Eight years ago, after Donald Trump won the election, there was a 21.6% increase in the number of IUD insertions. On the day the Supreme Court overturned Roe v. Wade in 2022, IUD appointments scheduled at Planned Parenthood increased by more than 375%. Now, with a possible second term for the Trump Administration and more states limiting healthcare for people who can get pregnant, long-acting reversible contraception (aka LARC)—which includes IUDs and implants—has clear appeal with a less than 1% failure rate and years-long efficacy.
One LARC, the copper IUD, may become more interesting thanks to its more than 10-year indication—the longest of any reversible contraceptive method. Like other IUDs, the copper IUD (also known by its brand name, Paragard) promises more than 99% efficacy with no maintenance save for checking its string. However, the copper IUD is unique in that instead of releasing hormones, it relies on the chemistry of a tiny copper coil. Paragard can also be used as a form of emergency contraception.
I am a 39-year-old mother of a one-year-old and have used a copper IUD as my primary form of birth control since I was 19—I’m on my third. I have always been surprised that I don’t know more women who use it, too. I got my first Paragard at Planned Parenthood in 2005, the same year it became an approved option for women who had not yet given birth—previously a contraindication—and have never looked back.
While I do not subscribe to or agree with the social-media-fueled rejection of hormonal birth control altogether, I simply never found a birth control pill I liked. When I was in high school and college, my doctors prescribed me a variety of pill options: Ortho Tri-Cyclen, Yasmin, Yaz, and others, but all made me feel sensitive, edgy, and unhappy to various degrees. This is a common concern. A 2023 study published in the journal Contraceptive and Reproductive Medicine found that 43.6% of respondents reported mood swings as a side effect of hormonal contraception. With no evidence to suggest that the copper IUD is associated with mood changes, the Paragard can be a welcome relief for some. I, for one, wanted a nonhormonal option that was foolproof.
But now there is a new appeal for nonhormonal birth control: the rise of weight loss drugs like Ozempic. A spate of unplanned pregnancies among women taking GLP-1 agonists has doctors cautioning patients to be extra careful with contraception. “Medications that affect glucose metabolism, insulin sensitivity, and weight will affect hormonal regulation,” says Banafsheh Bayati, a Santa Monica–based ob-gyn and cofounder of Perelel women’s health supplements. “Contraception needs to be discussed when taking such medications.”
But, like with any medication, there are downsides. Paragard—which accounts for 23% of IUDs used according to data from 2015 to 2017—has a known side effect of heavier and more uncomfortable periods, a change some women simply won’t consider or tolerate, especially when hormonal IUDs can sometimes provide lighter menstruation. Read on to learn more about the copper IUD, the only nonhormonal IUD and LARC.
How does copper prevent pregnancy?
While hormonal birth control—pills, implants, and hormonal IUDs—works by safely stopping ovulation, copper IUDs work by creating an inhospitable environment for pregnancy.
“The T-shaped copper-supported IUD releases copper ions, and copper and sperm don’t really mix very well,” says Dr. Bayati. “Essentially, it forms a little inflammatory cytotoxic environment in the cervical mucus as well as the endometrial lining. We consider it to be spermicidal.”
A copper allergy is a contraindication, but otherwise the inflammation, which is a sterile inflammatory response, stays local and minimal. As for the risks of having copper in your body for extended periods, a concern perpetuated on social media: “There’s not enough copper in it to be copper toxic,” says Elizabeth Bailey Rodgers, an ob-gyn at Spring Ob/Gyn in New York City. “It’s not a thing.”
How painful is insertion?
The notoriously painful insertion (and removal) can be a dealbreaker for some women, but the good news is more doctors are providing pain management—something that was not even part of doctor training a few decades ago.
Insertion requires grabbing and pulling the cervix with an archaic sharp hooked device called a tenaculum and inserting a tube through the cervix for up to a couple of minutes. “We put the IUD in folded and then pop the arms open inside the uterus cavity,” says Dr. Rodgers. Paragard is one of the largest of the IUDs. While it’s described as “temporary discomfort” on the website of the American College of Gynecology, most anecdotal descriptions on social media are pretty raw and use language such as “the worst pain I’ve ever experienced.” There is even a corner of TikTok where women record their faces to capture their pained expressions during appointments.
Both Dr. Rodgers and Dr. Bayati use more sophisticated pain management methods than I was ever offered. “I don’t do an IUD without a paracervical block—that’s a lidocaine or lidocaine-like substance injected into the cervix,” says Dr. Bayati. “It makes a huge difference. I also have them take an Advil or Tylenol an hour before. We might talk through pelvic relaxation techniques, maybe make sure they have a driver, a heating pad, bring in some headphones with relaxing music.” While admittedly “above and beyond,” Dr. Bayati will also do an exam and ultrasound to get a sense of the uterus angle and size. “I do not think an IUD insertion has to be painful,” she says. “You can absolutely always ask your doctor what they can do to help manage pain.”
