IUDs: A Love-Hate Story

“In so many ways, the hormonal IUD is the new American dream.”

11.03.16
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You haven’t really lived until you’ve Googled “did my boyfriend’s penis poke my IUD into my intestine” while writhing in pain on the floor of his parents’ basement.

Turns out it was only (only?) a cervical bruise, but the subsequent ER visit and the quick glance at my Mirena, shiftless and foreign on the dark screen of the ultrasound, reminded me, for the first time in the two years since its implantation, what an odd thing it truly is, a tiny fish hook of hormones locked tight in my uterus.

I started taking the pill at 15, even though I wasn’t having sex (I SWEAR, MOM). I simply wanted some measure of control over my reproductive system. I’m incredibly grateful to the pill for 12 years of pregnancy-free sex. My experience was net positive, although I was knocked out cold at least once a cycle by menstrual migraines that, at their worst, caused me to slur my words and vomit. Neat! Eventually my doctor pulled me off the pill as a result of studies linking estrogen-based contraceptives to an elevated stroke risk in patients with migraines accompanied by aura. Also neat!

Around that time, it seemed like every cool girl in New York was getting an IUD. They were the new green juice. Fewer than 10% of American females use an IUD as contraception (primarily due to residual concerns over the Dalkon Shield scandal of the ‘70s, in which an earlier version of the IUD caused dangerous infections and infertility), but Planned Parenthood has reported a 75% increase in patient use since 2008 — growth largely prompted by a decrease in cost and an advocacy campaign that highlighted the low rate of failure (less than 1%). By the time I was considering new contraceptive options, I had heard more and more stories of women my age who had been on the pill since adolescence and who were growing increasingly frustrated by both its inconvenience and its myriad of side effects.

“I decided to get an IUD because I was going to be leaving my job and knew I may not have health insurance for a while,” says Caitlin, 32. “I also had high blood pressure and was advised that it would be a good move because the Mirena is less of a health risk than the pill I was taking.”

She had a great experience. “My nurse kept telling me how great I was doing and what a rockstar I was. The pain was a burning, shocking pain that lasted for the rest of the day. The few days after were painful, but no worse than the cramps I was used to. Since getting the IUD, my periods have been the most manageable they’ve ever been.” She’s become somewhat of an IUD evangelist, noting that since moving to a red state, she hasn’t met another woman who has one. “It makes me sad, because it’s so effective and my experience has been so positive!”

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In so many ways, the hormonal IUD is the new American dream. It’s a quick-fix for your pesky fertility that you can set and forget for up to five years, and it simultaneously makes your periods lighter — or even causes them to disappear altogether. Give me your huddled, tamponed masses, and I will give you this IUD.

Getting mine was simple. My doctor referred me to an OBGYN who went over the options and risks; we settled on the Mirena, which delivers a small dose of progestin directly to your uterus; the procedure and the device were covered by my health insurance (thanks to the contraceptive provision of the Affordable Care Act); and I made an appointment to come back in a couple of weeks once my period had started, when my cervix would be thinner, making implantation easier.

The internet told me I could expect pain similar to a pap smear. Internet, you are a filthy liar. Some doctors use a local anaesthetic to minimize pain; mine didn’t, as she said that for most women, placing a huge needle in their vagina spiked anxiety more than the actual insertion. (Touché.) During implantation, your doctor first measures the length and direction of your cervix with a long instrument called a sound before going in again with the IUD, which is placed up close to the top of the uterus with two thin strings hanging outside the cervix. (These soften over time, so no, your partner shouldn’t be able to feel them.)

The cervix is miraculous. This piece of muscular tissue changes position, shape and size throughout your cycle, knits itself up to hold a baby in, then thins and opens to let that baby out. It is a biological marvel. And it does not want to be forced open. It is antithetical to everything it was designed to do. In my case, my body went into vicious revolt. I broke into a clammy sweat. I involuntarily tried to jack knife my gyno, who calmly dodged my flailing leg while murmuring “sorry sorry sorry sorry” in a sweet sing-song. It was a visceral, eruptive, intensely wrong feeling, something much more primal than pain. During her first year in OBGYN residency, my friend saw more women pass out cold during IUD insertions than anywhere else in her practice.

Ten minutes later, I was shaky and wild on the floor of the elevator, then reclining in the back of an Uber, and two hours after that I had a hot water bottle and some tea and The Good Wife and felt fine enough to text all my friends. “Y U LIE TO ME THAT WAS DEATH?!?!?!”

Over the next few days I had some light bleeding, and then my period vanished entirely for eight months. I now get my period maybe once every other month (minor cramping, and insignificant bleeding I can manage with a panty liner). I have a new relationship with adult acne, and, excepting the aforementioned bruised cervix, no reason to worry. I’ve been a happy advocate for Mirena; that is, until a recent Danish study that linked hormonal birth control to depression.

