Intra-lower device (IUD), intrauterine system (IUS)
The intrauterine device, known colloquially as a "coil", is a means of contraception that is inserted into the woman's uterus. Modern intrauterine devices are usually T-shaped, 2.5 to 3.5 cm in size and made of tissue-friendly, flexible plastic.
The spiral was first used in 1928 Graefenberg described. He developed a spiral ring that was inserted into the uterus. However, its use was banned due to an increased rate of ascending infections and the resulting deaths. Only after IUDs were made of plastic in the 1960s, which apart from a small thread had no connection to the vagina, was the IUD considered a real possibility of contraception.
Today only 3rd and 4th generation IUDs, also called intrauterine systems (IUS), are on the market due to further development.
Types and mechanism of action
The following types are known:
- IUD with copper
- IUD with added hormones (Progestin)
- IUD made of plastic without additive ("Inert" IUDs)
IUDs with copper:
The vertical arm of the T-shaped spiral is wrapped with copper wire and thus stabilizes the position in the uterus. The copper ions are continuously distributed into the surrounding tissue. The surface of the copper varies between 195 mm2 and 375 mm2, depending on the product.
The mechanism of action is not fully established. However, the following factors are involved:
- The foreign body irritation of the uterine lining (des Endometrium) leads to superficial inflammation, which is accompanied by an immigration of white blood cells (Leukocytes) and specialized phagocytes (Macrophages) is connected to the mucous membrane. This prevents the fertilized egg from implanting in the uterus.
- Copper ions are harmful (toxic) on the fertilization ability of the sperm. The contraceptive effect is directly proportional to the total surface of the copper used.
- Copper ions also have a locally toxic effect on the fallopian tubes and on the fertilized egg cell itself and thus directly inhibit implantation (direct nidation inhibition). Through this mechanism, the IUD can also be used as a means of termination of pregnancy (postcoital abortion), be used.
There is also speculation about a positive effect of copper ions on preventing the development of a malignant tumor of the uterine lining (Endometrial cancer). At least it is known to be less with the use of copper IUDs Endometrial cancer to be watched. This effect seems to be related to the length of time the IUD was in place.
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IUDs with added progestogen (also called intrauterine system (IUS)):
The shape of the coil corresponds to that of the copper coil, but the vertical arm of this coil contains 52 mg of levonorgestrel, a synthetic gestagen. Like the copper coil, it causes a foreign body reaction of the Endometrium. In addition, progestins cause the cervical secretion to thicken and the ability of the fallopian tubes to move less (Tubal motility) and a constant remodeling of the endometrium, which leads to a decrease in bleeding intensity. This is how existing period pains (Dysmenorrhea) and increased menstrual bleeding (Hypermenorrhea) mitigated.
IUDs without coating:
Inert IUDs are no longer on the market in Germany due to the local irritation of the endometrium.
Indication and contraindication
The IUD is particularly suitable for women who have already given birth but whose family planning has not yet been completed. Even women who rely on swallowing contraception (oral contraceptives) want to or should forego because they are unreliable when taking pills, benefit from the IUD method. Finally, the use of the IUD also makes sense for women from the age of 40 if the "Pill risk“, For example in connection with blood clots (thrombosis), increases.
The IUD should not be used in cases of genital infections, unexplained bleeding abnormalities, uterine abnormalities, genital tumors and pregnancy. Special advice is required, for example in the case of frequently changing sexual partners, age under 25, bleeding disorders, anemia, diabetes mellitus and heart disease. Even for women who are to be born first (Nulliparous), you must be particularly careful when using the IUD, as there is an increased tendency to inflammation from rising germs (ascending infection) consists.
Application and security
The IUD must be selected in shape and size according to the uterus. For this purpose, the uterus is measured with the help of an ultrasound and, if necessary, with a rod-shaped or tubular instrument (probe) inserted into the uterus. The insert is made under sterile conditions during menstruation, as the cervix is then easily accessible. Exceptions are the use directly after sexual intercourse as "Spiral afterwards“And the insertion approx. 6 weeks after the birth (postpartum insert).
