IUDs

[walkitout]

Probably everyone's heard of the Dalkon Shield, its recall, the lawsuits that ended the company that created it, blah, blah, blah.

Probably most readers know about IUDs since the Dalkon Shield, which continue to be a contraceptive option around the world, including in the United States. For a wide variety of reasons (breastfeeding and hormonal birth control immediately after having a baby are not particularly compatible; people tend to be inconsistent with condoms, at least in part because they don't like them; people _really_ don't like diaphragms, etc.), IUDs have been recommended to and used by several women friends/relatives of mine.

Uniformly, they volunteered that this wasn't like the Bad IUDs of the past, that it didn't have the complications/risks, etc. And here are the outcomes I've encountered in a very small (count 'em on one hand) number of women I know who've used an IUD in the last decade:

(1) Disappeared. This was discovered when she was going to "start" trying to get pregnant a second time.
(2) Persistent bleeding that continued for a year. Complained after a few months; health care provider convinced her to try just a little bit longer.
(3) Failed, that is, got pregnant. Arguably, this could be lumped in with (1), because the IUD was never found.

I don't know anyone who developed an infection/PID.

But ya gotta admit -- that's a bad set of outcomes for such a small number of users. But I have taken a statistics class and, honestly, I'm apparently still really naive and optimistic; I chalked this up to what can happen when you have a small data set.

Prior to the Dalkon Shield, a massive variety of designs of IUD were tried around the world over a period of years. And guess what? 40% failure rates were absolutely typical (either pain or bleeding leading to the woman insisting it be removed and/or spontaneous ejection/disappearance of the IUD) within the first two years. Infection/PID/uterine puncture are much, much rarer.

But don't you think that 40% would have been worth mentioning to the women who are having one inserted _now_? Given the design variations tried, it's hard to imagine that a new version is going to behave that differently. And my small sample size indicates that past trend is playing out in the here and now. So why are health care providers telling my friends/relatives that Things Have Changed and This Version is Better?

As a little further commentary on the whole IUD thing, Connelly describes how many of these were inserted in various years in India and China and around the world. He also describes how the Population Control/"Family Planning" crowd of those years was willing to take money away from public health/operate in advance of the ability of the local medical industry. The justification was that pregnancy and childbirth was a larger threat to the health of women than the "small" risk associated with IUDs, sterilization, etc. Let's sit with that idea, and contemplate, literally, MILLIONS of IUD insertions in some years in one of those two countries. Which implies tens of thousands of cases of PID, uterine rupture, bleeding, etc. On top of this, the devices used to insert the IUDs had to be sterilized between each use (this didn't happen even with sterilizations on men, and there were tetanus epidemics that resulted from mass vasectomies -- that's gonna really encourage the local populace to sign up the next time the "family planners" are in town, hunh?) because it was considered to expensive to ship single use, pre-sterilized kits. Anyone who has read about the transmission of Ebola and similar recognizes this is how hospitals wind up amplifying/creating epidemics of diseases that are otherwise very difficult to transmit.

No medical professionals were involved in implementing these insertions, in many cases (just like what would happen with Depo, years later), policy was _not_ to take medical history because it would just slow the process down. Etc. All in the name of, the bad cases are going to be rare, the outcome is Really Important and We Know Better Than You Do.

Don't even get me started on the connection between X-raying women's pelvises to determine a baby's position when she was in labor, and how when they finally stopped doing that the childhood leukemia rate took a dive off a cliff.

Comments

I have an IUD

[ethelmay.livejournal.com]

And it's worked perfectly for years and years. The strings are still there, I haven't gotten pregnant, and the only trouble I had was some cramping the day of insertion (basically no worse than I've had many times during ordinary periods) and longer periods the first two cycles. (I have a copper-T, by the way -- hormonal IUDs, which they *certainly* did not have until many years after the Dalkon shield, typically reduce bleeding, and sometimes stop one's period altogether.) Oh, and I now usually get a tiny amount of spotting the day before my period, which I'd never had before, and which I actually appreciate as a kind of early warning system.

Here's something from a midwife I trust:

"One: Surveys of women using the same contraceptive method for one year or more consistently find the highest user satisfaction ratings for the IUD over any other method. Helen's point about some women having heavier periods or more cramping or even cramping the IUD right out of their uteri plays into this statistic: obviously the women who had these problems aren't in the "more than 1 year of use" group. Discontinuation amounts to about 10-15% of women who try the IUD. But most women who try the IUD do keep it, and those women generally are extremely pleased with the method; again, more women more satisfied than with any other method. The 10-15% "didn't like it, had to try something else" rate is quite low compared to other methods. Although IUD's are relatively rare in the US, they are one of the most popular methods worldwide. Studies done in the US show an odd finding: among women who have not used the IUD it has the worst reputation of any method, but it has the best reputation of any method amongst women who have tried it.


"Two: Another respondent said she knew someone who had a uterine
perforation with the insertion procedure. This is extremely rare and
it's also inexcusable: it amazes me that this ever happens at all, and it could only be done by someone who has no business placing IUD's. Placing an IUD is not particularly difficult but it does need to be done by someone who takes the procedure seriously and who does it on a fairly regular basis. Those who are properly trained, experienced with the procedure, and who do it frequently can definitely insert an IUD without perforating your uterus, for goshsakes. Your provider's experience level can also make the procedure far less uncomfortable. Not all OB-GYN residents get adequate experience placing IUD's, so no matter who your provider is, I'd ask them if they've had the factory inservice and how many times they've done the procedure.