The study has been widely reported, and it’s validated many female experiences: here’s the science to tell you no, it’s not just you, and no, you aren’t insane. Women on the pill have been campfiring around this study with frightening narratives of psychological and emotional trauma such as crying jags that lasted weeks, depressive thoughts and suicidal ideation.

“I was ecstatic,” says Dr. Jerilynne Prior, professor of endocrinology and head of the Centre for Menstrual Cycle and Ovulation Research. She’s blunt, passionate and frustrated, and couldn’t be happier that the Danish study has garnered so much attention. Her own research has found persuasive and worrying links between the use of hormonal contraception in adolescents and negative long-term reproductive effects and bone loss.

She’s one of a growing number of doctors and researchers who believe adolescents should steer clear of hormonal birth control entirely. “These young women need to be making connections between what happens in their reproductive system and the rest of their lives,” Prior says. “Because hormonal contraception takes away their period, they don’t learn to live in their bodies.”

Interestingly, the Danish study found that adolescents using the patch, ring or hormonal IUD were three times more likely to be prescribed antidepressants — although, as critics have pointed out, merely being prescribed an antidepressant does not necessarily indicate depression (people use antidepressants to treat everything from migraines to chronic pain). And the particularity of the link between Mirena and anti-depressants is odd, since the hormone is localized in your uterus, releasing 1/10th the amount of progestin into the body than the pill. Why would lower hormones result in higher causation?

Dr. Prior is less than convinced about this facet of the study — “More work needs to be done to make that connection,” — and pointed out that in other randomized trials, older women actually experienced positive mood effects after hormonal IUD implantation.

It’s complex territory for any medical practitioner to navigate, and especially so for female doctors. As Prior told me, “The birth control pill holds a place of high honor in our culture. Both women and men are eternally grateful for it. But a pill cycle is now viewed as the same as a normal cycle, and in reality the medical community just hasn’t done enough to study this. We’re putting a high-dose of synthetic, powerful hormone into the bodies of our young women.”

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If you want to avoid hormonal contraception entirely, your options are limited. This is especially true for adolescent women, the demographic most in need of comprehensive contraceptive care and education. For young women wanting to protect themselves against unwanted pregnancy without hormones, the copper IUD (which is effective for 10 years) is the best option.

That’s what my friend Sarah decided. At 25, living in Portland, she was dating someone who worked at a health store and learning about alternative medicine. “I started seeing a naturopath, started taking vitamins, was weaning myself off of antidepressants and decided I didn’t want to be on hormonal birth control anymore either. And once I made that decision, you quickly find the IUD is the only non-hormonal option, really, besides barrier methods which are prone to user error.”

Like me, her insertion was intense. “I broke out in a sweat. I remember laughing after, like, ha ha, that was HORRIBLE!” Unlike me, it didn’t get better. “I had long, painful periods — like, call in sick to work-level cramps. I once had to pull over while driving.”

The most common side effect of the copper IUD is heavier, longer and more intense periods. “I was going through two ‘Supe’” tampons an hour. It was insane,” she says. She went back to Planned Parenthood to have it removed — and then re-inserted, a year later, when she found herself in another relationship and still without a simple hormone-less solution.

“I’ve basically only started being regular in the past year. I’m not having sex on the reg, the only reason to leave it in is like, future insurance. My periods do kind of suck — they’re long, heavy and I get bad PMS — but I’m just not up for trying tons of different pills, tweaking to see which ones don’t make me sad or gain weight, all of that. It’s fine.”

“It’s fine.” = Motto of all ladies everywhere.

As for me, I started taking anti-anxiety medication at 29, a full 14 years after I popped that first pill out of its plastic disk. I have a family history of depression, and, you know, I write personal essays for the internet, so I’m not willing to say that the pill is responsible. But entire generations of young women are growing up without an understanding of their own reproductive cycles, believing that ovulation is something that can and should be controlled with a pill, that “feeling sad” is an okay side effect. The burden of family planning still falls largely on our beautiful bodies. We’re also breathlessly lucky to have relatively safe, inexpensive and readily available access to options that allow us rich sex lives free from the consequences of unintended pregnancies.

The more I read about contraception, the more exhausted I become. Prior, who was prescribed birth control in 1966 — a pill containing a whopping 100 mg of estrogen that put nine pounds of water weight on her frame in the first week — is even more tired. “It is empowering and necessary for women to be able to control their own reproductive capacity, but if that is coming with an undisclosed price, as it may be, that is not good enough. It’s just not good enough.”

Is your birth control depressing the hell out of you? You’re not alone. But if you’re waiting for male birth control to pop up on the horizon anytime soon, don’t hold your breath. Here are some cute animals to make up for it. 

IUD necklace by Amanda Rabinowitz of Witz Jewelry Design. Shop her collection here. Collage by Emily Zirimis.

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