IUD Birth Control Guide to Side Effects, Insertion, Mirena and Copper Types and Pain

I recently got an IUD before having penetrative-vaginal sex for the first time and had a lot of questions about how the device works. While there are a lot of great resources online, there was no comprehensive guide to help quell my anxiety—so I decide to compile one of my own. Here, doctors and experts explain what to expect when you’re jumping into the unknown and getting an IUD for the first time.

To start off: it is safe to get an IUD, which is over 99 percent effective at preventing pregnancy, at any level of sexual experience. “IUDs are a safe and highly effective birth control option for most people of all ages—from young people who have not had children to people in their 50s who haven’t yet hit menopause,” Dr. Gillian Dean, Senior Director of Medical Services at Planned Parenthood Federation of America, told ELLE.com in a statement. “It’s safe to get an IUD even if you’ve never had penetrative vaginal sex. Your sexual history shouldn’t impact the method of birth control you decide to use.”

So what are the difference between all the IUDs on the market and how do they work to prevent pregnancy?

Dr. Katharine O’Connell White, Director, Fellowship in Family Planning, Boston University/Boston Medical Center: So there are five different IUDs on the market in the U.S. Four of them are hormonal—meaning they contain the hormone progestin—and one of them is non-hormonal, meaning it uses copper wire as a birth control method. All five IUDs work locally, meaning the area of greatest impact on preventing pregnancy comes from its effects on the lining of your uterus. Hormonal IUDs transfer a small amount of progestin into your blood stream, but overall, especially compared to other forms of hormonal birth control methods, there’s much lower levels of hormone in your blood. Most of it stays in your uterus.

The hormonal IUDs that are out all have the same hormone, progestin, but have different levels of progestin in it. Consequently, they last for different numbers of years and have different effects on your period. The lowest dosed hormonal IUD is Skyla, and it’s common to give women lighter but fairly regular periods, much like the birth control pill. The highest doses of progestin IUDs, which are the Mirena and the Liletta, very commonly cause women to have incredibly light periods, often only spotting or no periods at all. [Editor’s note: The fourth hormonal IUD is Kyleena, which lasts for five years. The fifth IUD is the non-hormonal copper one, ParaGard.]

Some birth controls pills are estrogen-based while others are progestin-based. What are the differences between what those two hormones can do to your body?

Dr. White: Both estrogen and progestin can prevent pregnancy, although they work in slightly different ways. The biggest difference between the two is that estrogen-containing methods tend to have more predicable bleeding patterns—meaning less spotting and more regular, lighter periods. The methods with progestin only are known for causing more breakthrough bleeding and irregularity. So if you don’t have any health conditions that preclude you from getting a method with estrogen in it, those methods can have better effects on your period. But there are some women who aren’t able to take estrogen because they have a chronic medical condition that makes it not safe, including high blood pressure or migraine headaches with aura.

I’ve read the copper IUD works by making your uterus toxic to sperm, is that true?

It’s true, but most women hate to think about anything toxic at all inside their body. I tend to describe it more as an inflammation in the lining of the uterus that happens to be toxic to sperm, that’s true, but it’s more of an inflammation just on the inside of the uterus that makes it very inhospitable to sperm or pregnancy.

Could you explain how the insertion process works, especially in the case of someone who hasn’t had penetrative sex and/or other forms before?

Dr. White: The first thing that your doctor does is to place a speculum inside your vagina, and this is an instrument that just holds the walls of your vagina apart so she can see your cervix. So if you’ve never had penetrative intercourse before, this exam can be a bit uncomfortable.

Then once your doctor has cleaned off your cervix, they’ll often put a steadying instrument on it to hold it still, and sometimes putting that instrument on can cause a mild cramp. I describe the IUD process as a series of three cramps. A cramp, a cramp, and then a big cramp, and then it’s done. So it’s not like it’s five minutes of constant, excruciating pain, just these little spikes of pain.

Next the doctor will often see how deep your uterus is, they’ll place an incredibly skinny instrument called a “sound” inside, which shows the depth of your uterus, so she knows exactly where to deliver the IUD inside. And then the last step is the IUD insertion itself. The IUD tucks into what looks like a very skinny soda straw, and that passes through the opening of your cervix and the IUD pops out the other end. So the doctor doesn’t need to make any incisions or cuts into your body at all. She’s able to use the natural opening of your cervix that leads to the uterus, where the period blood comes out of, to place the IUD.

For someone who isn’t familiar with anatomy, does that go near the hymen area?