After the insertion, the thin thread is shortened to 2 to 3 cm and the position of the spiral is determined using ultrasound (sonographically). After that, the seat must be checked regularly - the first time after the next menstruation, then every six months. The control can be based on the length of the thread and by ultrasound. Depending on the manufacturer's instructions, the coil can remain in the uterus for 3 to 5 years.
Although the Pearl index is between 0.9 and 3 for the copper IUD and 0.16 for the progestin-containing IUD, pregnancies can still occur. 50-60% of pregnancies with an IUD end up as Miscarriage (Abortion), so they are always considered high-risk pregnancies. The IUD should be removed if the thread is visible because of the increased risk of infection.
How is the IUD used?
The IUD, whether with or without hormones, must be placed through the vagina into the uterus. Because the cervix is softer and more permeable during menstrual bleeding, the IUD is usually placed on the second or third day of bleeding. A few hours before insertion, a drug can be taken, which makes the cervix even softer and thus makes insertion less painful.
For the insertion itself, the gynecologist first uses metal spatulas in order to be able to see the cervix clearly. Then the cervix can be opened slightly and the position of the uterus can be changed so that the guide rod with the spiral can be pushed straight into the uterus. Since moving the uterus stimulates the peritoneum, some women experience circulatory problems when they are inserted and should therefore not stand up straight away.
The insertion itself only takes a few minutes. Ultrasound examinations are carried out before and after the placement. First to determine the size and position of the uterus and afterwards to check the position of the IUD. Tampons should not be used immediately after insertion. However, this is possible again after a week.
Read more on the topic: The insertion of the spiral
The Mirena is a hormone coil. This IUD permanently releases the hormone levonorgestrel to the uterus and thus combines the effects of a hormone-free IUD and the pill. The Mirena can remain in the uterus for up to five years, after which it can be seamlessly switched to the next Mirena.
Other spirals with a similar effect are the Jaydess and the Kyleena. The Jaydess is slightly smaller than the Mirena and can therefore also be used on younger girls with a small uterus.
Find out more about the topic: Mirena spiral
IUD with hormones
With contraceptive IUDs, a distinction is made between copper IUDs and hormone IUDs, which achieve their preventive effect in different ways. Hormone IUDs contain the hormone levonorgestrel. This has different effects on the body. At first, similar to the mini pill, the uterine mucus becomes firmer and more impermeable to sperm, so that they cannot get into the uterus. The hormone also reduces the formation of new uterine lining.
In the female cycle, part of the uterine lining is rebuilt every month and expelled again with the menstrual period. The hormone coil ensures that the egg cell does not implant well and that the menstrual period is weaker, and often less painful. Levonorgestrel also reduces the mobility of the fallopian tubes, so that the egg cells can be transported more difficultly.
However, ovulation is not prevented by the hormone coil, so women continue to have a regular cycle, which can, however, be significantly weakened. Some women have stopped bleeding under the IUD. Depending on the manufacturer, the IUDs can be worn for three to five years before they have to be changed. The Pearl Index, i.e. the probability of unwanted pregnancies, is slightly better with the hormone IUD than with the copper IUD.
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Does the IUD influence my period?
Unlike the pill, the IUD does not prevent ovulation. The hormone coil can, however, restrict the structure of the uterine lining so much that women have significantly weakened or absent menstrual periods. The copper IUD often increases menstrual bleeding.
This difference should be considered when choosing the IUD, as women with period pain and heavy bleeding are more likely to benefit from the IUD. If the bleeding is very irregular, the gynecologist should be contacted, as this can also indicate a wrong position of the coil.
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Spiral and tampon- is that possible?
The coil lies in the uterus and only the retrieval threads extend a short distance into the vagina. Tampons lie opposite in the vagina and thus outside the uterus. The use of tampons is therefore possible without any problems. In the week after inserting the IUD, however, tampons should still be avoided, as the cervix is still irritated and tampons can lead to an increased risk of infection.
