11 Questions to Ask Yourself Before Getting an IUD

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The nonhormonal ParaGard IUD.Photo: iStockphoto/Getty Images

Perhaps you’re over taking a pill at the same time every day. Or maybe it was the recent study linking hormonal birth control and depression that finally put you over the edge. That’s it!! I’m getting the copper IUD, you fumed.

The truth is, there are plenty of options for birth control that are less annoying, more effective, and have fewer side effects than the pill. But it’s equally true there are pros and cons to every birth-control method. You’ll need to discuss your medical history and preferences with your gyno to find the best option for you, but these 11 questions should help you determine whether you’re ready for something like the intrauterine device, or IUD.

First, though, let’s talk about terminology. The five kinds of IUDs on the market are usually grouped with the upper-arm implant, Nexplanon, in a category known as long-acting reversible contraceptives, or LARCs. All LARCs are more than 99 percent effective at preventing pregnancy — rates that rival having your tubes tied. (The pill is 91 percent effective with typical use and 99 percent with perfect use.) It’s worth considering Nexplanon if you want low-maintenance birth control that does not live inside your uterus.

All LARCs contain synthetic versions of progesterone (IUDs contain slightly different amounts of a type called levonorgestrel, while the implant has etonogestrel) and they release small amounts daily. Among them, the implant releases the highest daily dose of progesterone. Since it’s in your arm, the hormone circulates through your bloodstream just like with the pill and prevents pregnancy by stopping your ovaries from releasing an egg each month. IUDs don’t stop ovulation, but the progesterone — or copper in the nonhormonal IUD, ParaGard — thickens cervical mucus so sperm can’t enter the uterus and fertilize an egg. In the rare event that some mighty sperm do get past the cervix, the progesterone or copper makes it more difficult for them to swim through the uterus and tubes toward an egg.

If this sounds appealing to you, it’s time to consider these questions.

1. How long do you want birth control?

Doctors usually start with some version of this simple but key question as they try to figure out what you’re looking for in your contraception, says Kristyn Brandi, M.D., instructor of obstetrics and gynecology at the Boston University School of Medicine. If a woman needs birth control for less than a year, a doctor would be more likely to recommend things that are easy to stop and start on your own like the pill, patch, or ring, says Laura MacIsaac, M.D., M.P.H., F.A.C.O.G., director of family planning at Mount Sinai Health Systems and associate professor of obstetrics and gynecology at the Icahn School of Medicine.

LARCs are better if you want at least a year of contraceptive coverage. The Nexplanon implant is approved for three years (but has been shown to be effective over 4 years), and IUDs range from 3 to 12 years, unofficially.

2. Have you had breast cancer? What about other health problems?

Doctors don’t recommend hormonal devices for women who’ve had breast cancer, because the hormones could promote cancer growth (and that’s regardless of whether the cancer has progesterone- or estrogen-positive receptors). Serious liver diseases are also a contraindication for hormonal birth control because it’s the liver that processes absorbed progesterone, Dr. Brandi says. Women with these conditions could get the nonhormonal IUD, ParaGard. And if you still smoke, an IUD is actually safer for you than a combined birth-control pill because any hormones are mostly limited to the uterus, Dr. MacIsaac says. (More on that later.)

3. Do you have any existing uterine issues?

The prescribing information for all of the IUDs also lists congenital or acquired anomalies (including fibroids) that change the shape of the uterus as a reason not to prescribe the devices. But Dr. MacIsaac says that doctors prescribe hormonal IUDs off label as a treatment for fibroids to reduce bleeding. If you have a congenital distortion like a bicornuate uterus or one with a septum, it’s possible that you’d have a higher risk of perforation during the placement or a higher expulsion rate, so ask your doctor for their opinion.

4. When Aunt Flo comes to town, does she stay a while?

The implant or a hormonal IUD would probably be better for you than the copper IUD. Hormonal birth control suppresses growth of the uterine lining, making periods shorter and lighter, and one of the hormonal IUDs, Mirena, is actually FDA-approved as a treatment for heavy menstrual bleeding, a.k.a. menorrhagia. Women with the copper IUD will have periods that feel longer, heavier, and crampier for the first three months after which it should go back to the baseline. But if you’ve been on the pill forever, you might not remember what your natural period is really like.

5. Do you want to keep getting your period at all?

Fun fact: All prescription birth control will alter your periods in some way, says Dr. MacIsaac. Depending on the type, you might stop getting your period after six months to a year of use. That’s because these devices are releasing hormones daily, whereas with the pill, you get your period only after a few hormone-free days on the placebo. Dr. MacIsaac says the overall amenorrhea rate for IUDs is 20 percent, though it varies based on the device and the dose — the more hormones, the more likely you are to be period-free. (Read more about the hormone levels in each IUD here.) Some women love the idea of skipping their periods, while others would rather have their “normal” bodily function intact just because that’s what they’re used to, or they prefer the reassurance that they’re not preggo.

