other issues. If that’s the case, it’s not for you. Continuation rates after one year of use are almost 90% for the hormonal IUD so most women who try it, like it and keep it.

I recommend that all women interested in preventing pregnancy or dealing with heavy periods at least consider an IUD. Here are some things to keep in mind as you decide.

1. You can have irregular bleeding. This is usually limited to the first one to two months. Many women experience daily spotting, light bleeding or brown discharge. Some women will have longer but lighter periods. This improves. For many women, it will completely resolve and you will either have no period, a light but regular period or spotting every couple of months. Sometimes it can take longer than 1-2 months.

2. The insertion can be uncomfortable. The whole procedure only takes a few minutes, but it can cause cramping. Whenever an instrument is passed through the cervix into the uterus, the uterus cramps as a response. The instruments and the IUD itself are foreign bodies. The uterus wants to get rid of them and cramps as a way to do that. The cramping usually improves in the first 10-15 minutes after insertion and then steadily improves throughout the day. By the evening it is usually much better and essentially gone by the next day. For young women or women who have never been pregnant, the cramping can be a little more intense and last a little longer.

3. The IUD can move or even fall out. Rarely the uterus continues to cramp attempting to remove the foreign body that is the IUD. Even more rarely it succeeds, and the IUD falls out or in a tiny fraction of cases gets embedded in the wall of the uterus. This is most likely to happen in the first few months but can occur at any time, so I recommend you check the strings once/month to confirm it is still placed correctly. This can be hard. The strings are high and can be difficult to reach. If you continue to have cramping weeks after the insertion, make sure to check that your IUD is still there.

4. The out is way easier than the in. Removing your IUD takes 10 seconds. It’s much easier than the insertion. So if for any reason you do not like the IUD it can be removed. And your return to fertility is immediate.

5. The IUD does not protect against sexually transmitted infections. After the Dalkon Shield catastrophe, the risk of infection remained a concern, but recent data show that IUDs are not associated with serious infections unless an STI is present, undiagnosed at the time of insertion. There is a minuscule risk of pelvic infection with insertion for all women ranging from 0-2% which increases to 0-5% when an STI is present.

6. There are two hormonal IUD options which last for five years. The Mirena which has been available since 2000 and the Kyleena which was just released in 2016. The Kyleena releases a lower dose of hormone than the Mirena and is a little smaller. It was created for younger women or women who have never been pregnant, as their uterus is usually smaller. Although in my experience both young women and women who have never been pregnant do well with the Mirena.

Women using the Kyleena are less likely to have no period otherwise known as amenorrhea. Your periods should be light and easy but will exist. Some women may prefer that. There is a third option known as the Skyla which also releases a lower dose of hormone but is only good for three years. The Kyleena and Skyla are otherwise identical except for the length of their efficacy. Since you can always have your IUD removed, I don’t think the Skyla offers any advantages over Kyleena.

Most women love the Mirena, but it doesn’t work for well for everyone who tries it. Again, some women continue to cramp, are always aware of it, still have more of a period than they want or various other issues. If you don’t like it, you don’t have to keep it.

I am basing these recommendations both on my personal experience with patients and that of the American College of Obstetrics and Gynecology. I’m always interested to see how things translate to real life. What’s your experience with IUDs? Or any other contraceptive choices?