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Contraception, IUD, Uncategorized

Don’t remove your own IUD. Here’s why.

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Removing one’s own IUD is apparently “a thing.” There are even YouTube videos of women sharing their experiences. If you can get a medical degree from Google then why not get your OB/GYN residency from YouTube?

All kidding aside, I’m a GYNO and I’m going to explain why you shouldn’t.

It’s not that people can’t technically pull out their own IUDs. It does happen accidentally, albeit rarely. An occasional mishap with a tampon or a menstrual cup is the typical scenario. Considering how uncommon accidental self-removal is (in my 25 + years of experience I have heard of less than five) my guess is those cases are probably situations where the IUD was a little too low in the uterus or the strings were cut way too long to begin with. Longer string means easier to get tangled with something in the vagina.

Pulling an IUD out, when you know what you are doing, is not rocket science. It is technically a very easy medical procedure most of the time. A speculum is inserted and we look at the cervix, grasp the string with forceps, and pull. They usually pop right out, but sometimes you have to tug a little. You need training to know how much to tug and when to stop. The more you have inserted and removed the more you know how much force you can use. Then there is the direction to pull. If you have never instrumented a uterus for any reason and you don’t know what an acutely retroverted and retroflexed uterus (or acutely anteverted and anteflexed) means and how to tell if that’s the case you might not know sometimes you should angle ever so slightly in a certain way as you pull.

Medicine, like many things, is easy until it isn’t and it’s the years of training that tell you when something is going wrong or just isn’t quite right. Pulling out a straightforward IUD doesn’t require 4 years of medical school and then another 4 or 5 years of residency, but identifying when something might not be quite right and knowing what to do about it does. If an IUD has become embedded in the wall of the uterus or in the cervix there is no way to know before you pull. We pull quite gently because an IUD should really just pop out. If there is resistance we don’t know if one of the IUD arms just doesn’t want to collapse or if the IUD is embedded in the uterus or cervix. At this point we stop and wiggle the IUD a little to get a feel. Gynecology is very haptic as much of what we do is blind. Learning the subtle tells of too much or too little pressure or tension takes time and training. Not just training pulling out an IUD, but cumulative training of multiple pelvic exams and other procedures. It’s that training that tells us when to stop and when it’s ok to pull a little harder. It’s the training that tells us when to get a different instrument or when we just need to stop and arrange a hysteroscope (a telescope that goes into the uterus) to remove the IUD while we are looking at it. Blindly ripping out an IUD that won’t budge (i.e. what would happen at home) is less than ideal. You can pull off the strings and then end up definitely needing a more invasive procedure or you might get it out, but lacerating the uterus or cervix as part of the deal.

Fine, you say. I’ll pull and stop if I am pulling too hard.

How will you know if you are pulling too hard if you have never pulled one?

When I needed my own IUD removed I did not do it myself. Even though I have inserted and removed thousands I went to a gynecologist. We all WANT our IUD to slip out easily, so I can tell you not only from years of seeing patients who have done minor (and sometimes not so minor) procedures on themselves and from personal experience that when you are your own surgeon you have inserted a dangerous bias. I have cut corners on myself that I would never dream of doing were I someone’s physician. “Oh sure, that’s sterile enough,” or “It’s only a small cut, really, and it’s not pumping blood so much anymore.” Being your own doctor is about as smart as being your own lawyer.

Let me tell you what happened when my gynecologist pulled out my IUD. It was stuck. As in put-your-foot-up-on-the-side-of-the-bed-for-leverage stuck. My partner at work pulled and here is the most important point – I could tell from the look on her face that there was something wrong before it became uncomfortable. This is important and it bears repeating, I am a gynecologist and I couldn’t tell that something was wrong with my IUD removal until it was already past being wrong. If you are pulling your own string, with less knowledge and no idea how hard is too hard you may not know there’s a problem until it’s really obvious that you have caused one.

There is also the issue of why a woman wants her IUD removed. Sometimes it’s because of the concern over side effects or bleeding issues or another health concern. These are red flags and might suggest other health issues, meaning conditions best checked out by a health provider. When a woman goes to the doctor for an IUD removal these other health issues can be addressed. Then there is the issue for those not wanting to be pregnant post IUD removal. Going uncovered contraception wise is a major risk factor for an unplanned pregnancy, so when you see a doctor or nurse practitioner for removal you should be getting contraceptive counseling as part of the deal. I have seen many women with unplanned pregnancies who thought they could wait after their IUD removal to pick another option as they “weren’t sexually active right now” or “would figure something out.”

What if you want your IUD out because you are planning on getting pregnant? Well, that’s a great opportunity for prenatal counseling. Taking a prenatal vitamin with folic acid three months prior to conceiving significantly lowers the risk of a baby with neural tube defects, but use of preconceptual folic acid in the United States ranges from a dismal 11% to 60%. Yes, overall < 50% of women who take prenatal vitamins start them after their positive pregnancy test. That visit to remove the IUD for the wanted pregnant might help motivate/remind/encourage a woman to pick up some prenatal vitamins on the way out of the office. The visit may also be an opportunity to discuss other health behaviors, like binge drinking and marijuana use, that can negatively affect pregnancy outcome.

Obviously some people have removed their own IUD without issue. It’s also true that many people who have never flown an airplane could sit in the cockpit and babysit the autopilot for an hour, but you know I’d prefer a pilot to be at the controls all the time. Just in case. Lots of things are technically “easy” until they aren’t and I prefer my disasters averted when possible as opposed to damage control. That’s why as a gynecologist I still went to a GYNO to have my own IUD removed.

 

 

Discussion

8 thoughts on “Don’t remove your own IUD. Here’s why.

  1. I cannot imagine anyone fool enough to do such a thing.

    >

    Posted by petalsf | June 4, 2016, 1:55 pm
  2. I thought I read an article about this… ah here it is. Interest in and experience with IUD self-removal http://www.contraceptionjournal.org/article/S0010-7824(14)00035-3/abstract

    Perhaps less of a money issue (although that and access issues in general can certainly be a problem), but maybe a control / sense of empowerment thing, as suggested by the article? Speculation on my part.

    Interesting that only one in five women were successful in removing their own IUD when given the option. Maybe they didn’t watch the YouTube video?😉

    Also – minor point, on access – family physicians are perfectly capable of removing IUDs, no need to see a specialist. Unless as Dr Gunter says, it is stuck, which should be referred. Or maybe I am too Canada-centric, where a Gyne referral takes months.

    Unfortunately too few family MDs are comfortable inserting IUDs these days, or worse, counsel nulliparous women / teens that they are contraindicated.

    Posted by Dr Gyula Voros | June 4, 2016, 11:45 pm
    • I think family doctors who have a lot of GYN training could easily do it. Some are more comfortable with OB/GYN than others. Also, NPs who do a lot of IUDs as well.

      Posted by Dr. Jen Gunter | June 5, 2016, 9:18 am
    • Thank you for the family MD shout out! We definitely can insert and remove IUDs, provide contraception and pre-conception counselling, basically everything listed above except the hysteroscopy for the lost strings/stuck IUD situation. I do think it’s a bit of a culture thing – American specialists seem to do a lot more primary care (I’m thinking gynecology, pediatrics, internal medicine, in particular) that in Canada would be done by a family doc.

      Posted by Lindsay Hancock (@lindsayhancock) | June 6, 2016, 3:34 pm

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