6. Are you willing to deal with potential, unpredictable period changes?

Sadly, no. Hormonal IUDs can cause spotting in the first six months, and that’s probably due to the slightly higher amount of progesterone released during that time. Initially, there’s a burst effect where the device sheds more hormones and it levels off around six months, Dr. MacIsaac says. The amount your body absorbs is just high enough to interfere with ovulation and can cause some spotting. Afterward, the amount of synthetic hormone circulating in your body is so low that it doesn’t have any effects — now it’s just the progesterone acting directly on your uterus, she says.

The implant can also cause longer-lasting spotting, and it can be brutal. “One thing we find with the implant that we don’t see with IUDs is that some women have continuous spotting. They’ll use one tampon or one pad a day, it just continues [for three years],” Dr. Brandi says. “It happens in about a third of women. Another third, nothing happens [their period stays the same], and another third have light or no periods.” And there’s no way to predict which group you’ll be in. Dr. MacIsaac reminds us again that there are no clear winners in birth control, it’s just whatever you’re more likely to tolerate. “The spotting can be as annoying as the heavy bleeding,” she says. “One’s not better than the other, it’s about patient fit.”

Whatever happens with your period after you get a contraceptive device, Dr. Brandi says to give it a chance to settle down. “We try to encourage women to wait about three months after they have their [LARC] inserted to see how their bleeding patterns change before deciding that the bleeding is not a good pattern for them.”

7. Do you get hormonal side effects from the pill?

You might prefer an IUD. That’s because they mainly work directly in the uterus, while the implant causes more systemic hormone absorption since it’s in your arm and delivering the drugs through your bloodstream, Dr. Brandi says. Thus, the implant can cause mood swings, headaches, and weight gain, but the IUD side effects are mostly related bleeding patterns, Dr. MacIsaac says.

Some women with IUDs might experience so-called hormonal side effects because your body technically does absorb some of the hormone, especially in the first six months when they’re shedding more of the medication, she says. “There is a very small, systemic absorption in all of the hormonal IUDs and some women do feel the systemic effects with breast tenderness, a little acne, but it’s such a low dose that” it’s less than you’d experience with the pill.

8. Do you take the pill because of the added bonus that it clears up your acne?

Long-acting hormonal devices only contain progesterone, unlike combination birth-control pills, which also have estrogen. But that means if part of the reason you take the pill is because it helps keep your skin clear, an IUD or implant will not help you there. “I’ve said to people who have really significant acne, ‘if you can be a perfect pill taker, this will be better for you [than an IUD] because it will kill two birds with one stone,’” Dr. MacIsaac says. “If they say, ‘I can’t’ we would choose a LARC and then use other strategies for their acne.” And bummer alert: Some implant users report acne as a side effect, too.

9. Have any small humans ever passed through your cervix?

Have you had a Pap smear? Getting an IUD is kind of like that. But unlike with a Pap, there can be cramping and some bleeding afterward. That’s because the IUD is put in a thin plastic tube that has to go through your cervix and into your uterus to place the device. Dr. Brandi suggests taking ibuprofen before your appointment to preempt any discomfort. Insertion is relatively painless for women who’ve had kids vaginally. If you haven’t birthed and you’re nervous, you can ask your doc for drugs. “For people who aren’t that comfortable with pelvic exams or have not had children, sometimes we do something called a para-cervical block, where we use injections to numb the cervix, kind of like when you go to the dentist and they give you a numbing medicine,” she says.

If you get an implant, you’ll get a local anesthetic before your gyno uses a specially made inserter to shoot the little rod under your skin. No incisions or stitches required. When it’s time to remove it, she’ll make a small nick with a scalpel and the implant just slides right out.

10. How squeamish are you?

Dr. Brandi says her patients prefer implants to IUDs because of the insertion. “I think a lot of patients are concerned about the IUD placement and the removal process. It’s something that’s a little bit more foreign. But people feel pretty comfortable getting a shot.”

Dr. MacIsaac says IUDs are more popular, though, citing a study of more than 9,000 women which found that continuation rates after three years are highest for IUDs, at about 70 percent compared to about 56 percent of women who kept their implants for that long. She thinks this is because the bleeding pattern with the implant is less predictable than with IUDs.

11. Are you turned off by all of these options?

If you want something reversible and are sick of the pill, perhaps you should talk to your doctor about the NuvaRing. It delivers a combination of estrogen and progesterone to the uterus without any dramatic-sounding insertion procedures. You put one in, wear it for three weeks, take it out for a week to have a placeholder period, then insert a fresh one. Or you can skip your period by putting in a new ring after three weeks. There could be some hormonal side effects but, again, the hormones are mostly localized in your vagina and uterus. Who knows, it could be the perfect option.

Which IUD Should You Get?