My first two insertions were really intense: take-my-breath-away, seeing-stars painful. I cried. Each time, I was always told to take a high dose of ibuprofen beforehand, but I can’t say it seemed to do much. However, I felt that less than about 60 seconds of this pain for 10 years of efficacy was worth it: I never second-guessed the choice. To my surprise, my third insertion was much easier. Not only did my ob-gyn use topical novocaine foam (the first doctor who ever offered it to me), but this was also post-pregnancy when my cervix was naturally more relaxed—a common experience for women who’ve given birth, whether vaginally or Cesarean.
“All health care should be very individualized,” says Dr. Bayati. “IUDs are a great form of birth control to provide as an option. I would give all the information, but if I know a patient for whom it’s hard for them to even do a pelvic exam or I’ve just met them and I know they’re about to leave for college in just a few weeks, I might say to them, ‘I’m not sure the IUD world is where we’re at now.’”
Also on the horizon: a new insertion device called the Carevix that relies on suction instead of the tenaculum is in tests.
Do periods get worse with the copper IUD?
“I tell people you can expect a heavier period in first three to six months with more cramping and spotting,” says Dr. Rodgers, who asks Paragard patients to try to wait six months to see if the response levels out. “If you have a light period to begin with, it’s not a huge change in quality of life. As long as you go in with the right expectations, people do fine. Even patients with heavier periods feel it’s worth it. Now, if someone has a really heavy period to begin with, it’s probably not the right choice for them.”
Research shows that bleeding increases by an average of 50%—which can be a little or a lot, depending on the person. I always had a light period as a teenager, so Paragard turned my period into a more normal flow. It never felt unmanageable for me. Alternatively, a close friend who had a more normal to heavy flow found her heavier periods with a copper IUD intolerable and had it removed within two months.
“On the bell curve, if you have pain issues but you don’t bleed that much or if you’re having heavy cycles or long cycles or are borderline anemic, then the copper IUD isn’t going to be the best fit for you,” says Dr. Bayati.
Still, studies show that satisfaction rates with IUDs in general are good and significantly higher than other contraceptives, according to a 2011 study of more than 5,700 women. After 12 months, hormonal IUDs (which typically decrease the amount of bleeding) had the highest satisfaction rate at 88%, followed by the copper IUD at 84%. Oral contraceptive pills were 54%.
How effective is it?
“It’s the most effective form of reversible contraception, as effective as getting your tubes tied, and requires no compliance,” says Dr. Rodgers. “Even accounting for user variability, it’s a no-brainer.”
The efficacy for Paragard is 99% with a 0.8% failure rate—hormonal IUDs are similar with a 0.1 to 0.4% failure rate. IUDs require no daily maintenance or compliance other than a quarterly self-check to ensure the thin plastic string (it feels like fishing string) hanging down from the IUD through the cervix is still present. This tells you the IUD is still in the right place in the uterus.
But a friendly reminder: The IUD is 0% effective against STDs, and Bayati says data is showing an uptick. “I do think this is coming from a younger generation, and even though the IUD is really nice from a pregnancy standpoint, you really do need to think about STD standpoint.”
How long can I keep an IUD in?
Paragard is approved for up to 10 years, but Planned Parenthood says it can be used for up to 12 years as studies show it remains effective. Hormonal IUDs last between three and eight years, depending on the type. Any IUD can be removed whenever you want, and you can swap it out for a replacement in the same appointment.
I had consecutive 10- and 7-year stints with copper IUDs and a year and a half break to get pregnant and give birth; I am now on my third.
While it’s mostly covered by insurance, the longer you keep it in, the more economical it is. Paid for entirely out of pocket, Paragard costs about $1,300, according to Planned Parenthood.
What are the risks?
All IUDs have a small risk of perforation of the uterus, expulsion, and infection. In addition, Paragard manufacturer Teva Pharmaceuticals is facing ongoing multidistrict litigation regarding the device breaking during removal.
“The risk of perforation and being in the wrong position can happen to anyone, and there is a slightly higher chance if you’ve recently been pregnant,” says Dr. Rodgers. “But I think if you go to somebody who does a lot of them, your risk is a lot lower.” Bayati agrees that a very experienced practitioner makes a world of difference.
Dr. Rodgers also says that some women notice that they get more frequent yeast infections and bacterial vaginosis, but “many women have a reaction to any foreign body in the vagina whether it’s a partner, tampon, etc. Recurrent BV and yeast infections will be uncomfortable but won’t be dangerous to long-term fertility.”
There is a history of resistance to the IUD that dates back to the days of the Dalkon Shield, a long-since discontinued IUD in the 70s that was badly designed and was associated with pelvic inflammatory disease (PID) and subsequent infertility. This created a particularly bad stigma in the United States and is part of why women who had not yet had children or were not monogamous were either discouraged from or not allowed to get an IUD up until the early 2010s. Other outdated concerns around STIs or increased risk of ectopic pregnancy have been tempered or assuaged by studies, says Dr. Rodgers. “There was a long period where there was a lot of resistance, but a lot of it was unwarranted.”
[Editor’s note: This story has been updated to reflect new information about the copper IUD.]