With and without a coil, you should always change the tampons regularly after a few hours to prevent infections.
Does the IUD remain effective when taking antibiotics?
The copper IUD is a purely mechanical form of contraception that prevents the egg cell from implanting in the uterus and does not interact with antibiotics. The hormone coil also retains its effect despite taking antibiotics, since the hormones work locally in the uterus and do not have to pass through the bloodstream through the liver as when taking the pill. The hormones in the pill are increasingly broken down in the liver by taking antibiotics, which cannot happen with the IUD.
Complications and side effects
Complications can occur when inserting the IUD:
With the spiral there is a risk of perforation (perforation) the uterine wall. If the uterus is too deeply seated or too small, severe dysmenorrhea can occur. There is also the "lost IUD", I.e. the thread of the spiral can no longer be seen. Pregnancy must be ruled out and the coil located sonographically. It is important whether it is still in the uterus (intrauterine) or outside the uterus (extrauterine), e.g. through a perforation in the uterine wall. It is also possible that the IUD is spontaneously ejected unnoticed, which occurs in 0.5-10%, depending on the type, most often during menstruation in the first few months.
Side effects are pain, bleeding disorders and inflammation due to the rising germs. The main bleeding disorders in the copper IUD are hypermenorrhea and dysmenorrhea, and in the progestogen-containing IUD, intermenstrual bleeding and spotting. 20% of users even have no bleeding at all after 12 months (amenorrhea). The inflammation of the endometrium that immediately follows (consecutive endometritis), which occurs in about 0.16 cases per 100 users. This can result in permanent destruction of the fallopian tubes and resulting sterility.
Read more on the topic: Menstrual irregularities
What should you do if the IUD slipped?
The coil is usually very securely in the center of the uterus and holds onto the mucous membrane with its side arms. However, since the spiral is not sewn in place, it cannot slip. For this reason, women with an IUD should go to their gynecologist annually to check the situation. A slipped IUD can have a reduced contraceptive effect. Especially the copper spiral, which works purely mechanically, is hardly effective if it is incorrectly positioned. Most women do not notice slippage themselves, while a loss of the IUD is often noticed when using the toilet.
A slipped spiral must be removed and replaced, since a position correction is not possible. If the slipped position leads to a pregnancy, a direct appointment with the gynecologist is necessary, as an IUD increases the likelihood of an ectopic pregnancy. In rare cases, the coil migrates into the fallopian tubes or even into the abdomen. Since there is a risk of infection and pain is triggered in the fallopian tubes in particular, the coil must be surgically removed.
Can you feel a spiral?
Shortly after inserting the IUD for the first time, most women still have pain in the lower abdomen, which can be caused by both the IUD itself and its insertion. After a short period of acclimatization, most women no longer feel the spiral because it is a piece of plastic that is only three centimeters in size.
The threads shouldn't be noticeable either. Should the threads interfere, they can be shortened later. If there are long-term complaints, a new position check should be carried out and in case of doubt the IUD should be removed early.
Can the IUD cause pain?
The insertion of the IUD is described by many women as uncomfortable to painful. In the first few days, most women also have abdominal pain, which is usually not much stronger than the normal menstrual pain. If the pain does not subside after a few days, the gynecologist should be consulted and the situation should be checked again.
Some women generally cannot cope with the IUD and should have it removed. While the menstrual period and the pain associated with it are weaker with the hormone IUD, the copper IUD can lead to increased bleeding and thus increase the menstrual pain. The IUD is therefore recommended for women with heavy menstrual bleeding.
Cost of the spiral
The costs vary depending on the type of IUD. The copper IUD is around 120 to 300 euros, while the hormone IUD is a bit more expensive at up to 400 euros. The cost is made up of the actual price of the spiral, the value of the other materials and the cost of inserting it. In addition, there is usually an initial position check with the ultrasound, which is actually always paid for by the health insurance companies. Every further position check, which should be carried out once a year, is again in the lower double-digit range. Removing the IUD, depending on the type, after three to five years, costs around 20 to 50 euros.
