By Jandra Mueller
Are you currently on birth control? Have you used birth control in the past? These are common questions I ask when doing an evaluation of a female patient who is experiencing painful intercourse, also known as dyspareunia. Most women I see are currently, or have been in the past, on some form of birth control. Typically they are prescribed initially for non-contraceptive related reasons starting in adolescence for skin conditions (acne), painful or heavy periods, or mood disorders, and then just continue using them once they become sexually active.
I’ve evaluated many women, both young and old, that have a history of using at least the pill, but many whom have also reported using other various types of birth control like the patch, the Depo-Provera shot, or the NuvaRing. Most of the reasons reported for switching birth controls were not because they weren’t effective in preventing pregnancy, but because there were individual intolerances to the various forms, like extreme mood shifts, abnormal bleeding, weight gain, headaches, changes in energy levels, diminished sex-drive, vaginal dryness and breast tenderness. Another big reason women switch from the pill to, lets say the patch or the ring, is the convenience of not having to remember to take a pill every day at the same time, especially if that is the only medication you take. This becomes a disaster when you miss 2-3 pills and have unprotected sex – you fear an unwanted pregnancy and you end up taking the plan-B pill “just-in-case.”
Here are some common responses (and the reasons) women often report trying all sorts of different birth control pills or methods or eventually why they stop using birth control all together:
- Compliance “oh, I just kept forgetting to take my pill”
- Adverse reactions “I’m so sensitive to hormones,” “I’m an emotional wreck,” “I hated the way it made me feel,” “I gained so much weight”
- Sexual changes “I lost my sex drive,” “I feel dry down there”
If some of these sound familiar, you are not alone. To make matters worse, recent research suggests that oral contraceptive birth control pills can cause vulvodynia, as well as other side-effects such as recurrent UTIs (or symptoms of UTIs), yeast infections, or the menopausal state in which our bodies are temporarily in. This is also true of other forms of birth control such as the depo shot, NuvaRing, or the patch. For more information on how birth control wreaks havoc on our bodies, check out Dr. Gonzalez’s blog here.
When our doctors counsel us on the use of these medications, they are understandably concerned with the life-threatening effects of birth control, such as blood clots and effectiveness of the type of contraceptive which can change based on weight. What doctors often do not mention is since your ovaries are essentially shut down to prevent pregnancy, your body will also stop the production of very important hormones like estrogen, progesterone, and testosterone, which can significantly decrease your sex drive, and cause dryness and irritation in your vagina. This can make sex painful because your tissues stay chronically irritated, which can put you at risk for recurrent UTIs and yeast infections, and your clitoris and labia may shrink in size.
Yikes! I know 100% that I wouldn’t volunteer to take this pill knowing that information. Guess what? Like many of you who are reading this blog, I’ve taken the pill for many years, unknowing of the consequences. My first experience with the pill was when I was 13 years old, after my mom took me to the ER because I ended up curled up in the fetal position in the bathtub from relentless stabbing, knife-like pain in my lower abdomen. I was diagnosed with a ruptured ovarian cyst with multiple cysts still present in my ovaries. The treatment: oral contraceptives.
For the next 7 years of my life I tried multiple forms of the pill as well as the NuvaRing. It was a struggle to find the right fit for me. I was on and off birth control because of weight gain and extreme mood swings, though when I became sexually active I worried about unwanted pregnancy so I’d return to the pill or the ring and the cycle would continue. When I was 20 years old I was in a serious, monogamous relationship and I couldn’t think about the side effects of using one of these methods on the regular, it was just not an option – I needed something different. Then my Ob Gyn offered Mirena, an IUD.
What is Mirena?
Some of you reading may have heard of Mirena, but don’t be alarmed or feel you are out of the loop if you haven’t! Mirena is a levonorgestrel releasing intrauterine device (IUD) that is FDA approved for use up to 7 years.10 At that time it was the only hormone releasing IUD approved for use in the United States.
IUDs are forms of long acting reversible contraception (LARC), and are T-shaped flexible devices made from either copper or a backbone. They release small amounts of levonorgestrel, a type of progesterone, throughout either a 3- or 5-year period. They are known to be the safest and most effective forms of birth control in preventing unwanted pregnancies.1 They were initially designed for women who were seeking birth control after they had a baby; but due to the high effectiveness in preventing unwanted pregnancies, they are the first line choice of birth control for all women – baby or no baby, teenager, young, or old according to the American College of Obstetrics and Gynecology.1
Naturally, my follow up question during my evaluation is “Have you considered using an IUD?” The responses here are mixed but overall they aren’t in favor of the IUD. Here are some answers I’ve heard:
– “My Ob/Gyn never told me about it”
– “My doctor said it would be too painful to insert it”
– “My doctor said it isn’t a good option because I haven’t had a baby”
– “I thought I couldn’t have one because I haven’t had a baby”
– “It’s weird to have something in my ‘vagina’ for that long”
– “Oh yeah, my friend told me it hurt really bad when she got it and she bled for a really long time”
– “I’m worried about getting cancer”
– “I’m worried it will get lost”
For those of you who have heard of the IUD or have asked your doctor about them, do any of these responses resonate with you?
