If you've considered birth control over the past few years, chances are you've had at least one friend wax enthusiastic about an intrauterine device, or IUD. The method, which is the most effective reversible form of contraception on the market, has grown exponentially in popularity over the last decade, despite low national rates.
There's now even a small sub-genre of personal essay related to choosing IUDs, ranging from testimonials to tales of medical misadventure.
Laura MacIsaac, M.D., an ob-gyn and director of the Family Planning Division at Beth Israel Hospital in New York, says that she's noticed a big uptick in women asking about and selecting IUDs. That's partially through word of mouth -- women recommending them to friends (or writing about them on the Internet) -- but it's also related to a shifting demographic among doctors: A generation ago, most ob-gyns were men, but now, according to MacIsaac, 80 percent of the American College of Obstetricians and Gynecologists fellows under 40 are women. And 40 percent of female gynecologists who use contraception choose the IUD, compared with just 6 percent of the general population of women.
That influence has an effect. "Fifteen years ago, a gynecologist would not be able to say, 'This is what I use,'" explained MacIsaac, who herself uses a Mirena IUD and has previously used a Paragard. "It's a different kind of intimacy when a female doctor can draw on personal experience."
The result? In practice, "a 60-year-old man starts with the pill, a 30-year-old woman starts with the IUD," she said. While the pill is more common and more familiar, IUDs "work the best and women like them the best," according to MacIsaac.
Younger practitioners may also be more up-to-date on changes to the American College of Obstetricians and Gynecologists professional guidelines, which shifted their recommendation to doctors to first offer IUDs and other forms of long-acting reversible contraception, or LARC, to young women. The American Academy of Pediatrics recently followed suit.
Of course, gynecologists and public health officials of both genders and all ages are fans of the IUD, too -- unintended pregnancy is still a major source of concern in the United States, which has the highest rate of any industrialized country. And IUDs are 20 times better at preventing pregnancy than the pill or patch, according to a 2012 study in the New England Journal of Medicine.
So should you get one? First, the basics: IUDs are small t-shaped devices that are inserted into a woman's uterus. There are three current models on the market in the United States: The Mirena and the Skyla use hormones that may prevent ovulation, create a barrier by thickening cervical mucus and create an inhospitably thin wall to prevent fertilized egg implantation. The Paragard uses copper, which is toxic to sperm and has a "slickening" effect on the uterine wall, making it difficult for an egg to implant.
Pro: It's The Most Effective At Preventing Pregnancy
This pro is probably the most important of all potential factors. Simply put, it's the best at what it is supposed to do. While the pill has a failure rate of 6 percent -- meaning six out of every 100 women on the pill will get pregnant in a given year -- the failure rate of the IUD is between .2 and .8 percent.
The "set it and forget it" nature of the IUD is it's strength. Birth control pills are not inherently faulty; the failure rate is higher simply because pills rely on more human action. They require remembering daily doses and picking up refilled prescriptions, and they are vulnerable to interactions with other medicines. IUDs are just there -- they don't require any maintenance or attention, and they provide several years of pregnancy prevention while remaining fully reversible. The FDA approves three-year use for Skyla, five years for Mirena and up to 10 years for Paragard.
Pro: Women Stick With It
In possibly the world's most elegant contraceptive study, a team of researchers led by Dr. Jeffrey Peipert at Washington University, St. Louis gave women free access to any form of birth control they wanted. After a year, they looked at continuation rates for women who still did not want to be pregnant but were sexually active. Because cost was taken out of the equation, the researchers determined that personal preference and convenience were the only factors leading to continuation.
Among IUD users, continued use at a year was 88 percent; for pill users, it was close to 50 percent.
Con: It Requires An Actual (Sometimes Painful) Procedure
Ob-gyns and some nurse practitioners are equipped to insert an IUD. Insertion requires dilation of the cervix, which is the opening of the uterus. Many women find this painful, and some women even faint or feel dizzy after insertion, according to Planned Parenthood.
Pro: There Are Fewer Hormone-Based Side Effects -- Even With The Hormonal IUD
Many women first seek out IUDs because they have had bad experiences with side effects from contraceptive hormones, particularly estrogen, which can have an impact on things as varied as mood and libido to acne and risk of blood clots. The copper IUD is completely hormone-free, so many women choose it for that reason. But the Mirena and Skyla IUDs are also distinct from other forms of hormonal birth control because they contain no estrogen and because the release of the hormone progestin remains local, according to MacIsaac, who describes it as "barely released in circulation system."
Con: It Can Change Your Period... For The Worse
The most common reason women have IUDs removed early relates to changes in menstruation. Many women who use Paragard have heavier flows, particularly in the months after insertion. Some even report more painful menstrual cramps, according to MacIsaac.
Mirena, on the other hand, can cause very light spotting or cause a period to disappear entirely; 20 percent of Mirena users don't get their period and for many women, this is a bonus. There are some women who are uncomfortable with never menstruating, according to MacIsaac, so early removals happen among both groups.
Pro: Long-term Costs Are Low As Can Be
One reason women discontinue the pill or are spotty in their use of it relates to cost: It can be hard for some women to spare the co-pay on a month-to-month basis. While an IUD requires some investment upfront, the cost effectiveness evens out after roughly a year of pills or the patch or ring. Given that the IUD can last up to 10 years, that's a major saving. "Even a year is worth it," said MacIsaac. "I tell people to consider it a one-year method or longer -- if you don't want to have a child in next year, then you're a candidate for all three of the IUDs."
This article has been updated to include additional information on the ways that a Mirena IUD can prevent pregnancy.