IUDs and Other Reversible Long-Acting Contraceptives Are Extremely Effective

Belle, yes, I would think something could be done about the pain, if the doctor cared. Big if, unfortunately. I didn’t know what to expect and I wonder now whether the doctor didn’t just plain disapprove of a young unmarried woman wanting birth control (this was in the early 1970s.)

With any painful procedure it is so important to be well-prepared, to know whether and how much something will hurt, and for how long. All it takes is some conversation beforehand. Oh, and some compassion. I had the impression the doctor, if he didn’t actually hurt me deliberately, wasn’t sorry to have done so.

Ack — second link failure in my posts today. The study comparing US and European attitudes and practices is here:
http://www.guttmacher.org/pubs/gpr/10/4/gpr100419.html

Just a stray thought about ease of IUD insertion – it has been stated here (by Belle) and in one of the links that Peter Erwin posted, that insertion is generally easier, less like to fail (in the sense that it stays up there) and less painful after a woman has “given birth”. What does “given birth” mean here? Literally, producing a child, or pushing a child through one’s vaginal canal?

I ask because of the rising number of caesarians – up to astonishing proportions in some places, particularly the US. I imagine that most caesarians occur after a period of labour, which will have included dilation of the cervix, but perhaps not all the way, as mine did. And what about all the, possibly apocryphal, stories of women scheduling their birth by caesarian and thus not experiencing labour at all?

Will this affect the efficacy of IUDs?

Worth noting, when the cost barrier was removed, the percentage of women choosing long-acting contraceptives went way up, to 75%.

This suggests that if you are fortunate enough to live in a country that is not effectively ruled on such issues by religious fanatics, subsidizing these methods would be an excellent investment, from a public health perspective.

I had an IUD inserted while in my early forties, and it was painful at that age too. It is normally recommended for women who already have children, and this may be because the insertion will go more easily with a woman who have given birth.
Getting it out was even more fun — not possible in the Gyn’s office, a day trip to the hospital, full anesthesia. However, those five years were contraceptive bliss.

You asked how IUD use fares in countries with better health care — I am in Austria, where health care and coverage is indeed very good, but contraception is not covered here. It might be if needed for reasons other than contraception alone, but I don’t know that. (One thing it’s definitely not is a political argument. I assume that with so many other costs covered, and with lots of govt support and child care leave for both parents, people let this one slide.) My IUD cost 400 Euros in 2005. The hospital visit was free, being a necessary procedure.

“Getting it out was even more fun — not possible in the Gyn’s office, a day trip to the hospital, full anesthesia. However, those five years were contraceptive bliss.”

Isn’t that one of the main reasons they’re not used more often? Given difficulties of removal, unless you’ve a fixed long term plan not to get pregnant then methods you can more easily stop using might be more appropriate.

Just for a datapoint, we’d talked about getting me snipped after we had #2, but our beloved doctor convinced my wife that an IUD was a better bet – reversible, no (likely) side effects, no surgery, and, once she reaches menopause (probably after her 2nd IUD), we’re all done with worrying about it. The report was one sharp, pretty intense moment of pain, but pretty quickly past (and nothing on the scale of childbirth).

AFAIK no one ever even mentioned an IUD to her before that time, presumably for all the reasons mentioned above. It does seem that, if the insertion in birth-free cervices can be handled (perhaps with local anesthetic?), it would be a vastly better method for most women.

“Doctors often fail to give sufficient consideration to a woman’s pain in a situation like this, so I’d like them to err on the side of caution even though I haven’t regarded it as terrible pain. Surely they could stick your cervix full of novocaine and hand you painkillers?”

Being the ignorant middle aged male I am I had to go look this up. The NHS website says the following:

“The fitting process can be uncomfortable and sometimes painful, especially if you have not had children and your cervix is not stretched. You may experience cramps afterwards.

You can ask for a local anaesthetic or painkillers, such as ibuprofen, before having the IUD fitted. Discuss this with your GP or clinician beforehand. An anaesthetic injection itself can be painful, so many women have the procedure without one.

You may get period-like pain and bleeding for a few days after having an IUD fitted. This is normal. Painkillers before and after the procedure can ease this.”

So, umm, hurrah for the NHS basically.

Although even with free provision (and insertion etc) it’s still only 6% of all contraceptive users apparently.

Belle, I was thinking also of this from a link by Peter, which I appreciate you won’t necessarily have read:

the scientific consensus that the IUD is safe holds even for single women and women who have never given birth (presuming they do not have an active STI at or near the time of insertion), which is a significant change from a decade or two ago. Perhaps the most salient problem is that fitting an IUD can be somewhat more difficult in women who have never given birth. Among such women, the device is more likely to be expelled from the uterus, which can lead to method failure, if undetected.

