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Wednesday, July 27, 2016

IOU one IUD: Demanding Reproductive Justice

Photo Cred: Diego Delso Wikimedia Commons, License CC-BY-SA-4.0

Estimated reading time: 13 minutes, 9 seconds.

Dr.- Okay And, what's going on with the Mirena that you're concerned about?

Clair- So, um I've had it for about three years

D- Right

C- And after not having a period-

D- Right

C- for most of those three years-

D- Yeah

C- last month I got a period.

D- Okay

C- and Not spotting, it was like a-

D- Okay.

C- full period.

D- Okay, yup

C- So, I was concerned that perhaps the hormones in the IUD had begun to wear off.

D- Uh-huh. Right.

C- Um, so, I wanted to replace it with a different IUD. Um, before I was thinking about just changing it to the new Mirena. But I would prefer to get the Skyla-

D- Now, now why do you think it's not working? Or why do you- Just because you got your period?

C- Um, I think I was just worried about that possibility.

D- Yeah, right right right.

C- And because it had been three years, I mean, I know they're technically good for five-

D- They're good for 7 actually. I mean, we tell people change them at five, but they can last up to seven years.

C- Right, so I guess that was my only concern.

D- Right. It's working as well today as it was when you had it first put in for contraception.

C-Well, I don't know if I'm pregnant yet, but...

D- Yeah

C- Um, I mean that- it's just a concern,

D- Yeah

C- is that if I were to become pregnant with an IUD, which I know is a possibility that that would- that would be-

D- Right, but it's no more of a possibility today than it would have been when you had it put in.

Friend- Did you tell him about the strings though?

C- Oh, I also don't have a string. So um, the nurse practitioner yesterday said that we should do, a ultrasound.

D- That's right.

C- So that we could see whether or not it was actually still in.

D- That's true, absolutely. So did she order that?

C- I have no idea. She said that-

D- Well, no you would have scheduled it if she ordered it. Right?

C- Okay, I guess so.

D- Yeah. So she didn't order that.

C- I guess not.

D- [chuckles] Okay, it would've been helpful if she had ordered that because you would've been all set at least to make sure the IUD is still in place.

C- She called me yesterday about it.

D- At least to see about why you're not getting your period- why you're getting your period.

C- Yeah, she called me yesterday at like maybe 4 o'clock so perhaps it was just too late for her to schedule it or too close. But I'm more than happy to schedule-

D- Well, she examined you right?

C- No, she called me over the phone. Um-

D- Well, how does she know the string wasn't there? You- 'cause you told her that?

C- I can't remember what it was, yeah-

F- Yes, she did.

D- Oh, so it's not that she examined you and said "I don't see the string", you just can't feel the string.

C- Yeah, that's corr-

D- Okay, alright. Okay. So, we can check for the string and see if I see it. I don't know if I will or not.

C- Okay.

D- If we don't see it then we'll get you an ultrasound to see that the IUD is still there.

C- Mm hmm.

D- I mean, that's a valid concern.

C- Mm hmm.

D- But if the IUD is there, then it's working fine. There's no reason to replace it with the same IUD essentially. I mean the Skyla is just a smaller vers- slightly smaller version of Mirena.

C- Mm hmm.

D- It's only good for three years.

C- Mm hmm.

D- The amount of progesterone in your bloodstream is pretty similar maybe a little bit less.

C- Mm hmm.

D- In fact, if you have a little bit less progesterone in your bloodstream now because that IUD is three years old, it's gonna be equal- the amount of progesterone you have in your bloodstream from the new skyla versus a three year old Mirena. It'll prolly be about the same.

C- Yeah

D- So, y'know, it won't make any difference.

C- Okay.

D- And then the Skyla will only last for three more years. So if you have this Mirena that's still there, you get two more years on Mirena.

C- Mm hmm.

D- You only get one more year after getting a new Skyla. I mean it doesn't make any sense.
Now if you didn't like the Mirena because of some hormonal side effect, then I can replace it with a copper IUD. That would make sense.