Dr. White: The speculum does go into the vagina, and the hymen does cover the entrance into the vagina. It is very uncommon for women to get to their teenage years without the hymen naturally opening. I hate to use the word ‘break’ because it sounds really traumatic, but usually with exercise and natural movement and natural play, it will open even before intercourse. For some women though it is true that it doesn’t, and if the hymen is still completely in tact, it does make getting an IUD more complicated.”

But a girl whose hymen is in tact could still get an IUD if she wanted one?

Dr. White: Yes, absolutely. It will just involve a process to actually cut through the hymen. Which means it might not be able to happen in the office and might need a procedure in a procedure unit.

Why are some doctors more hesitant to prescribe one to someone who hasn’t had penetrative sex?

Dr. White: It’s more the speculum exam itself can be really uncomfortable if you haven’t had penetrative sex [than any issues relating to hymen]. A lot of it is the size of the speculum the doctor uses, how slowly they go, and how relaxed you can make the muscles in your pelvis. It doesn’t require yoga or any specialized techniques but when you get nervous, you get tense. That’s a really normal response that you need to try to work against to relax enough to allow the speculum to go in.

Alison Macklin, Vice President of Education and Innovation at Planned Parenthood of the Rocky Mountains: There’s [also] certain hospitals and other health care providers who will not prescribe or insert an IUD or have limited IUD insertions—organizations that are typically religiously-affiliated, so per their guidelines they won’t do certain types of reproductive health care. For an IUD, they may only be able to prescribe certain IUDs, like a Mirena and not offer the copper IUD, because the Mirena has other benefits, [such as reducing] heavy periods or cramping. By law, they should be able to give you all of the options that are available to you in your state and in your location, but that’s not always the case. I do know that there are a lot of [more limited] healthcare providers will then refer out to an organization like Planned Parenthood, for example, who will provide all of the options available.

Being sexually active is not a requirement to get an IUD so that’s kind of an old school mentality surrounding IUDs. There are definitely providers who will dissuade, and a lot of that has to do with a provider’s level of comfort with the procedure itself. So it’s important for an individual to know that regardless of their sexual activity or what kind of sex they’re currently engaging in, you have a right to have an IUD inserted. If your provider is putting up barriers to that, it’s worth asking, “Is this the right provider that aligns with the needs of my health?”

How should you cope with nervousness before the procedure?

Dr. White: First, having a provider or a nurse practitioner that you really trust and feel comfortable with and always be[ing] honest about what your sexual activity has been like. If you’ve never had penetrative sex, you need to tell the doctors that because they’re going to use a different-sized speculum and go more slowly. The other trick that works for some women is they place the speculum themselves, that way you get to control how fast you put it in. So if you feel like the doctor’s going to quickly then you can ask them to stop and ask for you to place it yourself. [Editor’s note: Dr. White also said you can also always ask for your doctor to use a smaller speculum if the one they’re using feels too painful.]

Is there anything you can ask your doctor to do to make the process less painful?

Dr. Pari Ghodsi, LA-based ob-gyn: The only thing we would typically recommend would be taking Advil prior to the procedure. You could just take a high dose of Advil, so you could take four tablets which would be 800 milligrams of ibuprofen about 30 minutes to an hour before the procedure [to help reduce some of the cramping].

But what about the numbing shot, cervix dilation pill, or spray I’ve heard some doctors use to reduce pain?

Dr. White on the shot and spray: The studies that are out about using local anesthesia, which is what the dentist would use to numb you for a cavity, don’t show a significant difference in pain reduction, which is why it’s not standard practice for all doctors. The reason why I don’t think it works all the time for some women is that a lot of the pain is actually not at the cervix; it’s at the uterus. Because when the instruments touch the top of the uterus, that causes cramping and the local block around your cervix [a paracervical block, the numbing injection some gyns give] doesn’t tend to reach up that high with regards to what it numbs. For some women, para-cervical block is very painful [getting injected].

The [Lidocaine 10%] spray, [another method some doctors use to reduce procedure pain] only works for that steadying instrument on the cervix. And it doesn’t work for any of the rest of the procedure. But every doctor has their own technique and what they’ve seen good results with so I don’t want to disparage anything anyone who has done.

Dr. White on the dilating pill: The evidence against that is really strong, that the pill doesn’t make any difference at all with making the procedure easier. That pill does cause an increased amount of cramping, nausea, and diarrhea so we really don’t tend to use that. And I’m going based on what the published literature shows.

