Presenting a new series that I am very excited about. In Covering Contraception, I will discuss multiple forms of contraception in use and available today. Back in the beginning of my path towards Midwifery, I faced an important decision; should I become a CPM or a CNM? I was dedicated to Community Birthing and supporting families out of the hospital, so it seemed logical to go with the CPM route. However, I was also passionate about the full scope of women’s health care; well-woman care, contraception, peri-menopause and menopause support as well as primary care. In particular, I was drawn to be able to support clients through contraceptive choices and access. Eventually, and after much soul searching, I choose the CNM path with the promise to keep to my roots of defending and providing physiologic birth and a dedication to serving my clients during the full cycles of life journey’s.
Whenever, I have a ‘family planning’ or ‘contraceptive counseling’ visit with a client, I usually start with questions about what types of contraception they have used in the past. Did they like those methods, if so why? And if not, why? I obtain a comprehensive health history to screen for any potential contraindications to birth control. I ask questions about lifestyle; are they monogamous, who (men, women or both) do they have sex with, are they at risk for exposure to STI’s? Are they looking only for pregnancy prevention or do they have concerns about their menstrual cycles? How do they feel about using synthetic hormones? Have they ever had children? Do they want to have children sometime in the future? Have they had children and feel they do not want anymore? The answers to these questions will help guide me to offering and discussing particular options for contraception. It is important to remember that all forms of contraception come with risks and these should be discussed and assessed for each individual.
So, here I am, ready to explore one of my passions with you here; contraception. In this first edition, I will cover LARC’s or Long Acting Reversible Contraceptives. These are birth control options that offer protection against pregnancy for years. There are two options in this category: Intrauterine Devices (IUD’s) and implants (Nexplanon).
***Disclaimer: this article is not intended to replace a comprehensive evaluation by a trained health care provider and may not cover all potential questions, concerns or issues. It is intended solely as an informational overview.***
Intrauterine Device or IUD
Although there are several different types of IUD’s, they all share some essential functions, shapes and risks. In general, in the United States, IUD’s are small T-shaped devices that are placed in the uterine cavity. They are placed by a trained professional in a clinic setting and can be utilized by folks who have given birth as well as folks who have never been pregnant. IUD’s work by preventing sperm from fertilizing the ovum or egg. Hormonal IUD’s also have the effect of thickening cervical mucous which prevents the sperm from entering the uterus and fallopian tubes and also thins the uterine lining. All types of IUD’s have anti-microbial strings attached to the ends, that when in place extend out of the cervix into the vagina. Once a month, the person who has an IUD in place is instructed to insert their fingers into the vagina and feel for the strings to ensure the device is still in place.
Benefits and Effectiveness: One of the biggest benefits of IUD’s is their effectiveness. Both types of IUD’s offer over 99% effectiveness at preventing pregnancy. (The hormonal devices offer slightly more protection but the difference is negligible.) Another benefit, and one of the reasons why they work so well, is that the user does not have to remember to “do” anything; no daily pill to take, no inserting a diaphragm or putting on a condom…in this way it protects against “operator error or forgetfulness”. There is no getting caught up in the “heat of the moment” and forgetting or neglecting to use. Also, IUD’s are good for up to 3-12 years depending on the type utilized. Due to their long term coverage, they are also extremely cost effective. Although they may require more money up front, in the end they are one of the cheapest forms of contraception when the cost is divided out over the time of potential use.
Side Effects: These will vary depending on the type of IUD and are often used to help a person choose which device to use. The main side effects of the non-hormonal/copper IUD is periods that may be heavier and longer with increased cramping. For folks who have manageable periods with little to no cramping, this effect is usually minimal. The main side effect of the hormonal IUD’s is irregular spotting which typically resolves in the first few months, and then periods that are shorter and lighter and may even stop all together. For folks who have a history of heavy, painful periods this may sound fantastic. Other folks are uncomfortable with the idea of not having a period.
Risks: Overall, the rates of potential complications from IUD’s are very small, the primary ones are:
- Perforation: this can happen at the time of insertion and involves the IUD not being properly placed in the intrauterine cavity. When an experienced provider is placing the device the risk is less than 1 per 1,000 or less insertions. When the IUD is not in the uterus, prompt removal is recommended. The removal may have to be done via laparoscopic surgery. There is some debate as to whether the device itself may perforate the uterus at some time after insertion and migrate outside the uterus, some sources state their is no evidence for this and others do but that it is extremely rare.
- Expulsion: This can happen in 2-10% of cases in the first year. Symptoms may be, lengthening or absence of the strings, unusual vaginal discharge or pain, spotting or painful intercourse. The biggest concern with expulsion is that the user is not protected against pregnancy. When an IUD has been spontaneously expelled, there is a 30% chance that it will happen again if a new device is placed.