Read more on the topic: What does the IUD cost?
When does the health insurance company pay for the IUD?
The cost of contraception is fully covered for girls and young women up to the age of 18. Up to the age of 22, women have to make an additional payment of 10 percent of the sales price.
If there is a medical need for an IUD, the health insurances will pay the costs for the IUD later. The first ultrasound check is generally carried out by the health insurances, while further checks usually have to be paid for yourself.
How is an IUD removed?
After three to five years, the IUD must be removed or changed and the IUD must also be removed if you want to have children or if you have symptoms. The spiral has return threads for this purpose. These hang down from the actual spiral and lie just outside the cervix. First the gynecologist uses the metal spatula again so that the cervix is clearly visible. If the threads are then recognizable, the gynecologist can grab the threads with small pliers and pull out the spiral. In most cases, this is almost painless as the IUD folds over and slides out.
If the threads are no longer visible, the gynecologist has to examine the cervix and grasp the spiral directly with fine forceps. A new IUD can be inserted immediately after removal. The removal and the change can be carried out at any time and do not necessarily have to be precisely adapted to the menstrual period. In rare cases, the coil has slipped or even moved into the abdominal cavity in such a way that surgical removal is necessary. To rule out such a complication, an ultrasound of the vagina can be performed before the procedure and the position checked.
When do you have to change an IUD?
Depending on the manufacturer, the IUD can remain in the uterus for three to five years until it needs to be changed. The copper spiral can remain in place much longer at around ten years. If the spiral slips, however, a change must be carried out immediately. If symptoms arise, it may also be necessary to switch to another IUD or another method of contraception. If the IUD is used for a longer period of time, the contraceptive effect can decrease significantly, especially with the hormone IUD.
What does it cost to have an IUD removed?
An IUD needs to be removed after three to five years or sometimes sooner. When removing the spiral, there are no material costs for the spiral itself. Only the actual workload is included as a cost factor. Depending on the type of IUD and individual factors of the woman, the costs for the removal are between 20 and 50 euros. In most cases, these costs are not covered by the health insurance company. In the case of a removal that is necessary early for medical reasons, the health insurance company can partially cover the costs.
When can I reinsert an IUD after giving birth?
After the birth, the insertion of the IUD is very easy through the dilated cervix. However, there should be a gap of six weeks until the onset after the birth to reduce the risk of infections.
The effect of the hormonal IUD can be reduced during breastfeeding because the hormonal balance is changed. In women who have given birth several times, the loss of the IUD is slightly more common because the cervix is wider than in women who have never given birth.
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Comparison between pill and IUD
The IUD, both hormone IUD and copper IUD, is a local method of contraception, while the pill is absorbed systemically through the digestive system.This uptake of the pill is a disadvantage, as in gastrointestinal infections the hormone uptake is reduced and thus the effect can decrease. The use of antibiotics and some other drugs can also impair the effectiveness of the pill, as the liver breaks down more active substances.
Read more on the topic: Failure of the pill to work
Both of these disadvantages are absent with the coil. Another advantage of the IUD is that, unlike the pill, there can be no incorrect use. The effect of the pill is significantly reduced if the woman does not take the pill regularly and at the same time while the IUD is permanently in the uterus. Furthermore, the hormones in the pill, which work throughout the body, can lead to a higher risk of thrombosis in the first year of use.
The disadvantage of the IUD is that slipping and thus a loss of effectiveness is not necessarily noticed, while the woman is aware of a gastrointestinal infection or an ingestion error. Another risk of the IUD is the likelihood of an ectopic pregnancy in the event of an unplanned pregnancy. The risk of infection of the uterus and fallopian tubes is also greater with the IUD, while the pill has no influence on this. A general recommendation as to whether a pill or an IUD is better cannot be named as every woman has to consider for herself which method of contraception is right for her.