The Resurgence of IUDs

“Every time I place an intrauterine device I feel like Margaret Sanger!” Lisa DiGiorgio-Haag exclaimed.

DiGiorgio-Haag has been a nurse practitioner at UCSF Student Health for 24 years and specializes in women’s health.

She completed her Bachelor of Science in Nursing at the University of Pennsylvania, and went on to earn a Master of Science in Nursing and certification eligibility as a Family Nurse Practitioner from UCSF.

It was during her graduate studies that DiGiorgio-Haag decided to focus on women’s health, despite being discouraged to do so.

“I had one professor who really challenged me and insisted that I should not be a women's health nurse practitioner” DiGiorgio-Haag said. “I really had to take a look at [this and ask] is this really something I want to do if this expert thinks that I shouldn't be doing it? And [that challenge] motivated me even more to achieve my goals.”

Although she didn’t have strong female role models during her graduate studies, DiGiorgio-Haag says she “grew up really marinating in the power of women,” and feels she was meant to do work in the field of women’s health.

After learning about intrauterine devices (IUD) at a contraceptive technology conference, DiGiorgio-Haag spearheaded an IUD program at UCSF which allows students on the University of California Student Health Insurance Plan (UC SHIP) to get IUD’s inserted at no cost.

IUD’s, which look like a small plastic T, are the most effective form of birth control currently available apart from sterilization. They are long acting, reversible, and the best part is once they’ve been placed you don’t really need to think about them.

“I was so thrilled when I heard about IUDs because for so long in women's health there were no new options,” DiGiorgio-Haag said. “It was just years and years of this drought of contraception and then the IUD came out and it was just this mindblowing thing for people.”

Education First

One way in which UCSF’s IUD program is unique is that it requires two appointments, one for counseling and one for insertion.

During the counseling session your provider will go over all the options with you, and inform you of the pros/cons of each option.

“What a lot of providers I feel like are doing is they’re not really having that conversation with people,” DiGiorgio-Haag said. “My philosophy is let me educate you. Whatever you decide is fine, but I want you to have the information.”

UCSF Student health offers students a choice between three IUDs: the Skyla, the Mirena, and the ParaGard.

The Skyla and Mirena are made of plastic and contain levonorgestrel, a progestin hormone that induces thickening of the cervical mucus and thinning of the uterine lining to inhibit sperm from reaching and fertilizing an egg.

Although Mirena promotional materials recommend it for women who have had a pregnancy to term, many providers, including DiGiorgio-Haag, have placed Mirenas in women who have never been pregnant.

The reason DiGiorgio-Haag recommends the Mirena is because it lasts longer (5 years versus 3 years for the Skyla), and after one year 70% of patients have amenorrhea, meaning no menstrual period at all.

With the Skyla only 25% of patients have amenorrhea, while the other 75% are likely to have irregular, unpredictable bleeding.

“I think the only reason to choose a Skyla over a Mirena is if the uterus doesn't measure large enough for the Mirena, which happens rarely,” DiGiorgio-Haag said.

She has been placing IUDs for over 5 years and, to date, has only placed one Skyla.

For individuals who don’t want any hormones, the ParaGard is a hormone free IUD option. It is made from copper, which works to inhibit sperm function, and lasts up to 10 years. The downside to the ParaGard, however, is that it tends to make periods heavier and more crampy.

After laying out all the options and explaining the insertion procedure, your provider will answer any questions you have and schedule an appointment for the insertion. It is important to note that the IUD insertion appointments last one hour and cannot be booked online.

Dispelling myths

You may have heard women from previous generations say IUDs are dangerous and can cause serious infections and infertility. While one version of the IUD released in the 70s, the Dalkon Shield, did cause severe infections in women, today’s iteration of the IUD is safer.

Infections caused by the Dalkon Shield arose due to the use of multifilament strings, but now all IUDs use monofilament strings which have not been associated with a risk of infection.

Monofilament strings are thought to offer protection from infections because the total surface area of the string is exposed to cervical mucus, which blocks bacteria from entering the uterus (source: http://www.aafp.org/afp/1998/1201/p2077.html).

Another common misconception relates to the IUD insertion process.

“If you look on the Internet IUD insertion sounds like the most excruciating thing,” DiGiorgio-Haag said. “The thing I hear a lot is ‘it wasn't nearly as bad as I thought it was going to be,’ and I think that's because of the Internet. I feel like we're always working against that perception that it's gonna be this horrible, excruciating experience.”

Speaking from personal experience, IUD insertion was definitely not as painful as online accounts made it seem.

Providers at UCSF also do several things to minimize discomfort, such as recommending students schedule their insertion appointment during their menstrual cycle, when the cervix is naturally open, and offering patients a cervical block--something not all providers do.

“I think [the cervical block] makes a big difference,” DiGiorgio-Haag said. “It's very analogous to having Novocain when you get a filling. You can get a filling without Novocain, but it’s a lot tougher.”

Additionally, providers at UCSF encourage patients to eat and take ibuprofen before their insertion appointment. They will also ask you about your medical history to determine if you are prone to such things as vasovagal syncope (fainting when your body overreacts to stress).

Once the procedure is finished patients can rest in the exam room and enjoy apple juice and hot or cold packs for tender areas.

Individuals who have had a bad reaction to oral contraceptives may think they will have similar problems with the hormonal IUD, but there are some big differences between these two forms of contraception.

“The oral contraceptive is two hormones, we completely eliminate one [estrogen] with the [hormonal] IUD,” DiGiorgio-Haag explains. “And the [hormone in this IUD] is 1/20th the dose of that in the pill and it acts pretty much locally.”

With Trump now officially in the oval office, seeking out long acting birth control should not be delayed.

“We’ve had a huge run on IUDs since the election. Literally since the election our demand has doubled,” DiGiorgio-Haag said. “We're really trying to meet the demand and so far we've been able to do it.”

Students can book an appointment for IUD counseling online through myhealthrecord.ucsf.edu. If you don’t have UC SHIP you can call your local Planned Parenthood health center to find out about getting an IUD placed by providers there.

“Know your rights and be aware of the women who came before you who fought for those rights,” DiGiorgio-Haag advised. “Even though our students have grown up during a time where they have options it’s important to remember that not very long ago women didn't have many options, and that we could return to that.”