I ditched birth control pills five years ago to join the growing number of women embracing intrauterine devices, or IUDs. The doctor who inserted my IUD told me she shortened the strings dangling from the bottom of the tiny t-shaped device so that my partner wouldn’t feel them. Horrified at the prospect of my then-boyfriend bumping into my birth control, I said okay without a second thought.
Earlier this year, when my IUD reached its expiration date, I regretted saying okay. Most of the time, doctors remove IUDs by gently tugging on their strings. But my doctor (a different one) couldn’t see the shortened strings, so she performed an ultrasound to find the device. Then, using an instrument, she reached past my cervix to get the thing out. I didn’t know what to make of the IUD rescue mission, and the large Motrin I’d taken earlier didn’t dull the pain piercing my lower abdomen. I left my appointment convinced my IUD days were over.
The truth is, I should have known more about the object that spent half a decade in my uterus. But research suggests a lot of women are similarly underinformed or misinformed about IUDs. If I decide to give IUDs another chance, I won’t make the same mistake. Courtesy of a few experts and recent research, here’s what you (and I) should know before getting an IUD.
What are my options?
IUDs fall into two main categories: hormonal and non-hormonal. Both types are highly effective forms of contraception.
All IUDs work to prevent pregnancy by blocking sperm from fertilizing eggs. Non-hormonal IUDs do this by releasing copper, the metal coil wrapped around the IUD and a natural spermicide. Hormonal IUDs, on the other hand, release progestin (a synthetic form of the sex hormone progesterone), which thickens the cervical mucus, making it tough for sperm to swim through the uterus. Hormonal IUDs can additionally prevent eggs from leaving the ovaries to get fertilized.
Currently, the only non-hormonal IUD on the market is ParaGard, which lasts for up to a decade. The main side effect of ParaGard is the possibility of abnormally heavy periods, though this tends to decrease over time, usually after the first year.
When it comes to hormonal IUDs, there are four options: Mirena (the one I had), Liletta, Kyleena and Skyla. They differ in terms of how much they cost (typically $500 to $1000, and insurance may cover part or all of the insertion), how long they last (three to seven years) and how much progestin they release. In general, hormonal IUDs are known to lighten periods and lessen cramping. Some women stop menstruating entirely, which is more likely with higher-progestin options (Mirena and Liletta).
The “right” IUD for you is the one with the side effects you can tolerate best, according to Dr. Lisa Perriera, an OB-GYN at Thomas Jefferson University in Philadelphia.
When can I get an IUD?
Pretty much whenever you want, as long as you’re not currently pregnant. There’s no minimum age for IUD insertion. They’re safe and effective whether or not you’ve been pregnant in the past. Copper (non-hormonal) IUDs can even double as emergency contraception if inserted within five days of unprotected sex.
“You don’t even have to wait for your next period,” said Dr. Carrie Cwiak, a family planning expert and professor of gynecology and obstetrics at Atlanta’s Emory University School of Medicine.
Some women choose to get IUDs right after giving birth, explained Cwiak, who’s studied postpartum IUD placement. “A lot of people feel like, if I’m here, and you have easy access to my uterus, and I have good anesthesia, this sounds like a great option,” she said, noting that IUDs don’t interfere with breastfeeding.
A potential downside of postpartum IUD insertion, meaning anywhere from 10 minutes to four weeks after delivery, is the increased chance of expulsion — 15 to 20 percent, compared to 5 percent for IUDs inserted at other times. An IUD is considered expelled when it moves out of its correct position in the uterus or leaves the uterus entirely. If you can feel the device itself, rather than just the strings, that’s a sign of expulsion. Severe pain and/or bleeding can also indicate that the device has shifted.
Does it hurt?
It depends. Insertion is least likely to be painful for women who’ve given birth vaginally within the past two years, according to Dr. Hannat Akintomide, a sexual health expert at the New Croft Centre in Newcastle, England. Akintomide led one study on IUD insertion pain in which 4 in 5 women reported between no discomfort and moderate pain. More than 70 percent of study participants had never been pregnant.
In a study Perriera worked on, about 77 percent of women said they were satisfied with their insertion procedure, while 83 percent said the IUD was worth any discomfort they felt.
Some women also report pain for up to a week after insertion.
Okay, but what if I’m really worried it will hurt?
You can take something. Perriera tells patients they can take ibuprofen before insertion, to ease discomfort during it and subsequent cramping. You can also ask about local anesthesia, which comes in the form of a shot in your cervix. Cwiak compares the pain to that of novocaine: a pinch and some tingling. “I’m sure it’s not the most comfortable thing,” she said, “but most people do tolerate it pretty well.”
Are there risks associated with IUDs?
“Any time something goes in your body, it could come out,” Perriera said. Expulsion is most likely to occur within a year of insertion. If an IUD does shift out of place, it may become ineffective against pregnancy.
There’s also an exceedingly low chance that an IUD will poke through the wall of the uterus and end up in the belly cavity. In that case, surgical removal would be necessary. Of the possible complications, this one is the most serious.
Even though IUDs have a solid safety record, post-insertion pain is worth paying attention to. If you have persistent lower abdominal pain, pain during sex or bleeding after sex, Akintomide recommends heading back to your doctor.
What do I have to do after insertion?
Virtually nothing. It’s a set-it-and-forget-it method of birth control, which is partly why it’s so effective. An IUD lasts between three and 10 years, depending on the type, but you can remove it after however long you want.
While you have the device in, you can get it checked during OB-GYN exams to make sure it hasn’t moved. You can also do this via a self-check. If you can’t feel the strings, don’t worry — as long as there’s no pain, bleeding or unusual discharge. In a study on women’s ability and willingness to feel their IUD strings, about half of participants either didn’t check the strings or couldn’t feel them, and their IUDs were just fine.
What else should I know about those strings?
Strings are attached to IUDs to make removal easier — sort of like a tampon. A few different complications might prevent a doctor from removing the device with a gentle tug. For instance, the strings might not be visible due to expulsion. Or they could be broken, which happens most often to IUDs placed after childbirth. IUD strings can also become longer when they’re inserted postpartum, Cwiak says, because the uterus changes shape and shrinks during this time.
If the strings aren’t visible, Cwiak adds, a diagnostic procedure, like an ultrasound, would be needed to locate and remove the IUD. This can get expensive: As of 2015, one study found, an ultrasound-guided removal cost $465. Regular removal of the IUD could be included in the cost of an IUD, or covered by insurance, or cost an additional $150 to $250. Don’t hesitate to ask.
Typically, doctors cut IUD strings to 2 to 3 centimeters long, Perriera says, but you can talk to your doctor about keeping the strings longer or shorter, depending on your preference. One study found that 14 percent of male partners were bothered by the strings. An additional 13 percent noticed the strings but weren’t bothered.
Cwiak also said that a doctor can go back in and trim the strings after insertion if they become bothersome, such as if they’re long enough to reach the opening of the vagina.
Knowing the consequences and risks for different aspects of getting an IUD makes it easier to decide what’s important to me. Pain and discomfort don’t have to be a given when inserting or removing an IUD. I have much more control over the length of IUD strings, as well as the length of time an IUD stays inside me, than I initially realized.There are lots of ways to make an IUD fit my body and my lifestyle — especially now that I know what to ask for.