Why does the IUDs cause more cramping in the first couple months after insertion (and for the copper one, beyond)?

Dr. White: There’s an exchange in your uterus [with the IUD insertion], which tends to have predicable responses from your uterus, and the first is spotting. [That] tends to be worse with the hormonal IUDs, to be honest, than the copper ones, but it can happen with the copper as well as your body is sort of acclimating to this new occupant.

But the shoot of the progestin hormone in the hormonal IUDs tends to counteract cramping; in fact, the hormonal IUDs are used for chronic pelvic pain, they’re so effective at reducing pain and cramping in the uterus.

The copper IUD, because of that inflammation that’s caused by how it works, for some women that can lead to very intense or painful periods. It’s related to the inflammatory response, which is how the copper works. It does tend to get better after the first 3-6 months, and women who have a hard time with the cramping can get a prescription for an anti-inflammatory—like ibuprofen or naproxen—from the doctor and start taking the medication even before their period starts. That’s the best trick for women, whether or not you have an IUD, is to pre-treat the pain even before it begins. And that can be really effective with an IUD.

At what point should you be concerned about spotting?

Dr. White: No one has spotting that is too much medically, but I would say heavy bleeding, like if you have a very uncommon response of all the sudden your period is getting very heavy—and I mean lasting for weeks where you’re changing multiple pads or tampons a day—that’s probably a lot, but that’s not common. Spotting is more annoying; it’s medically not unsafe, [but] it can be a real nuisance and [is] a very common side effect. I joke that the starter pack for an IUD should be a box of panty liners and a 12 pack of underwear from Target.

Dr. Ghodsi: After a few months with either of them, if it’s something that’s bothering you, then you should contact your doctor.

What should you expect happening after the first six months?

Dr. Ghodsi: If you have a copper IUD then for sure, no spotting by that point. You might just notice that you have heavier periods than you did before. But you shouldn’t have any bleeding in between your cycles. For people who have the hormonal IUD, unfortunately, sometimes they still have spotting. That’s why I said it’s important, if it’s bothering you—because for some people it doesn’t bother them, they just know “Okay, I spot sometimes”—but typically if you have the hormonal IUD what happens after that adjustment period is you actually go to lighter periods than you’re used to. And some women have no periods at all, but of course there’s always the risk factor of the spotting.

How would you know if the IUD moved or something happened after insertion, especially if you don’t feel anything different a few weeks after insertion?

Dr. White: That’s exactly what you should feel. You shouldn’t feel anything different. We’ve talked about all of the side effects that can possibly happen, but the hope is that everybody feel just normal after it goes in. We used to make women do a string check on themselves after every period, but we stopped that when we realized that it can be really hard to feel your IUD strings, and a lot of women would call their doctor’s office panicking. But if you’re ever concerned about the IUD, you can place one finger inside your vagina up to your cervix to feel the strings, to kind of give you reassurance that the IUD is still in place. If you don’t feel the strings or you’re too uncomfortable to do a check like that then you can always go to your doctor and they can do a quick check for you.

I think a lot of young women, especially those who haven’t been very sexually active, may not know how to check their cervix. Do you have any advice for that?

Dr. White: The vagina is longer than you expect. I always say that, you know, after a glass of wine, lay down in bed with your knees bent and then try to place a finger in as far back as you can. And if you bump up against something that feels like your nose, that’s your cervix. That’s essentially what your cervix will feel like. And then you can feel around in that area. But a lot of women who try don’t go in far enough because it either feels weird or uncomfortable or they just don’t want to do it, so it can make it difficult to find your own strings. But if you have a partner, you could also have your partner try to feel them.

For young women who maybe haven’t had any sexual experience, does it hurt more to get an IUD or lose your virginity?

Dr. White: I think it depends on the woman. The thing about sex when you lose your virginity is that you don’t have to feel pain the first time you have intercourse. There’s this mental picture that it’s always going to hurt. And it can be uncomfortable, but it shouldn’t hurt. Because you should be getting enough foreplay—and even lubrication—before you let someone inside you for the first time. Your first is not the time for a quickie; this is the kind of time where you want a lot of playing around before actually reaching intercourse.

And sex only goes into the vagina, it doesn’t go all the way up into the uterus, which is why the IUD can be painful for people whether or not they’ve lost their virginity because you’re going in a place where you don’t usually go. But having an IUD placed lasts a lot less time than sex. Most people do have sex for more than about three minutes. Maybe not if their partner is a teenage boy, but normally it lasts a little bit longer than that.

