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Safe, Reliable, and Cost-Effective Birth Control

In 2012, the American College of Obstetricians and Gynecologists (ACOG) revised its practice guidelines on Long-Acting Reversible Contraception (LARCs), including implants and IUDs. Based on research and expert opinions, the new guidelines advise that adolescents who are sexually active and at high risk of unintended pregnancy should be encouraged to consider LARCs as a contraceptive option. ^[1]

LARCs are ideal pregnancy prevention options for many young women. These methods are safe, effective, inexpensive, and reversible, require little to no maintenance, and have much better compliance rates than other hormonal methods. Still, the use of LARCs is not widespread among young women. Youth serving professionals, educators and health care providers should know the facts about these methods.

Two types of LARCs

Intrauterine Devices (IUDs): These small flexible plastic devices are inserted into the uterus to prevent pregnancy. There are two types of IUDs available in the United States; one uses hormones and the other releases copper. All IUDs prevent pregnancy by interfering with the movement of sperm toward eggs keeping the two from meeting. They may also change the lining of the uterus preventing implantation of a fertilized egg (though this theory has not been proven). IUDs must be inserted and removed by trained professionals.

Contraceptive implants: This hormonal method consists of a thin rod made from flexible plastic that is inserted just under the skin on a woman’s upper arm. The implant releases a steady amount of progestin in order to prevent pregnancy (primarily by suppressing ovulation) for up to three years. Implants must be inserted and removed by trained professionals.

It is important to note that neither IUDs nor contraceptive implants protect against sexually transmitted infections (STIs).

Intrauterine Devices (IUDs)

There are two types of IUDs available in the United States; a hormonal method that releases levonorgestrel, the progesterone hormone frequently used in birth control pills and one that contains no hormones but releases a small amount of copper instead. The hormonal method is sold under the brand name Mirena and the copper method is sold under the name ParaGard.

What It Is

• Both types of IUDs are small, T-shaped devices made out of flexible plastic that are inserted into the uterus, and both have very thin strings tied to the bottom that hang through the cervix.
• ParaGard (also called the Copper T 380 A) includes a copper wire that is wrapped around the base of the device. ParaGard can stay in place and remain effective for up to 10 years. ^[2]
• The top part of Mirena is made of a radiopaque plastic that can be seen in X-rays. It consists of a silicon cylinder that contains 52 mg levonorgestrel, a hormone that is gradually released over time. Mirena can stay in place and remain effective for up to five years. ^[3]

How It Works

• An IUD is inserted into the uterus through the cervix by a trained medical professional. In order for the device to fit through the cervix, the arms of the T are folded down during placement. The thin string at the bottom of the device hangs through the cervix after insertion throughout the duration of use. These strings are used for removal, and also allow a woman to check that the device is still in place. ^[3]
• Insertion usually takes place during a woman’s menstrual cycle when the cervix is softest and an existing pregnancy is least likely. However, insertion may occur at any time in the cycle, including immediately post-partum or post-abortion.
• All IUDs prevent pregnancy by interfering with the movement of sperm toward eggs keeping the two from meeting.
  • It is thought that ParaGard inhibits sperm movement and causes white blood cells to produce a substance that is toxic to sperm. ^[3]
  • Mirena releases a hormone like those found in birth control pills. These hormones can prevent pregnancy by thickening cervical mucus which creates a barrier to sperm, slowing the progress of sperm toward the egg. Like other hormonal methods, Mirena may also prevent ovulation. ^[3]
• IUDs may also change the lining of the uterus preventing implantation of a fertilized egg (though this theory has not been proven).
  • Specifically, it is thought that Mirena makes the uterine lining thin thereby preventing implantation.^[3]

How Well It Works

• IUDs are over 99 percent effective in preventing pregnancy. This means that of 100 couples who use an IUD as their primary form of birth control, only one couple (at most) will experience an unintended pregnancy within a year.
• In clinical trials from 2006–2008, Mirena was found to have a failure rate of 0.1 percent while ParaGard had a failure rate ranging from between 0.6–1.0 percent. ^[4]
• Once inserted correctly, users do not need to take any action in order to ensure that the IUD remains effective. Therefore, IUDs essentially remove the risk of user failure.

Cost Effectiveness

• IUDs are very cost effective. Though they have higher upfront costs than other methods, these costs can cover pregnancy prevention for between five and 10 years.
• The cost of IUDs range from $500 to $1,000 upfront for the device and insertion. Removal may incur additional costs. ^[5] These costs are often covered by insurance. Some women may also qualify for financial assistance for an IUD through Medicaid or other state programs.

Safety

• IUDs are safe for most women including adolescents and women who have not had children. ^[3]
• ParaGard is also safe for women who are breastfeeding and those who cannot use hormonal contraception for medical reasons. ^[3]

Side Effects

• Over half of young women experience discomfort at the time of insertion. ^[1] Some clinicians use a local anesthetic or recommend taking NSAIDS before the procedure. Taking Misoprostol 6 to 12 hours prior to insertion can help with cervical dilation. ^[6]
• IUDs can cause spotting and cramping for three to six months after insertion. ^[3]
• Between two percent and 10 percent of women who use IUDs experience an expulsion of the device from their uterus. If this happens a women needs to return to her health care provider to have a new device inserted. ^[3]
• A rare but serious side effect involves the perforation of the uterus during IUD insertion, which can possibly allow the device to move outside of the uterus. This is estimated to occur in less than one out of 1,000 insertions. ^[7]
• Mirena may stop some women from menstruating. Some women see this as a benefit but others may be uncomfortable with this possibility.
• After an IUD has been removed, a woman may experience cramping.

