By Jandra Mueller
In my last blog, One and Done: The IUD and the Future of Birth Control, I talked about how the American College of Obstetrics and Gynecology (ACOG) are recommending long acting reversible contraceptives (LARC) as their preferred contraceptive option. The two main forms discussed were the implant and the IUD. In part one I mentioned that although the implant is excellent in preventing pregnancy, it is not the BEST option of the two because of the rise in sex hormone binding globulin (SHBG). Both the implant and oral contraceptives can have undesirable side effects because of the the rise in SHBG. To read more about this, read Dr. Goldstein’s blog post here.
That leaves the IUD as a reasonable choice of birth control. ln this post I’ll go more in depth about the different types of IUDs, and provide some education about what the research has to say about who can and would benefit from the use of an IUD.
Paragard
Paragard is a copper IUD, which means it is 100% hormone-free. It works to prevent pregnancy for up to 10 years by acting like a natural spermicide; the presence of copper and copper ions in the uterus renders the sperm useless. This sounds great after all that hormone talk right? Unfortunately, this isn’t exactly the case. The copper IUD tends to worsen menses, especially in women who suffer from endometriosis or adenomyosis.7 It also has a higher discontinuation rate in women, it is suggested but not confirmed, that the size of it may be an issue.The paragard is a larger IUD, measuring 32mm by 36mm.
Did you know: In women who have not given birth, the average size of a uterus is 27mm wide and 27 mm long? 6
Hormone releasing IUDs (Mirena, Skyla, Liletta)
The hormone releasing IUDs are T-shaped flexible structures that are placed into the uterus and release varying amounts of levonorgestrel, a form of progesterone. The primary way this IUD works is that the progesterone released into the uterus prevents the endometrium (or inner lining of the uterus) to build up, which prevents implantation of the egg. In addition, it thickens the cervical mucus, making it harder for sperm to pass.
Similar to the implant, there is no synthetic estrogen, so our ovaries are free to continue producing our sex hormones. There are not the systemic effects we see with all the other forms of contraception, including the implant, which raises SHBG; so our testosterone stays available for our body to use. It is suggested systemic testosterone is important for libido and vulvar tissue health.
In addition to their effective contraceptive benefits, there are non-contraceptive benefits of the hormone releasing IUDs. The hormone-releasing IUDs may help women who suffer from painful or heavy periods, adenomyosis, as well as prevent or treat endometrial hyperplasia in women with polycystic ovarian syndrome and in estrogen users.8 The hormones released from the IUD protect the endometrium from stimulation in women who are taking estrogen replacement therapies (usually post-menopausal women) and in women who take tamoxifen (in women with receptor-positive breast cancer). 8
So why are there so many hormone releasing IUDs? What’s the difference?
Mirena, Skyla, and Liletta
Mirena
The Mirena was the first hormone-releasing IUD to be FDA approved in the U.S. It was formerly approved for use up to five years, and just this month the FDA approved use for seven years. It used to be thought that it was used only for women who have had kids previously due to pain with insertion and the uterine size. Studies show however, that there was no difference in the rate of expulsion, contraceptive failure, and premature discontinuation in women who have or have not had babies. The only difference shown was that nulliparous women (women who have not had a baby) reported pain with IUD use compared to women who have not had a baby.7
The size of the Mirena is a bit smaller than Paragard, but comparable it measures 32mm wide by 32mm long. One study that looked at IUDs in nulliparous women showed the statistics were similar in women who have had babies.
– 96% of women had successful insertion on their first attempt
– 80% of women had minimal to no pain one week after device insertion
– There was a high satisfaction rate: 83% said they were ‘happy’ or ‘very happy’ with the device. 9
Best population: Studies show that any woman – young or old, baby or no baby – can safely and effectively use the Mirena IUD 11. Also, any women that suffer from endometriosis, adenomyosis, or painful or heavy periods may have significant benefit. 8
Skyla
Skyla was introduced in 2013 as a hormone-releasing IUD FDA approved for 3 years as it has less total progesterone than the Mirena. It is essentially a “mini-Mirena.” It was primarily created because Mirena was too large for some nulliparous and even postmenopausal women. The Skyla measures 28mm wide and 30mm long.