"Very often, the best provider for placing an IUD is a nurse
practitioner who specializes in family planning. In my institution, it is the family planning NP's who train the OB-GYN residents to place IUD's and if I were getting one, they're the ones I would go to. OB-GYN's spend a lot of time learning hysterectomies and oophrectomies and pelvic reconstructions and everything else: you want someone who spends a lot of time inserting IUD's if you decide to have one.


"This last point is a very flame-able, but I'll make it anyway: if you are considering an IUD, check it out with your local Planned
Parenthood. Contraceptive management is 95% of their business, they
know what they're doing, they know how to counsel you and help you make your decision, and they certainly aren't going to perforate your uterus."

[jinasphinx.livejournal.com]

I know 2 or 3 women who have had IUD problems in the last few years and had to have it taken out; also from a small sample. So I've never seriously considered it as an acceptable form of birth control. I mean, we have so many other options!

[ethelmay.livejournal.com]

But keep in mind that you're not likely to hear about the people who *aren't* having problems -- unless you ask everyone you know, which is unlikely. If I went solely by what I hear about oral contraceptives from people who've used them, I'd think they were absolute devil's spawn, because what I hear about is things like nasty side effects and people who got pregnant despite the pill and condoms. Heck, I wouldn't go to the dentist if I went by what people *say* about their experiences there.

dentists, and the not having problems people

[walkitout]

Your comment above is a pretty good indication I _am_ hearing from people who aren't having problems. You're the second person I know personally (and whose judgment I trust) who love love loves the IUD.

I know a ton of people (dozens, at a minimum, compared to the less than a dozen using the IUD) who are using or who have used some form of the pill. The vast majority of those people have relatively positive things to say about the pill, including people who had to go off the pill at some point (to get pregnant and breastfeed, because they were smokers and hit 35, etc.). I know a couple women who have negative things to say about the pill -- but it's a smaller absolute number than the IUD, and a much smaller relative number.

I, too, have met people who've gotten pregnant despite double birth control (pill + condom, diaphragm + condom, cervical cap + condom, etc.). I don't recollect that any of those people blamed specific forms of birth control; they generally had a very philosophical attitude to the whole thing and when they didn't want any more kids ever, the guy got snipped. People who've had vasectomies fail -- years later -- those people are _shocked_ (so am I).

As for dentists, I've heard far more positive things about dentists (both particular dentists and dentists as a group) than negative. I've heard this is non-representative. I do actually _get_ small sample size.

I absolutely think that anyone getting an IUD should make sure their provider has done this (a lot) before, and that NPs in general would be a better-than-average choice, and Planned Parenthood a particularly smart approach. I'm a little surprised to hear that the didn't like it had to try something else on the IUD is supposedly quite low compared to other methods. I'm a little suspicious of that assertion.

[jinasphinx.livejournal.com]

You have a good point, mostly you hear from people when things go wrong. Although what also scares me is the type of problems (typically bleeding and cramping, sometimes a *lot*) and the difficulty of the remedy (have to go see a doctor, and maybe stay in the hospital). Whereas with the pill, the complaints are like "gave me some bad PMS" and "made my face break out" and the remedy was simpler (get doc to prescribe a different formulation, or just switch to condoms). I am glad the IUD is working perfectly for you.

[ethelmay.livejournal.com]

I haven't heard of anyone having to be hospitalized, I must admit. I was thinking more along the lines of another doctor visit to get the thing taken out not being a lot worse than another doctor visit to get a new brand of pill prescribed, or whatever. The whole idea of using artificial hormones tends to freak me out, but obviously I'm outnumbered there. And I'm not pretending this is a medical judgment, as I think there are arguments both ways -- e.g., that women are "meant" to be pregnant for more of their lives, therefore the pseudo-pregnancy state of the pill is more normal than having so many periods -- only squeamishness and heel-digging on my part.

I think I can count on one hand the number of women I've talked to face-to-face about their contraceptive history, now that I think about it, though on newsgroups it's another matter. I have three sisters, with whom I get along quite well, and I don't think the subject's ever come up.

hormones, IUDs, talking to other women about contraceptive choices

[walkitout]

I'm totally loving this conversation. :-)

I got a call from a friend of mine last night and we had a little chat (so, not face to face). She is now my third trusted friend who love love loves her IUD, but at this point I'd just like to note that some IUDs _have_ hormones in them (the Mirena), and the kinds of outcomes (good and not so good) associated with the Mirena and the Copper T (non-hormonal) are different. The Mirena is more likely to make it so you don't have any period at all, or only incredibly light ones, for example; the Copper T is more associated with non-stop spotting.

One of the known, rare (I don't know anyone who had this happen) side effects of the Copper T (but apparently not the Mirena) and other non-hormonal IUDs is ectopic pregnancy. That could certainly result in hospitalization.

I don't know that you are precisely outnumbered on the artificial hormones thing. I have several friends who won't use the pill for this reason (and some of those friends are the source of dual contraceptive failure resulting in kids; ultimately, dad got snipped after they had had as many children as they wanted).

I've talked to a lot of people -- men and women -- over the years about their contraceptive history. Just another instance of the kind of weird conversations I wind up having with people. ;-)

not to be a big ole downer

[walkitout]

But a FOAF on the pill had a clot. She had to go off the pill and go on blood thinners for a year. Of course, you never know if that was the pill, or if it would have happened anyway.