- Ectopic Pregnancy: this refers to any pregnancy that implants outside the uterus. The most common place for ectopic pregnancy is in the fallopian tubes. Ectopic pregnancy is a very serious condition that can be life threatening for the woman. It is important to note that, overall, IUD’s protect women against ectopic pregnancy as they provide such good protection against pregnancy. However, in the rare event of a pregnancy conceived with an IUD in pace, there may be an increased risk that the pregnancy may be ectopic. Therefore any suspicion of possible pregnancy should be immediately confirmed or ruled out and a health care provider consulted.
Insertion: the procedure typically takes less than 10 minutes and often includes some uterine cramping, that may range from mild to severe. The client is assisted to a supine position and the feet may be placed in stirrups. A speculum is inserted into the vagina and the cervix is visualized. The cervix is then “washed” with a cleansing solution like Betadine. Some providers then use a tool called a tenaculum to help hold and stabilize the cervix, this often causes the initial cramping and discomfort. Next, a tool called a uterine sound is inserted through the external cervical opening until resistance is met at the top of the uterus or fundus and that distance in cm’s is noted. This is how the practitioner knows how far to insert the IUD. The average measurement from the external cervical opening to the internal uterine fundus is 6-9cm. (Women who have carried a baby will be closer to 9cm and women who have never been pregnant will be closer to 6cm.) From here the insertion varies depending on the type of IUD being inserted as each one has a slightly different insertion tool. Basically, though, the device is paced in a small cannula with the “arms” of the T-shaped device tucked inside to easily fit through the cervical canal and is then inserted to the depth measured earlier with the uterine sound. The cannula is then removed, leaving the IUD in the uterus. At this point, the IUD strings are trimmed to approx 3-4cm. Then the tenaculum (if used) and the speculum are removed. Some providers, based on availability, may then immediately confirm correct placement by ultrasound. From here, the client will typically be instructed to return for a follow-up visit in about a month to check-in.
Contraceptive Implant or Nexplanon
Currently, in the United States, there is one type of implantable contraceptive available, the Nexplanon. The Nexplanon implant is approximately the size of a wooden matchstick and is placed under the skin of the inner, upper arm. It works by releasing a synthetic form of the hormone progesterone, called etonogestrel, into the person’s body. Nexplanon primarily works by preventing ovulation but has a secondary action of creating thick cervical mucous that prevents sperm from entering the uterus and also thins the uterine lining. The Nexplanon device also contains barium sulfate which makes it visible via X-ray.
Benefits and Effectiveness: As with the IUD’s, one of the biggest benefits of Nexplanon is that it is over 99% effective at preventing pregnancy. Again, as with IUD’s, one of the reasons why they work so well, is that the user does not have to remember to “do” anything; no daily pill to take, no inserting a diaphragm or putting on a condom…in this way it protects against “operator error or forgetfulness”. There is no getting caught up in the “heat of the moment” and forgetting or neglecting to use. Once in place the Nexplanon provides pregnancy protection for 3 years, and some sources report safety for up to 4 years. Cost effectiveness is another benefit of the Nexplanon, as when the cost is divided over the length of use it becomes inexpensive.
Side Effects: the primary side effect of the Nexplanon is menstrual bleeding changes and between cycle spotting. Periods may become irregular, longer or shorter and may stop all together. For most women, these effects will decrease after the first few months but for some they may happen for the entire time the device is in place. Some folks may also experience weight gain, acne, headaches, mood swings, and pain at the insertion site but these are relatively rare.
- Insertion site complications: rare but possible infection at the insertion site. Arm pain and scarring at the insertion and removal site, are also possible. Injury to nerves or vessels in the arm. These side effects occur in less than 1% of cases.
- There have been very rare cases of the implant migrating into a vessel and traveling to vessels that feed into the lungs or heart. Any concerns about this happening should be discussed immediately with your health care provider.
- Bent or broken implants. The implant itself is very flexible but it may be possible for it to become bent or broken. If this ever happens, it is important to contact your health care provider right away.
Insertion: the procedure is typically quick and takes place in a clinic setting. The client is assisted to a supine position, with the non-dominant arm out at a 90 degree angle from the body with the elbow bent up. The upper arm is then examined to determine the exact location for placement. The chosen site is then cleansed with Betadine or another similar cleanser and this is allowed to air dry. Next, the site is numbed using an injection of lidocaine. Using the insertion device, the implant is then inserted under the skin. The insertion site is then dressed with a pressure bandage. Bruising is common and usually resolves over the course several days.
***It is very important to remember that LARC’s do NOT protect against Sexually Transmitted Infections, so the dual use of condoms is recommended when appropriate***
A truly fantastic resource for birth control options of all types is Bedsider
Image is of a Paragard educational tool and was taken by Aubre Tompkins, CNM