Best population: Since the actual IUD is smaller in size than the Mirena, there is some evidence to suggest for nulliparous women it is a good option to help reduce pain with insertion. This is often why many nulliparous women are hesitant to choose an IUD as a contraception method. 11
Liletta
Liletta is the newest addition of the IUDs. It became FDA approved in 2015 for use up to three years. This IUD is basically an exact replica of the Mirena; it is the same size and has the same amount of total hormone, though it is released at a different rate. The FDA will likely increase the usage of this device to five years once more research is performed. The benefit of this device is that it was meant to be a more affordable option than the others, as one of the barriers to using this form of contraception is the cost for some consumers.
Best population: Same as the Mirena; however, this may also be a better option for women whose insurance plans do not cover the cost of the IUD. This IUD was made to be the most cost effective for women. 12
Which LARC should I choose?
Just like many of you, I too have suffered the effects of taking systemic hormones, and have been frustrated that many doctors never offered me this form of contraception. Also like many of you and many women I see on a daily basis, I was young when I was started on the pill for a reason other than preventing pregnancy, which resulted in a 7-year history use of OCP use, side-effects and all. But now there are other options, and you should utilize them.
If you are currently on the pill, the patch, the shot, or even have the implant, I encourage you to talk with your ObGyn about the options for an IUD. If your current insurance company does not cover the IUD or you do not have insurance, check out this website http://www.mirena-us.com/how-to-get-mirena/insurance-coverage.php for information on how to get an IUD at low or no cost to you.
If you read this blog and you are suffering from painful intercourse, vulvodynia, or vestibulodynia, or identify with any of the other side-effects that were mentioned, talk to your ObGyn about your symptoms and consider finding a pelvic floor physical therapist to evaluate you and help identify the source of your pain. For more information on female pelvic pain, click here.
References:
- Adolescents and long-acting reversible contraception: implants and intrauterine devices. Committee Opinion No. 539. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:983–8.
- Trussell, J. Contraceptive failure in the United States. Contraception. 2011;83(5):397-404.
- Teal SB, Romer SE, Goldthwaite LM, et al. Insertion characteristics of intrauterine devices in adolescents and young women: success, ancillary measures, and complications. Am J Obstet Gynecol 2015;213:515.e1-5.
- Buhling K, Zite N, Lotke P. Worldwide use of intrauterine contraception: a review. Contraception 89 (2014) 162-173.
- Usinger K, Gola S, Salas M, Smaldone A, Intrauterine Contraception Continuation in Adolescents and Young Women: A Systematic Review, Journal of Pediatric and Adolescent Gynecology (2016), doi: 10.1016/j.jpag.2016.06.007.
- Benacerraf B, Shipp T, Lyons J, et al. Width of the Normal Uterine Cavity in Premenopausal Women and Effect of Parity. Obstet Gynecol 2010;116(2):305–10.
- Aoun J, Dines V, Stoval D, et al. Effects of Age, Parity, and Device Type on Complications and Discontinuation of Intrauterine Devices. Obstet Gynecol 2014;123:585-92.
- Rose S, Chaudhari A, Peterson M. Mirena® (Levonorgestrel intrauterine system): A successful novel drug delivery option in contraception. Advanced Drug Delivery Reviews 61 2009;808-812.
- Hall AM, Kutler BA. Intrauterine contraception in nulliparous women: a prospective survey. J Fam Plann Reprod Health Care 2016;42:36-42.
- Rowe P, Farley T, Peregoudov A, et al. Safety and efficacy in parous women of a 52-mg levonorgestrel-medicated intrauterine device: a 7-year randomized comparative study with the TCu380A. Contraception 93 (2016);6:498-506
- Aiken A, Trussell J, Recent advances in contraception. F1000Prime Rep 2014, 6:113
- Angelini K. A lower-cost option for intrauterine contraception. Nursing for women’s health 2016; 20(2):197-202.
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
Thank you for sharing the different types of IUDs. I would suggest you add “pregna” to your list. It is also, one of the best contraceptive devices. I am using it for the last 2years and have no issues with it.