What is considered a long acting reversible contraception and why have I not heard of them?
Like I mentioned earlier, an IUD is a form of a LARC and they are considered to be the first line choice of contraception for all women. ACOG released a statement in Sept/Oct 2015, which urges obstetrician-gynecologists to encourage use of a LARC device, educate patients on their options in LARC devices, and advocate for insurance coverage, payment, and reimbursement.
The use of LARC devices in adolescents and young women was initiated due to the high rate of unintended pregnancies, mostly due to inconsistent use with other forms of contraception in this population, which has become a significant public health concern. Think about it, it’s a hassle to remember to take a pill at the same time every day or to make sure you schedule your doctor appointments on the regular to get your depo shot every 3 months or re-fill your prescription for the patch or the ring. In addition to the compliance issue, there is also a higher failure rate of these methods – 9% with the pill, patch, and ring and 6% with the shot, compared to 0.2-0.8% with LARC devices.2
My question now is, if this is THE thing to have, research shows that it is the safest, most effective, and the device recommended by ACOG, why am I seeing all these young women still on the pill with very little knowledge about an IUD? Statistically speaking, less than 10% of all U.S. women use a form of LARC as their method of birth control, and only 4.5% of women under 20 use a LARC device3 most commonly the IUD. The percentage of women who use contraception and an IUD as their method are much higher in other countries. For example: Asia (27%), Europe (17%), Africa (15%), Latin America/Caribbean (9.6%) are all ahead of us in using these forms of devices.4
The biggest reason stated is that Ob Gyns may not have the most recent evidence on IUDs and even ObGyns who have a favorable attitude towards IUDs may use overly restrictive criteria when recommending an IUD to an adolescent or nulliparous women, meaning women who have not had babies. Studies show that approximately 67% of Ob Gyns consider a woman who has not yet had a baby an inappropriate candidate for an IUD, and 43% of Ob Gyns feel this is true of adolescents.5
Now that you know some information about LARC devices, let’s talk about what they actually are.
There are two categories of LARC devices: the implant and the IUD.
The Implant – Nexplanon
Nexplanon is the implant that is FDA approved for use in the US. It is a small device that is inserted into your arm and can last up to 3 years. It works by slowly releasing a hormone called etonogestrel, a type of progesterone, into your bloodstream and stops ovulation. The implant differs from short acting reversible contraception (SARC) aka the pill, the patch, the shot, and the ring, in that it does not contain ethinyl estradiol (synthetic estrogen).
This is an important difference to understand. What this means is that due to the lack of the synthetic estradiol, in the process of preventing pregnancy it does not shut the ovaries off from producing other sex hormones like estrogen and testosterone. However, because it is inserted in your arm, the synthetic progesterone gets released into your bloodstream and has to go through your liver to be processed (similar to other systemic forms of contraceptives). Similar to OCPs, this process causes an elevation of a protein called sex hormone binding globulin (SHBG), which is produced by our liver once our liver metabolizes, or breaks down, the synthetic progesterone.
SHBG basically sucks up all of our available or free testosterone rendering it ‘inactive.’ In short, testosterone is really important for the health of our tissues ‘down there,’ and can ultimately be responsible for those side effects such as low energy, diminished sex drive, poor tissue health, vaginal dryness, as well as conditions known as vulvodynia, vestibulodynia, and dyspareunia. To read more about SHBG check out these blogs.
The implant was ultimately designed to be a more convenient form of birth control that could release a steady state of hormone over a longer time period without interrupting a woman’s ability to get pregnant once she decided to go off contraception. It is very effective in preventing pregnancy, which is what your Ob Gyn is ultimately concerned about. However, though it is better than other forms of contraception because of the lack of synthetic estrogen, it is not the BEST option considering it still raises your SHBG, which puts you at risk for developing some of those nasty side effects.
The IUD – Paragard, Mirena, Skyla, and Liletta
Again, an IUD is a flexible T-shaped device that is inserted into the uterus (not the vagina). There are now 4 IUDs that are FDA approved for use in the United States. One of the IUDs is a copper releasing device (ParaGard) and the others are levonorgestrel-releasing IUDs (Mirena, Skyla, and Liletta).
According to a study that looked at differences in the effect of age, parity, device type on expulsion, perforation, or failure (unintended pregnancy), they showed no difference in these areas in adolescents or in nulliparous women. The only differences they found were with the copper IUD causing increased pain and was more associated with higher rates of expulsion and premature discontinuation. (7) What I also found that was interesting about this article is they looked at the type of providers that were placing the IUDs. Often a family practice or nurse practitioner you may see for your annual exams are the ones who place the IUD and there have been shown to be more complications with non-OB Gyn practitioners who are performing the insertion.7
If you would like more information on the use of a long-acting reversible contraceptive device, contact your Ob Gyn office to make an appointment and discuss this option. Stay tuned for more detailed information regarding the different IUDs and why we believe an IUD is a superior choice over the implant.
Stay tuned for next week’s blog on more IUD differences and questions to discuss with your physician.
- 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