What's the Deal with IUDs?
By Dannielle Stewart
An intrauterine device, or IUD, is a small, T-shaped device that sits within the uterus. Two main options currently exist - the hormonal IUD (most commonly Mirena), and a non-hormonal IUD. For the purposes of this blog we are going to focus on the former, more specifically the Mirena IUD - which contains the progestin hormone levonorgestrel. Isn't that a mouthful?
Dr Susan Evans and Deborah Bush, in their book Endometriosis and Pelvic Pain, explain the benefits of women with endometriosis using medications containing progestogen (similar to the hormone progesterone made by the ovary in the second half of the menstrual cycle) - these medications make endometriosis lesions less active and often as a result less painful. They also have the benefit of delaying periods and stopping ovulation. Oral medications often have a systemic effect, however, due to how they are broken down by the body in their journey through the digestive tract - resulting in side effects that some women find unpleasant. The Mirena offers the potential benefit of avoiding these symptoms as it has a local effect, with only a small amount of progestin reaching the rest of the body. Mirena is a contraceptive, but it also has the effect of lightening (or in some cases completely stopping) periods, and it may also discourage new endometriosis lesions from forming. Doesn't that sound great?
Like any treatment, not everyone is enamored with their Mirena IUD, or even enamored with the idea of it. The insertion is enough to put some people off - this is done by your doctor either in office or under a sedation/anaesthetic. Some providers will suggest anaesthetic for women who have never had a vaginal birth - talk with your doctor about which option is best for you. After placement, there is a chance that you may have irregular bleeding until the device settles, which can become annoying. Additionally, while the IUD is finding its place within your uterus, you may have some cramping pain that varies in severity from person to person. Usually an ultrasound is done to confirm the IUD is sitting where it should be, and you can check your strings regularly to make sure there has been no migration. Ensure you find a health professional who is experienced with Mirena to talk you through the process and explain risks and side effects to you. You are in control of your health!
All of this information is all well and good, but a question I get asked often is - but what is it actually like to have a Mirena? Does it actually live up to the hype for the women living with one?
I can vaguely remember sitting in the world's most uncomfortable sex ed class in year eight, that was in serious need of some actual menstrual education and not just a forum on how not to get pregnant, while the school nurse passed around various contraceptives including this strange little device she called an IUD. Everyone's face turned the same shade of pale when she told us that this little friend went through our cervix and sat in the uterus - um, how about no Karen? Six years later, my GP broached the subject with me after several years of coming to her with period pain and heavy bleeding, and barely any relief from the three different pills I had tried. She suggested the Mirena alongside a referral to a gynaecologist to investigate possible endometriosis, some guy at the Wesley named Graham who, naturally, I had never heard of. Ah the naivety of youth. i took her referral, begrudgingly, thinking what a waste of time it was to look for something I obviously didn't have. I quickly avoided the subject of an IUD, telling her that I would think about it. By eighteen I had read enough Cleos (remember Cleo girls? RIP) to know how the hell a Mirena ended up in your uterus and I couldn't say I was a keen bean. When I went to see my new gynaecologist I saw the same little device that the nurse had showed us at 13, sitting on his desk...in a pen cup. It was so casual, like it was so frequently used that it warranted a place beside his mountain of mismatched paperclips and highlighters like nobody's business. I had clearly entered a very strange world.
Fast forward two years and I sat in front of the same desk, looking at the little Mirenas in the pen cup, smiling a little, because there was now one sitting firmly in my uterus. I had my first Mirena inserted during my first laparoscopy in 2015 where endometriosis was found and excised. I'm not gonna lie, at first I hated my Mirena with a fiery passion. It hurt, all the time, and occasionally it was so horrific I could barely walk because I felt like there was a knife sitting between my legs. This was all in the few weeks after surgery, and so my body was both healing and adjusting, but I didn't really understand this at that point; all I could focus on was pain. So naturally I went back to my gynaecologist to ask what the hell he had done to me. He was sympathetic, and rather apologetic, for the pain I was in, but he urged me to try and stick with it because once it settled I would be fine and the benefits it gave me in treating my endometriosis would be innumerate. So for three months I did just that - heat packs and painkillers, and some amitriptyline from my pain specialist, firmly in hand. I really didn't believe him when he said it would get better. An ultrasound confirmed it was sitting in the right place, 10mm from the uterine fundus in case you were wondering, but it still hurt. I went to my ultrasound thinking that I had some terrible post op complication or that a cyst had decided to take up residence in my ovary. I sat through twenty minutes of the world's most uncomfortable scan, the doctor in question wearing cowboy boots to make things just a little weirder, in a state of pure anxiety. At the end, when cowboy doctor told me happily that everything was fine, I burst into tears, thinking that I was crazy...again. He patted me on the shoulder and told me not to worry, my specialist would sort it out - they were colleagues from way back and he had the utmost faith that I was in good hands. As I was preparing to call for another appointment to complain about the complete lack of improvement, something great happened - the pain stopped. Almost the first day of month four the pain went away, and it didn't come back. It was amazing. I had only occasional flare ups and was mostly pain free for two years. I also didn't get any bleeding, a miracle for someone who has never been able to use a light pad.
My symptoms began to return at the end of 2017, and became unbearable around June 2018. I had a second laparoscopy in September 2018 where it was found that I had adenomyosis growing out of the wall of my uterus - doesn't that sound lovely? However there was no new endometriosis, my good little Mirena had done its job. To combat the adenomyosis my gynaecologist inserted two during my procedure. After surgery I prepared for the onslaught that occurred the first time, but there was none. I couldn't even tell you for sure that they were actually there until I saw my two new friends on an ultrasound scan in November. They seemed very happy in there together. My gynaecologist explained that the idea behind two was to deliver a higher dose of progestin locally, where it would have its desired effect on both my endometriosis and adenomyosis within the pelvis, without any of the irritating side effects of drugs I had tried in the past like Primolut (hello 5kg on from one slice of pizza). At present I am rather content and very grateful for the service of my Mirenas, they appear to have done an excellent job in my case. At work a few weeks ago someone had to ask me if there was any chance I was pregnant before I attended to a patient in the nuclear medicine department, and I said with satisfaction that I was not - two IUDs baby, none shall pass.
Everyone will experience treatments differently, and it's important to find what works for you. Don't allow yourself to be convinced to try things that you're uncomfortable with. Seek out multiple opinions, find a knowledgeable specialist who considers all the options, and keep in touch with them while you're going through treatments. Keeping my doctor in the loop about how I was coping with my first Mirena was essential, I might not have gotten the chance to reap the benefits if he hadn't encouraged me and supported me through the tough times. Likewise, if you've got a Mirena and it's just not doing it for you, even after sticking it out - speak up! Try something new. Everyone is different and there is no one definitive treatment for endo and adeno, it's about finding what works for you.
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