Birth Control: is it in you?

At a recent meeting of the Sexual Health Network of Ontario, health care providers came together to examine and extol the virtues of the Intra Uterine Device (IUD).  The IUD is a plastic device wrapped with copper that is inserted into the uterus.  I have always been a proponent of this method of birth control, especially for women looking for an alternative to hormonal methods.

The IUD had to overcome a terrible reputation from the bad old days of the Dalkon Shield.

I remember the Shield well.  I was a very young married woman when I had one inserted.  I complained to my gynecologist that I had ongoing pain on one side which lasted several days a month.  It felt like there was a plumb line attached to my ovary.  It wasn’t until returning from overseas that I had it taken out – or rather dug out – because that’s what it felt like.  The little claws were embedded in my uterus.

It was a deadly device.  The Dalkon Shield’s strings acted like a wick, drawing bacteria into the uterus, causing infections – and in nearly two dozen cases in the US – death.  The deaths in developing countries continued as “developed” countries offloaded their products abroad.

However, in the early 1980s, long after the discredited Shield had tarnished the reputation of all IUDs, new research indicated that the newer copper IUDs were both safe and effective and, in particular, did not cause ectopic pregnancies.  It also became clear that they functioned as a true contraceptive by creating an unfriendly environment in the uterus which repelled sperm.  This opened the door to women who had worried it was an abortifacient.

Copper IUDs

Copper IUDs are 99 – 99.8% effective.  In those rare cases where pregnancy occurs with an IUD in place, the pregnancy can continue as long as it is not ectopic.  Statistically, pregnancy outside the uterus is more likely with an IUD; but given its high effectiveness rate, the risk is very low.  A copper IUD can usually be removed if there is a pregnancy; but that would increase the risk of miscarriage.

A woman with average or no cramps and average bleeding is a good candidate.  She can expect a 10 -20% increase in cramping and bleeding with a copper IUD.  Counselling has changed over the years with regard to multiple partners.  Health care providers were concerned about untreated Sexually Transmitted Infections (STIs) causing Pelvic Inflammatory Disease (PID) with an IUD in place.  However, now STIs can be treated without removing the IUD; although, clearly, a woman with more than one partner is encouraged to use condoms.

Adolescents and women who have not been pregnant can also use the IUD.

Copper IUDs can also be used as emergency contraception up to seven days after unprotected intercourse.

There were a number of questions asked during the presentation; for example, the reason why some IUDs can stay inside the uterus longer than others.  Copper IUDs vary in the number of years they can stay in place: 3, 5 or 10 years.  The main difference between one copper IUD and another is the quantity of copper used.  Although Nova-T is a five year IUD, one practitioner said that they do not use it beyond 30 months because, after that point, they have found an increased risk of pregnancy.  10 year IUDs are larger and more difficult to insert and may cause more cramping on insertion.

The only contraindications to the use of a copper IUD include allergy to copper or other components of the IUD, pregnancy, endometriosis, an abnormally shaped uterus, very heavy bleeding or cramping; or active Pelvic Inflammatory Disease. There are a few risk factors, like perforation of the uterus with insertion, but perforation is rare and the uterus often repairs itself.

Intra Uterine System (IUS)

This progestin-releasing device can assist women with severely heavy bleeding as well as women with endometriosis .  By three to six months, most women who use Mirena (the first IUS on the market) experience dramatically reduced bleeding.  About one third of women will stop having periods after 12 months.

Because it uses the synthetic progestin levonorgestrel, it causes similar effects to Depo Provera which also uses a synthetic progestin; i.e., changes in the cervical mucus and uterine lining, making it harder for sperm to reach the uterus.  And similar to Depo Provera, there may be side effects, including:

  • bleeding and spotting between periods
  • heavier bleeding during the first few weeks after device insertion
  • headache/migraine
  • nausea
  • bloating
  • breast tenderness or pain
  • weight gain
  • changes in hair growth
  • acne
  • depression
  • changes in mood

As always, it is important that health care providers explain fully what a woman may expect.

I learned about some newer IUS devices aside from the more commonly known Mirena: Jaydess, a smaller, low-dose version, good for three years; and Kyleena, which releases the lowest dose of hormones for the longest amount of time.  Mirena has the highest dose of progestin of the three and is approved for five years, although data indicate it is effective up to seven.

The IUS can cause spotting for two to six months.  During the presentation, I had noticed two Orthodox Jewish women and a Muslim woman in attendance.  I made a comment about my birth control counselling at clinic regarding spotting.  Because there may be religious strictures about having intercourse in the presence of blood, I always made sure that women for whom this was an issue were well informed.