Other Benefits

• Mirena greatly reduces the risk of ectopic pregnancy. It also helps to treat heavy menstrual bleeding and associated pain, irregular heavy bleeding, uterine fibroids, and iron deficiency, among other health issues. ^[2]
• ParaGard can be used as emergency contraception if inserted within five days after unprotected intercourse. ^[8] It is more effective than hormonal pills used for emergency contraception.

Important Facts About IUDs

• IUDs do not cause an abortion. IUDs slow the movement of sperm toward the egg preventing fertilization. They are a method of contraception, not abortion. ^[3]
• IUDs do not raise a woman’s risk of ectopic pregnancy. In fact, women who use IUDs are at significantly reduced risk of ectopic pregnancy compared to women who are not using contraception. However, women who do become pregnant while an IUD is in place may have a higher ratio of ectopic to uterine pregnancies. ^[3]
• If inserted properly, IUDs do not increase the risk of PID. IUDs do not appear to increase the risk of upper-genital infections that can lead to PID. In some instances and with some women, the insertion process can introduce bacteria into a woman’s uterus. However, the risk of this is considered so small that health care providers do not recommend prophylactic antibiotics to prevent infection. ^[3] Some people have concerns about the IUD and PID because of the Dalkon Shield an IUD with major design flaws that was on the market in the 1970s, but with today’s IUDs, PID is rare.
• Women should be screened and tested for sexually transmitted infections (STIs) at the time of IUD insertion. If there are visible STI symptoms, a woman should be treated and should get the IUD after the STI has cleared. If there are no symptoms, the device can be placed on the same day the test is done. If the test comes back positive for an STI, a woman should be treated without removing the device. ^[1]
• IUDs are safe for most women, including women who have had children as well as adolescent women. After the Dalkon Shield was linked to increased infertility in some women, medical professionals began to suggest that IUDs not be used by women who had not yet had children and/or wanted children in the future. In fact, when Mirena was first introduced the FDA only approved it for use in women who had already had children. This is no longer the recommended practice. In 2007, ACOG released a committee opinion that suggested that IUDs “should be considered as first-line choices” for teenagers. ^[9] In 2012, the American College of Obstetricians and Gynecologists released a committee opinion that LARCs are safe and appropriate methods for most women and adolescents and that adolescents should be encouraged to choose them. ^[1]

Counseling Adolescents About LARCs

The counseling process is critical in helping teens understand how LARCs work and what to expect. Both the IUD and the implant can cause a shift in menstrual patterns as well as some initial discomfort, and counseling can prepare teens for what to expect in the first weeks after insertion – as well as reinforce the importance of using condoms to prevent HIV and STIs. ^[1]

Conclusion

Long acting reversible contraceptives are safe and reversible, require little to no maintenance, and have much better compliance rates than other hormonal methods. For this reason they are ideal pregnancy prevention options for many young women. Health care providers, educators, and youth-serving professionals should include information about LARCs in discussions of birth control options with adolescents.

Written by Martha Kempner
Advocates for Youth © October 2012
Updated October 2018

References

1. Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices. ACOG Committee Decision No. 539, October 2012.
2. Espey E, Ogburn T. “Long-Acting Reversible Contraceptives: Intrauterine Devices and the Contraceptive Implant.” Obset Gynecol 2011; 117(3): 705-19.
3. Dean, Gillian; Schwarz, Eleanor Bimla (2011). “Intrauterine contraceptives (IUCs)”. In Hatcher, Robert A.; Trussell, James; Nelson, Anita L. et al.. Contraceptive technology (20th revised ed.). New York: Ardent Media. pp. 147–191.
4. Facts on Contraceptive Use in the United States, Guttmacher Institute, J une 2011. Available at http://www.guttmacher.org/pubs/fb_contr_use.pdf. Accessed on May 24, 2012.
5. IUDs at a Glance, Planned Parenthood Federation of America, 2012. Available at http://www.plannedparenthood.org/health-topics/birth-control/iud-4245.htm. Accessed May 24, 2012.
6. Hutten-Czapski P, Goertzen J (2008). “The occasional intrauterine contraceptive device insertion”. Can J Rural Med13 (1): 31–5. PMID 18208650.
7. Mechanism of action, safety and efficacy of intrauterine devices: Technical Report Series 753. Geneva: WHO, 1987.
8. Cleland K, Zhu H, Goldstruck N, Cheng L, Trussel T (2012). “The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience”.Human Reproduction 27 (7): 1994–2000.
9. IUDs and Adolescents, ACOG Committee Decision No. 392, December 2007.
10. Raymond EG. “Contraceptive Implants.” Contraceptive Technology 19th Edition (New York, Ardent Media, 2007) 145-56.
11. 11 Isley, M. (2010). Implanon: The Subdermal Contraceptive Implant, J Pediatr Adolesc Gynecol 2010; 23(6):364-7.
12. Birth Control Implants (Implanon and Nexplanon) At a Glance, Planned Parenthood Federation of America, 2012. Available at http://www.plannedparenthood.org/health-topics/birth-control/birth-control-implant-implanon-4243.htm. Accessed May 24, 2012.
13. Beerthuizen RV. Bone mineral density during long-term use of the progestagen contraceptive implant Implanon compared to a non-hormonal method of contraception. Hum Reprod, 2000;15(1):118-22.