I really think the phrase “given birth” is extremely ambiguous in this context.

Worstall, whether oblivious or consciously callous on issues of women’s power, probably shouldn’t be very welcome in this discussion given the way that he’s recently used women’s welfare as a wall to piss against in service to his corporate masters.

This is a pretty good point. It’s not for all women, but IUD’s are probably a better bet for a much larger number than those that currently use them. And is it actually more expensive over the long run than the pill?

I actually have a question that I am wondering if anyone can answer: what does it mean for a birth control method to be 99% effective? Is 1% the rate of pregnancies in a sample population after a fixed amount of time? Is it a fixed number of sex acts? Is it referred to the expected pregnancy rate of the sample population if they weren’t using birth control? This stat has always terrified me because 99% effective is not good enough is that refers to per sex act and I plan on having sex on the order of 1000 times in my life. Ten unplanned pregnancies with my partner or partners is not really acceptable.

@mpowell:

I often see that percentage described as referring to the chance that a woman using that method has of getting pregnant over the course of a year. however, i always found that a puzzling way of putting it, because surely it depends on how often the woman is having sex. Maybe they have some ideal ‘average’ sample population in mind.

If you’re uninsured, the IUD is still cheaper than buying birth control pills over 5-10 years. If you’re insured, it depends on your plan I suppose, but I suspect in most cases that the insured cost of the IUD is cheaper than paying for pill refills. Suppose you have a copay of $10 a month for pill refills. Over five years, this is $600, which is already most of the cost of an IUD. In my case, the IUD and the insertion procedure was covered 100%, so it was clearly the cheaper option.

Meanwhile the women who need them the most—young women still in their teens, who have never been mothers, and who lack the money for the upfront costs—get methods we now know for certain to be vastly less effective. There is really no excuse for this.< /i>

Effectiveness is a mushy concept, although researchers keep trying to enlarge diversify their samples to make it better. It means that if 100 women or their partners use X method, X percentage will get pregnant. The X percent is the failure rate. Your mileage may vary, if, say, you never forget your pill or if you always make sure your partner has his condom on well before actual intercourse, etc.

mpowell – I am pretty sure that contraception effectiveness statistics are always based on the number of pregnancies that come over the course of one year of use. So out of 100 women who used a 99% effective method for a full year, only one would become pregnant.

Remembering italic tags is tough enough – remembering to take the Pill can’t be any easier.

Or lone [/em] tag?

“Reviewing the thread, I hadn’t read the article linked in 28, and holy fuck! That is some bullshit right there. ”

I was hoping someone would tell me where the logic goes wrong.

The set up is: The European Union has declared that the hormones from the pill get into the water at the sewage works (this is true). Said hormones if released into the general fresh water system cause intersex problems with fish. (Arguable, not least on the grounds that agricultural run off is a much greater source of the problem)

The running cost of the necessary upgrade to the sewage systems, for England and Wales alone, is put at £3 billion a year. That’s roughly, £1,000 per pill user per year. Note that this is purely the sewage works, this is the cost of removing that additional pollution from the pill, nothing at all to do with cleaning up agricultural run off.

The question is, who should pay this cost?

We do normally say that polluters should pay. I certainly support a carbon tax for this reason. I support taxes and fines on agricultural run off, think BP should pay for having polluted the Gulf.

I’m hoping that someone can tell me why, in this particular case, we should not hold to the polluter pays principle?

I know what my own answer is: the benefits of regulating fertility men that the fish get it and no, the fish are not worth the £3billion a year clean up cost.

But starting from the EU’s point, that the clean up must happen, who is it that should carry those costs?

Sorry — hit the wrong button.
Anyway, either you persuade someone that your facts and analysis are correct or you can persuade someone that he’s a sexist jerk, but you can’t do both. I opted to try to do the first.

As far as the IUD goes, as I understand it, after the Dalkon Shield scare/deaths/corporate malfeasance, US OB-GYNs simply wouldn’t give a woman an IUD unless she signed a ream of papers promising never to sue no matter what. Now — and judging by this thread — people are rediscovering the IUD. Despite my horrendous experience with the IUD, I think it’s a great option for a lot of women, so I’m glad they are getting the choice.

“is there any real proof that 1) more are doing it and 2) that it is caused by human hormones in the water? I mean, did people study fish gender 50 years ago and have a good baseline? Do we really know that human hormones affect fish? Is fish gender-shifting caused by hormones? And do human hormones really affect fish hormones? Sounds, well, fishy to me.”

All of those are important. But we’ve gone past that stage to where the EU is now proposing that it must be cleaned up. So that part of the science, at least as far as the legislative system is concerned, is over (such environmental matters are an EU competence, not national governments).