Speaking of blood, there was an interesting discussion around using a menstrual cup with the IUD.  Because of the suction on the vaginal walls with a cup, to avoid expulsion it is best to gently break the suction before removing the cup.  Another precaution would be not to use a menstrual cup for two months after an IUD insertion because the risk of expulsion is highest in those first two months.

The copper IUD is an excellent choice for women who want long-term, safe and effective contraception, but prefer not to use hormones.  Make sure that your health care provider has plenty of experience with insertion.

 

 

 

 

 

Sex after baby – November 28, 2012

After my first baby (18-hour labour plus episiotomy without anesthetic) I thought I would never let anyone near me again—not even myself. The thought of peeing or having a bowel movement was inconceivable. And yet, we continue to pee, shit and have sex. How do we get back to that beautiful place?

Every woman, every delivery and every baby is different, as is a woman’s relationship status at delivery. What follows are some general remarks about sex after baby.

No matter how “easy” or difficult the delivery, every woman has to heal after childbirth. With a Caesarean section, clearly the healing period is longer: it is major surgery. Immediately, the baby’s needs are paramount. Anyone who has heard a newborn cry can attest to that. If there is a partner on the scene, hopefully they get it. You are sore. You are tired. If you are breastfeeding, your vagina (when it heals) tends to be dry. Your libido has been tamped down by all of the above.

You may not feel particularly gorgeous. Some women spend their pregnancies feeling undesirable, others highly sexual. If you are breastfeeding, you may feel closer to other mammals than any human except your baby. You probably feel “touched out” and want to get some of your body integrity back.

That said, if you have a partner and you want them to stay in your life while you go through this incredible adjustment, it means sharing tenderness. Everybody gets some.

Hopefully, you were still engaged in some way with your partner right up to the birth, whether with loving words, sweet kisses, warm embraces or other sexual activity. Some pregnant women prefer fingers or oral sex to other vaginal activity, especially close to the birth. For others, all physical contact may have come to a full stop long before.

For these women, the road back to feeling sexual may take longer. It starts with reminding yourself why you wanted to have a baby with this person in the first place (if, indeed this was a wanted pregnancy). You will need to re-establish some physical contact with your partner as a basis for future sexual intimacy.

When you first start feeling like some kind of lovemaking might be a real possibility, you have to progress very slowly. If you want to give your partner some pleasure, now is a good time to revisit your sexual repertoire. Use your hand, your breasts, your mouth—or whatever else feels good—to make your partner feel good. If the day comes when you want your genitals touched, touch yourself first. See how it feels. Take it slowly. Can you put in a finger without cringing? Is the lube handy?

If you want to let your partner touch you, show them the way you did at the beginning of the relationship and say clearly, “this feels good, this not so much—oooh, that feels wonderful.” And just like having anal sex for the first time, you need to start small if anything is going to enter your vagina.

Some people are okay having sex with the baby in the room (some even have sex with the baby in the bed); but others find it easier to concentrate on their pleasure and their partner without having to worry about the baby waking up. So even though the baby may not be on a fixed schedule, try to find the most likely time to be alone. You may need to make a date and have someone take care of the baby while you and your partner rediscover each other.

If you are fully breastfeeding, you may not ovulate for several months. If you are not breastfeeding, you can get pregnant in six to seven weeks. That means finding a way to avoid a second pregnancy too soon after the first if you have a male partner.

Choice denied – June 2, 2014

A law with teeth is only as good as its enforcement. But when a law is struck down, politics determines how it will play out in society.

When the Supreme Court struck down the law on abortion in 1988—the famous Morgentaler decision—a woman’s right to choose was enshrined in Canadian society. In 1989, the argument of “fetus as person” was rejected, as was the attempt by men in three provinces (Ontario, Quebec and Manitoba) to stop their partners from having abortions. These legal decisions left the right to choose firmly in the hands of individual women.

But a woman’s ability to exercise her choice is limited by several factors: location (it is hardest to get an abortion in the eastern part of Canada); cost, when a woman has to travel to get an abortion or a province does not fund the procedure; and by people, including doctors, who push their anti-choice agenda on a pregnant woman trying to make her decision. (Read more about which provinces cover hospital and/or clinic abortions and which ones do not).

Only 17.8 per cent of Canadian hospitals provide abortion services. Even hospitals that provide abortions may place obstacles in the way of women who try to obtain one, especially if their administration is anti-choice.