C- Um, I have had a copper IUD.

D- Okay.

C- I had it for a year. It gave me really heavy and very painful periods.

D- Okay yeah.

C- I was bleeding a matter of ounces.

D- Right.

C- Because I had- I have a [menstrual] cup so I was able to measure how much flow there was.

D- Uh huh.

C- So, I would prefer not to go back to that. The Mirena has been fine, um. I spoke with my husband about our reproductive choices-

D- Sure, sure.

C- and when we would like to have children.

D- Right.

C- I'm 26 now, we just got married and at 29 we're talking about having kids

D- Okay.

C- So, the three year mark is actually kind of when we're talking about having children anyway.

D- Right.

C- So I think that that was part of the reason why I was okay with getting an IUD that will expire in three years because I'll be planning to remove it at that point anyway.
The lower dose hormone- I understand that it is supposed to be a negligible difference. However, I also know that the Skyla is supposed to, in theory, have your periods come back, or that there's a less of a chance that you will not have a period.

D- Right

C- So, that difference being noted. I think that the hormones in the Mirena um, because I have mood disorders I am sort of trying to selectively take out anything that could be making that worse and I think that potentially getting a lower dose, um-

D- It won't end up being a lower dose in your bloodstream though.

C- Okay.

D- It'll end up being about the same.

C- Is there a reason, given all of the context that I'm trying to portray now, is there a reason why I cannot be given the Skyla?

D- There's not a reason, but it's actually a waste of resources. I mean, you have an IUD that's perfectly good and you're gonna take it out and replace it with a very similar IUD. For no good, really really good solid reason. So it's kind of a waste of reproductive resources. Of contraceptive resources.

C- Okay.

D- That's the way I look at it. So... I mean, I'll do it, but I'm not excited about it. I'm not happy about it because it's a waste...If there's a medical reason, then that makes sense. But I don't really, I'm not hearing a strong medical reason

C- Okay.

D- But, that being said, I mean, I'll do it, but I'm not- I'm not happy about it.

F- Can I ask a question?

D- Yes.

F- Just out of curiosity. So, if Clair's plan was to think about having children in three years, and she kept the Mirena in, then would you suggest she get a new IUD put in for one year and then removed?

D- You could do that, or you could actually- it's good for seven- so if you told me I was gonna get- you wanna be pregnant let's say in say three years, you could leave it in for an extra year.

F- Okay.

D- It'd be fine. As long as you were definitely planning on that.

C- Okay.

D- But...I'm not gonna y'know I'm not arguing with you. I mean, I'll do it if you want me to.

C- Um, I don't wanna make you do anything that makes you uncomfortable. Um, I think that's unfair to both of us. Is there a different practitioner in the office who might be amenable to the procedure?

D- Um, you could make an appointment with them and they may be.

C- Okay.

D- Absolutely, yeah. That's fine.
While you're here- I mean, it's no hard feelings I'm not- Do you want me to check and see if I can see the string?

C- That's probably a good idea.

D- Yeah, I think it is a good idea. since you end up...If I don't see the string, then we should order an ultrasound and check it out. Okay?

C- Sure.

v   v   v   

The day before this appointment, I received a call from YOUR nurse practitioner. She said "the doctor [which I can only presume means you] had some concerns about why you wanted to change from the Mirena to the Skyla."
I explained that my period had returned and she said that was a valid reason, and that you could likely give me a new Mirena, but not the Skyla. I also mentioned that I do not have a visible string, which was confirmed by my old gynecologist. But that was about three years ago, so I forgot that detail while you were grilling me in our patient-doctor consultation.

I told my husband and two female friends about this call. All three of us who are women found this to be odd, but my husband quickly replied "brand loyalty. I guarantee when you go in there, they'll have Mirena propaganda all over the office". I was stunned by my own naivete but sadly less stunned when I walked into your office and found he was right [about the propaganda anyway].

I understand now that Mirena, Skyla, and another BC, Essure, are all produced by the company Bayer. I expect my friends with an intimate understanding of the health care system will have something to say on this point, but for now, it looks like we can rule out brand loyalty.