“Or charge the companies that make them for not taking the side effect of them into consideration?”

That is suggested by one in the original article. But given that the companies charge the NHS something like £50 a year per user and the costs are £1,000 per year per user that doesn’t seem like a great goer. And if the companies are charged those costs, as I do say, the cost of the pill will go up which in a health care system free at the point of use means the taxpayer paying for it. That is a possible solution.

Yet when we talk about a carbon tax (for example) we do say that it is the person driving the car who should pay the costs of the emissions. So why is this different?

Belle @20: The IUD can become embedded, as mine had. My gyn did give extraction a try and saw that it wasn’t going to happen that way. Regarding having it done during one’s period, mine lessened to the point of stopping completely for those five years, so that wasn’t an option.
So the cost of the IUD (€400) was offset nicely by the fact that I no longer had to buy tampons at all.
You are right, the experience really varies from woman to woman. If I had to do it over again, I’d go for the under-the-skin implant.

“You claim to support a vast, bristling array of carefully calibrated Pigouvian taxes. I am…skeptical.”

I’m afraid I don’t know how to do those html linky things.

Arguing for a carbon tax in Forbes:

http://www.forbes.com/sites/timworstall/2012/04/08/james-hansen-both-right-and-wrong-about-global-warming/

http://www.forbes.com/sites/timworstall/2012/03/20/the-simple-solution-to-climate-change-hint-it-isnt-world-government/

In the Daily Telegraph:

http://blogs.telegraph.co.uk/finance/timworstall/100016929/why-the-answer-is-a-carbon-tax/

http://blogs.telegraph.co.uk/finance/timworstall/100017600/yes-climate-change-is-a-problem-and-yes-we-do-have-to-do-something-but-in-britain-weve-done-it-already/

So, yes, I am a supporter of carefully calibrated Pigouvian taxes, you’re right.

“but I still don’t get why the science part is over.” ….it is in political terms here in the EU. Because that political decision has already been taken, that those sewage works are going to be cleaned up. The only question left is who should pay?

“A better one is GE and PCBs in the Hudson River. GE dumped millions of tons of them LEGALLY.”

An example I use in the original post.

“By that paradigm, the pharma companies would be forced to pay (and take a cut in their profits) instead of the women and men users, i.e., the boat companies.”

No, the boat companies were the mechanism by which GE deliberately dumped. That’s not quite the case with the pill.

“the pharma companies would be forced to pay (and take a cut in their profits)”

But as I also note, the ongoing costs of this water clean up are £1,000 a year per person. The revenues a year per person are around £50. So that doesn’t really work either. For as soon as you say pharma has to pay those clean up costs then the pill obviously costs £1,050 a year in future.

That’s roughly, £1,000 per pill user per year. Note that this is purely the sewage works, this is the cost of removing that additional pollution from the pill, nothing at all to do with cleaning up agricultural run off.

The question is, who should pay this cost?

The sewage system is (properly) a public utility; it is there to ensure public health and (consequently) happiness. The cost for its maintenance is borne by the population as a whole. The Pill is, likewise, a public good, and is delivered for free by the NHS for good reasons — population control, health, and (again) human happiness (and I would contend that there are women who don’t really like their partners using condoms). To charge its users for upgrades to the (criminally neglected) maintenance of the sewage system by private companies is unreasonable, just as it would be to charge specific people with diseases who shit into it for the chlorine required to purify the water.

And, incidentally, the alternative to the IUD/Pill/condom difficulty is for the men(z) to stop their whinging and get snipped; it simply is not that horrible an experience, ferchrissakes. If you want kids later, you can get it reversed (which decision means y0u must really want those kids).

But as I also note, the ongoing costs of this water clean up are £1,000 a year per person. The revenues a year per person are around £50. So that doesn’t really work either. For as soon as you say pharma has to pay those clean up costs then the pill obviously costs £1,050 a year in future.

This doesn’t make any sense to me unless there is a special British pill company working only in the UK. The pills cost very little to make — far less than 50 pounds a year — and even if you take into consideration the research etc the companies that make them have raked in gazillions in profits from those pills over the years. They don’t need to “offset” the cost to break even.

And yet once again you fail to address the question of why women should pay. To encourage you, I also suggest that the vast VAST majority of contraceptive users are married women, which means the “choice” is a joint choice, one way or another.

51 and 53 both argue that defining the woman who takes the pill as the polluter is underinclusive, and the proper definition of ‘polluter’ in this case would include everyone who benefits from the pill-taking, including male sex partners of women who use the pill, and possibly society at large to the extent that it values and encourages contraceptive use. I’m not sure why you haven’t addressed that argument.

