IUDs are one of the most effective ways to prevent pregnancy, but they may not be the best fit for everyone.

By Susan Rinkunas
November 12, 2020
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After Supreme Court Justice Ruth Bader Ginsburg's death in September, some wondered if there would be a rush of women switching their birth control to an intrauterine device, or IUD. That's because a more conservative Supreme Court will hear arguments in a case that could overturn the entire Affordable Care Act (ACA), the landmark healthcare law that expanded eligibility for Medicaid and required most insurance plans to cover 18 types of FDA-approved birth control methods with no out-of-pocket costs. The 2010 law resulted in widespread insurance coverage of the most effective contraceptives available—IUDs and the implant—which were not often covered before the ACA. The total cost for a device and insertion is usually more than $1,000.

While it seemed unlikely after arguments in the case that the Supreme Court would, in fact, strike down the entire law, we won't know for sure until the ruling is released, which could take until June. If the Supreme Court were to overturn the ACA, these methods could become much harder to access. People were feeling this fear four years ago, and it's back to some extent. Laura MacIsaac, MD, a professor of obstetrics and gynecology at the Mount Sinai Health System in New York City, says in the lead-up to the 2016 election there was a "marked increase" in people asking for IUDs because they were concerned if Donald Trump won, their insurance would no longer cover them. In recent months, people have been concerned about the fate of the ACA, Dr. MacIsaac tells Health, but there hasn't been a similar burst in IUD visits. "You can feel it and people are talking about it, it just doesn't seem quite as big [as 2016]."

Contraception is essential, preventive health care, says Gabriela Aguilar, MD, MPH, an ob-gyn in Connecticut and a fellow with Physicians for Reproductive Health. "Everybody deserves birth control coverage, no matter where they work or go to school. That should never be a deciding factor for somebody," Dr. Aguilar tells Health. "And if we don't cover all methods, then people may not be able to choose the method that is best for them because of the cost."

Access is even more critical during the pandemic. "People are suffering financially, so it's completely illogical to add a financial burden," she says.

Yet, here we are: The Supreme Court decided to hear the lawsuit rather than dismiss it ouright, and the Trump administration continued to support the suit despite the COVID-19 pandemic. But IUDs aren't right for everyone, and just because the Affordable Care Act's future is uncertain doesn't mean you should rush to get one. Here's what you need to know about these devices and who makes a good candidate.

How many kinds of IUDs are there and how long do they last?

IUDs belong to a class of birth control called long-acting reversible contraceptives (LARCs) that are more than 99% effective at preventing pregnancy. And like the name suggests, they last for several years (three to 10, depending on the type) and you can have them removed any time you want, Dr. Aguilar says.

There are two kinds of IUDs, non-hormonal and hormonal. The non-hormonal IUD, Paragard, is wrapped in copper wire which makes the uterus hostile to sperm so sperm can't fertilize an egg (it can also be used as emergency contraception if inserted up to 120 hours after unprotected sex). The copper IUD is approved for 10 years. Hormonal IUDs contain varying amounts of levonorgestrel, a progestin, which thickens cervical mucus to block sperm and can also prevent ovulation. There are four levonorgestrel IUDs and they are approved for different lengths of time: Mirena (5 years), Liletta (6 years), Kyleena (5 years), and Skyla (3 years). Studies have shown that Paragard, Mirena, and Liletta are effective for one to two years longer than their FDA-approved lengths.

There's one more long-acting device: an arm implant, brand name Nexplanon, which contains another form of progestin called etonogestrel and lasts for three years. Meera Shah, MD, an ob-gyn and the Chief Medical Officer at Planned Parenthood Hudson Peconic, says that a lot of young people request the implant because the insertion procedure doesn't involve a speculum, an instrument which can sometimes make folks uncomfortable.

What are the pros and cons of IUDs?

The best thing about IUDs is that they're just as effective at preventing pregnancy as sterilizationwith failure rates of less than 1 percent, per the US Food and Drug Administration—but they're reversible.

Another pro of the two longest-lasting hormonal IUDs, the Mirena and Liletta, is that, after an initial adjustment period, they often change people's periods to be shorter and lighter, and between 20 and 30 percent of people's periods stop altogether which can significantly improve their quality of life, Dr. Aguilar says. Mirena is also FDA-approved for treating menorrhagia, aka heavy periods, Dr. MacIsaac says, and she has also used it off-label for patients with fibroids who aren't ready for surgery to remove them because the Mirena may reduce their bleeding. (Skyla and Kyleena can also lead to menstrual changes but not as commonly and people's periods are less likely to stop altogether.)

The copper IUD can make bad periods worse, but it's a myth that it makes everyone's periods heavier in the long term, Dr. MacIsaac says. The first few periods might be a little longer but most people go back to their baseline, she says. Dr. Aguilar says she counsels patients to see what things look like after six months for all IUDs but especially the copper one.