Women’s Legal Education and Action Fund (LEAF) decries these obstacles, particularly for women in rural areas, New Brunswick, Prince Edward Island and the North. They explain that provinces are able to limit access because abortion is on a list of “excluded services” in reciprocal provincial billing agreements. This means that women temporarily living outside their home province may not have access to publicly funded abortion care. Waiting for coverage is not feasible for a woman who chooses to terminate. For a woman who does not want to continue her pregnancy, every day that passes can be excruciating.

The Morgentaler Clinic in New Brunswick announced it would close its doors at the end of July 2014 after a lengthy losing battle to have that province fund clinic abortions, leaving local women bereft of an essential medical service. Moreover, for women in Prince Edward Island, the only province in Canada with no local access to abortion, women have had two choices: the Termination of Pregnancy Unit at the QEII Hospital in Halifax, where the costs of the procedure (but not those of travel or accommodations) are paid by the Province. At the Morgentaler Clinic in Fredericton, all costs have been privately paid by the woman (with many Island women accessing the Clinic’s subsidies). Over the years, roughly half of PEI women seeking abortions have used the services of the private clinic in Fredericton. The clinic was the only private option in the Maritime provinces. After the closure of the Fredericton private clinic, only one option will remain for Prince Edward Island women seeking a surgical abortion: travelling to the hospital in Halifax. (Read more about the current situation in PEI).

Why is this service essential?

It is estimated that 40 per cent of pregnancies in Canada are unplanned. A condom may break or slip, a pill may be forgotten, a woman may be sexually assaulted; or people may be unequipped to gain access to, negotiate or use contraception.

The decision to end a pregnancy is often based on economics, especially when she already has children and simply cannot afford to have another one. When money is tight and jobs are scarce, women think first of their existing children. When I had my abortion, we already had two children; the younger was a year and a half and our financial situation was precarious. Amongst the scores of pregnant women seeking help with their decision whom I counselled in sexual health clinics over the years, their distress was often financial.

But there were also more dramatic cases.

I vividly remember the woman who said she wanted to continue the pregnancy, but was afraid to. Her husband, who refused to allow her to use any form of birth control, had kicked her during a previous pregnancy. She had miscarried.

I remember the young woman who started having sex at 13 who had had three abortions and was a crack cocaine user. I am guessing that prior sexual abuse predisposed her to ongoing risk-taking.

I remember the 28-year-old who had been drugged and raped; the 16-year-old whose boyfriend wanted to trick her into getting pregnant.

These women all lived in a city where there was good access to services. But even when there is adequate access to the procedure, there is another component to the process which is as essential as the service itself. Every pregnant woman who came to the sexual health clinic where I worked was given the time to consider and explore her options. The counselling component is integral to the service of abortion referral and abortion provision. Counselling often leads to other service referrals, as in the case of the woman who was abused by her husband. It is expensive to pay people to help women make a fully informed choice. Whatever a woman chooses, she needs to feel that it is the right choice for her at that moment in her life. This can take time—and time is money. Counsellors who work in abortion clinics are supporting a woman who is facing a life-changing dilemma.

But health dollars are scarce and their distribution is political. For example, there is currently a lobby to extend HPV vaccination to boys despite the lack of evidence that it will save money in the long run. HPV DNA testing, which is part of good management for women over 30 is not covered by every province and territory. Pap screening and follow-up is not available to the women who are most at risk for cervical cancer. Mammography programs are not cost effective in terms of lives saved. Moreover, “potential harms considered by the [Canadian] Task Force [on Preventive Health Care] focus on over-diagnosis of breast cancer which can lead to additional imaging, biopsies and procedures, distress and other psychological responses, and additional radiation exposure from mammograms.” Yet women continue to be screened on a regular basis.

Women’s health facilities tend to be cash poor while hospitals are well-funded and able to raise huge amounts through donations.

Although the current federal government insists it will never reintroduce abortion legislation, they are choking funds for abortion services the same way they starve women’s organizations and women’s health clinics. If there was genuine concern about bringing wanted children into this country, there would be a national child care program and universal student nutrition programs.

Abortion is a medical procedure which should be accessible and fully funded—everywhere. It should be a priority for women to be able to choose when they want to continue a pregnancy and when they want to terminate one.

Women’s reproductive rights are central to their ability to control their lives. Without access to services and funding, the abrogation of a law is toothless.

Read more here:

CWHN Health FAQ on abortion

History of abortion in Canada, National Abortion Federation

Access to hospital abortions, Reality Check, Canadians for Choice report, 2006

Access to abortion in Canada, Women’s Legal Education and Action Fund (LEAF), April 2014

Abortion access for women in PEI, CBC website, April 2014