Also, are you sure about the numbers? The expense you give sounds implausibly high.

Anyone have any more details on the actual size of a modern, non-hormonal IUD? I also concerned abut feeling the IUD or damaging the uterus wall (or some such mishap, e.g. Marcellina commented on her IUD becoming embedded?) during sex. I find pressure on the lower abdomen and uterus really pleasurable, but I worry if that that could be dangerous if you have and IUD?

Thanks for feedback. I did know of the IUD’s fantastic success rate. I have seriously considered it, but those questions remain unanswered so I have not taken the plunge.

We typically regulate the power company that pollutes

But that’s usually with a regulation that covers all similar polluters, not just the power company. Presumably if you were just interested in making a big factory that spewed glop that nobody uses you’d be covered by the same regs.

A small minority of women need to take the pill to regulate problematic hormones, and the rest take it so that they can have condom-free sex with some number of men. I think I can speak for most women when I say that I don’t much care if my partner is wearing a condom, from the point of view of my own pleasure. Very occasionally some problem occurs which can be solved with lube, but on the whole, that’s on y’all. We don’t care. So, gay men and lesbians get to opt out, and straight men who don’t want to wear a raincoat in the shower pay 1500 pounds a year.

I like your solution, Belle. The fact that Worstall’s article fails completely to mention that men are getting utility from the Pill, not just women, is a triumph of tunnel vision and sheer selfishness.

Repeating the same action in the same setting makes it paradoxically impossible to figure out whether you are remembering last night or the night before.

This, god, this exactly. Among a bucketload of other meds there’s one that’s been cranked up, dosage-wise, as high as it can go, and if I don’t remember to take it at night, my body’s literally physiologically incapable of falling asleep. (For at least 96 hours or so, at least, accidentally experimentally verified. Vacation mishap. I might never go camping again.) But if I take two doses in one night, I allegedly stand a good chance of dying overnight from the overdose. (More realistically, I probably exhibit overdose signs which my life partner picks up on and I get driven to the E.R. and have vicious things done to me before I can fall asleep, which is a scarier prospect, or at least more conducive to long nightmares about having taken the meds twice. At least death ends the dream. Dreamnt doctors can go about their business forever.)

After a couple dozen stupid 3am frettings about whether I took the things or not, finally invested in a week-long pill box with enough compartments for everything. Works ok, except for when I forget to refill it or for when I’m traveling elsewhere and brought the travel bag with the three-day pack whose first-day doses I might have forgotten to refill when I got back last time. And still half the time I’m lying awake at 2am wondering if I forgot. Setting a nightly alarm on my cell phone has only served to inform me just how frequently I forget my cell phone in my car.

Anyway, FFS, you’d think it wouldn’t be so hard to remember something so vitally important to one’s own survival/restfulness. It’s a pretty good example of when an a priori commonsense notion of “personal responsibility” fails to provide a socially responsible means for distributing just outcomes. Sure, I’m “personally responsible” for my own self-care, blah blah. But on any meaningful larger scale, fuck if I’m ever going to hold someone else to account for forgetting a pill, and where and when less memory-intense alternatives exist, fund ’em. Some reasons to be lying awake at night worrying are literally unavoidable, but the less there are, the better.

“Apologies, but what economic world are you living in? If the future cost of selling the pill to women in England includes the £1,000 cost of cleaning up the water then of course, the future price of the pill in England will be above £1,000.”

Well, I live in Russia, which is in fact like no other economic world on the planet. And it’s true that I’m not in business. But still, I fail to understand your scare logic of a one-time lump payment. Companies don’t pass on costs this way. They divide it up and spread it out over the next 20 years, raising the price of the product by .0006 cents or something.

And you keep singing the song about “the polluter” (commonly known as “women”) and not responding to the criticism of this.

Sarah, there are photos of them lying on hands if you google. While I ultimately had a very bad outcome with my IUD, I never felt it, my partners could sometimes feel the little strings that hang out but didn’t find them unpleasant, and there was no discomfort during sex. Another good thing is that if you want to get pregnant, fertility resumes immediately after it’s taken out (it takes longer when you go off the pill). In Russia it was once just about the only available form of contraception and usage peaked at about 35 percent. Now it’s down to about 21 percent (other methods are now available). This is typical for the entire CIS and most of Eastern Europe. In other words, outside the US it’s really very widespread.

Another issue with IUDs is the medical gatekeepers – the doctors. It’s not reasonable to expect every childbearing-age woman to be totally up to date with all contraceptive possibilities, but it is in the job description of GPs, for example, to be at least vaguely up to date with this stuff and advise women accordingly.

So maybe the question isn’t just why aren’t women using IUDs, it’s also why/whether doctors aren’t advising them to.