The main (medical) drawback is that some people find the insertion of the IUD through the cervix quite uncomfortable, especially if they haven't had a pelvic exam before, Dr. Aguilar says. But providers can use a numbing medication before the procedure if people are concerned about pain. (And an FYI: the arms of an IUD don't extend out to the sides until the device is already in your uterus; its insertion width is much smaller than it looks.)

The implant is actually more effective than getting your tubes tied, with a failure rate of just 0.05 percent, or one in 2,000, according to the Centers for Disease Control and Prevention. But some people who use it experience unpredictable, frequent spotting and decide it's not for them and switch methods, or choose not to try it in the first place, Dr. Aguilar says. Dr. Shah says that she always talks with patients about how important it is to them to either have a period, not have a period, or have a predictable period and this conversation is particularly relevant with the implant. "For religious reasons people need to either know if they're going to have a period or not have a period so that they can plan prayer around that and religious ceremonies around that or any other cultural impressions around the body and your period needs to be addressed as well," she says.

How much does an IUD cost?

Cost can be a downside to IUDs. The devices themselves cost hundreds of dollars and how much you have to pay depends if you have insurance or not, whether your plan is required to fully cover birth control and the insertion appointment, and whether you see a provider who's in your insurance network. Not only did the ACA allow birth control exceptions for religious employers, but it's possible that your insurance plan only covers one kind of hormonal IUD out of the four.

The ACA also "grandfathered" some plans, meaning they're exempted from ACA rules to give them time to come into compliance. All of this is to say that there are people with insurance who shell out for birth control right now, even while the ACA is on the books. "Even if their IUD is covered, they might have to pay for the office visit, there might be a copay, they might be in their deductible, all that stuff happens," Dr. MacIsaac says.

It might also take two doctor's visits to get an IUD: Because the devices are so expensive, some insurance companies require preauthorization, meaning that after you discuss the IUD with your provider, they have to get it cleared with your insurance and sometimes have to order the device from the distributor. This process is usually less of a hassle at family planning clinics which often keep the devices in stock as they see patients without insurance and choose to order devices through discount programs or with grant money. The Liletta is actually a pharmacological equivalent of the Mirena (slightly different than a generic) that certain public health clinics can purchase at a lower price, and for that reason some clinics don't offer the Mirena.

Who shouldn't get an IUD?

It's somewhat obvious sounding but people who are allergic to copper or to levonorgestrel should not get these IUDs. Hormonal IUDs have one big contraindication: people with active breast cancer should not get them, and neither should people who are within 5 years of a breast cancer diagnosis. The non-hormonal copper IUD is a safe option for these people.

If someone has uterine fibroids, the benign masses may be an obstacle to placing an IUD but if the fibroids are small, providers can often insert one with the help of an ultrasound machine, Dr. Aguilar says. However, it may not be possible to safely insert the device for people with large, severe fibroids, or the IUD will just fall out after insertion. If someone knows they have a uterine anomaly like a septum, that would also be a strike against getting an IUD, but these are even more rare than fibroids, Dr. MacIsaac says.

So, who might be a good candidate to get an IUD in the next few months?

There's a lot on the line with this Supreme Court case, but Dr. Aguilar doesn't think any medical decision should be driven by fear, but rather made after talking over options with a healthcare provider. While people may be talking up these devices as smart choices, it's truly OK if you don't want one. "IUDs are not right for everybody, and the implant is definitely not right for everybody, and that is completely fine," Dr. Aguilar says.

Dr. Shah agrees. "I know that with Amy Coney Barrett on the Supreme Court, there's especially a lot of concern, and while the Supreme Court is a very real threat to our rights to accessing contraception and abortion services, I would hate to tell patients to hurry up and come in and change something." She emphasized that if people want an IUD at some point down the line, Planned Parenthood will be there. "Our doors are open and, if you feel that that's right for you, anytime is a good time—whether it's now, whether it's later."

Dr. MacIsaac has a slightly different view. "The cost barriers are profound, so anything that's going to make that worse potentially means that anyone who's considering starting a good birth control method should think about that now."

Dr. Aguilar also sees no harm in going for an IUD if you were already considering one. "There's no time like the present, especially while it's covered," she says. "Especially if they're already feeling positively about that method."

But definitely don't let a doctor pressure you into getting an IUD—or choosing any specific method, for that matter. Research suggests that providers are more likely to recommend IUDs to Black and Latina women living on low incomes than they are white women of similar socioeconomic status—a phenomenon likely tied to the United States' long history of trying to limit the reproduction of women of color.

"If anybody ever feels like they're being told what birth control method to use, they should try to find another provider, whether it's the same practice or another practice," Dr. Aguilar says. "Anybody who's doing appropriate contraceptive methods counseling should not be telling you what to do. It should be a shared decision, where you're talking about your health history and the risk factors that are associated with each device."

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