If you become sexually active for the first time during the first 3-6 months after insertion, what is normal to expect with bleeding?

Dr. White: Most of the time sex alone does not cause bleeding, even if it’s dry. It hurts, but it won’t cause bleeding. It doesn’t cause you to cut yourself. Sometimes sex can cause bleeding if you’re about to have your period—I joke that it can shake the blood loose, so most of the time the blood is coming from the uterus. I have heard women talk about post-sex spotting when they have an IUD, especially in the first few months. And I see it as that sort of ‘shaking loose’ of what would have come anyway. So it’s not atypical in the first few months. But if it continues after the first few months then it’s probably worth talking to your doctor about because post-sex bleeding can also be a sign of infection, not related to the IUD but related to your vagina and your cervix.

Macklin: Anytime something is inserted into the vagina for the first time, whether that’s a sex toy or a penis or even fingers, there’s a possibility for some blood. The blood shouldn’t be heavy; it’s going to be a bright, red-colored blood. And typically what’s coming out of the uterus as a result of the IUD insertion is going to be a little bit darker and a little bit more like period blood [because it has a longer way to travel]. There shouldn’t be a lot of bleeding with sex, with penetrative sex. And if it is uncomfortable beyond the first time that something gets inserted into the vagina, then that’s something you want to talk to your doctor about because sex should always be consensual and sex should always be pleasurable.

What kind of side effects can be expected if you’re going off of birth control pills to get an IUD?

Dr. White: The birth control pill, which might have given you nice, regular periods that are very predictable with not a lot of cramping, you may be trading now for irregular bleeding and the increased cramping that we talked about. The birth control pill also has other benefits on our skin with regards to helping decrease acne. So your skin may actually change, not because the IUD caused your skin to breakout but because you’ve lost the protective effect of the birth control. I think those are the three major things: bleeding, cramping, and acne.

Dr. Ghodsi: Anytime you’re switching from one birth control to the next, you could have some sort of adjustment period. Again, that could be over a couple of months period, but after about 2-3 months, if it’s something that’s irregular and bothering you then you should call your doctor.

Can some of the hormonal IUDs cause cystic acne?

Dr. White: For women who are incredibly hormonally sensitive, it can make it worse. Most of the situations that I’ve seen where women have bad acne on the IUD, they’re coming off the birth control pill. So it’s really tricky to know what their skin would have looked like off the pill because they’ve immediately substituted an IUD. But it is true that if you have a problem with acne, and the pill’s been controlling it, then it might be worse when you go off. And some people use a copper IUD and the pill. They use the copper IUD as the better birth control, and they use the pill for their skin. And there’s nothing wrong with that.

But you wouldn’t use the birth control pill with one of the hormonal IUDs?

Dr. White: It’s really controversial with that because there’s no data. So that’s one of the things I would say you can talk to your doctor about.

If something is wrong with the IUD after insertion, how would you know?

Dr. White: So it’s standard to come back six weeks after it’s inserted, but that check is mostly to make sure of two things: one, that the IUD wasn’t accidentally perforating into your abdomen, and secondly, just to check in make sure you’re happy with it. After that though you tend to only have the IUD checked once a year at the time of your checkup. That’s because once we know the IUD is in your uterus; the only place it’s going to go if it’s going to move is out of your body, meaning through your cervix, into your vagina, and out of you.

First of all, you tend to notice that. It isn’t going to happen quietly. You tend to have, all of the sudden, a lot more cramping, a lot more bleeding, or both. So I always counsel my patients that if all of the sudden your bleeding really changes, don’t just suck it up and be tough, come into me. Because there might be signs the IUD is starting to expel. And secondly you might feel it actually coming into your vagina. If you use tampons you might notice something in your vagina. Your boyfriend if you’re having any kind of penetrative sex whether with a finger or penis might feel something. But you tend to have symptoms. It doesn’t tend to be silent, so if you don’t feel like you normally do, it’s best to be checked out by a doctor just in case.

Is there a difference between the cramping you’d feel in those first three months and the cramping involved with an expelled IUD?

Dr. White: I hesitate to put a lot of words on it because every woman describes her cramps very differently That’s why I just sort of say “worse.” So let’s say your cramps have been sort of like your regular period cramps, but now you’re getting one that’s like “the worst period cramp ever.” That might be a sign to call your doctor.”

Can you have cramping during those first 3-6 months that’s not related to your period?

Dr. White: Yes, you can with the copper IUD. It’s much less common with the hormonal one.