My reasons for wanting a new IUD:

(Are not really your business, but I'll humor you anyway)

I want one.

It's not really your place to tell me that my request is a waste. Especially when admittedly, you don't have a good reason *not* to give me a replacement. You are speculating that this IUD is working the same as it was the day I got it. I have to trust the IUD because that's why I got it, of course. But I sure as hell don't need to trust my reproductive health to someone who bases his analysis of my choice on projected, estimated numbers rather than facts. Being pregnant calls for something a little more serious than "guestimates" and I really don't care if I'm being paranoid because I'd rather be paranoid than pregnant. Plus, pregnancy is a HUGE "waste" of resources, if you really wanna talk about that.

I have clinical depression.

I am desperate to improve my mood in whatever way I can. I am in therapy and on medication, and that isn't helping. My therapist suggested that perhaps the hormones in the IUD are making it more difficult to control my mood (albeit slightly). This is why I want to try an IUD which is marketed as a lower hormone dose than the Mirena.

I'm moving.

I am moving back to Missouri which, if you haven't heard, isn't quite as progressive on providing reproductive care to women as the Commonwealth of Massachusetts.
I will soon not have insurance and would like to get a new IUD at this time so I can have 3-5 years of coverage on a new IUD instead of keeping one which I got before I even worked at the job where I am now.
Speaking of which, you seem really sure that the Mirena is good for seven years (even though the manufacturer recommends patients take it out after five) so why doesn't any "extra time" apply to Skyla?

Since you seem to think the difference in hormones is so negligible, wouldn't it follow that the Skyla can also be used beyond its recommended date of three years and perhaps even be kept for five? If, by your logic, I can keep the IUD in for longer than recommended, then couldn't I get more than one additional year of protection from the Skyla?

The Skyla would give me three years of the recommended level of coverage for contraception, whereas the Mirena (if it's going to last until I want kids) would have to be in for one "lottery year" in which its effectiveness very well may be minimized. Though you seem comfortable with this, it's not a gamble I'm willing to take, thanks.

Which brings me to my next point...

I want to be pregnant in the next three years (but not before then)

Since I am hoping to get a new IUD soon, but I plan to have kids within the next five years, I didn't want to get another Mirena and "waste" a device that would be good for much longer than I needed it. Hence the request for a 3yr Skyla.
I really do try to be mindful of consumption, so it's not really helpful to have you try to patronize me out of getting a new device.

I don't have a string.

This isn't a huge issue on it's own, but I will say that it isn't ideal that I can't do string checks to make sure my IUD is still properly in place. Now, every time I have any kind of issue, you all order an ultrasound. I had one last year at your office because you couldn't find my string and now I'm having another one. I'm taking up an appointment slot, taking time off of work, using up the technician's time, and then using even more of it while they analyze the results.
Again, I feel *that* is a real waste of resources which might be resolved by having a properly placed, monitorable IUD with a string.

Photo Source

Now, before this turns into a huge back-and-forth like that woman who wanted a neck tattoo and the artist who refused her, it should be noted that, although there is an art to medicine, my ability to avoid pregnancy and to do it in the way which I feel is most beneficial to me and my body is not about me commissioning an artist, it's about protecting my reproductive health and safety.
If he doesn't want to take into consideration that a person's health should be paramount to whether or not a piece of plastic has completely reached its expiration date, then I question his right to serve in his current position.

That's probably what bothers me most; he is doing this to other patients. There are patients who have less experience, who are perhaps less informed, or who are simply intimidated by questioning a doctor (and perhaps particularly a male doctor) who may have left feeling belittled and disempowered by this practitioner, and that infuriates me.

And it's not just this guy. This is happening in OB/GYN offices all over the place. I know this firstly because I've experienced this attitude in many different offices, but also because I spoke with two women who are a little older than I am and who subsequently have more experience than I could have with these kinds of doctors. Neither of them seemed surprised by his terrible bedside manner, nor his disdain for my request. In fact, they both seemed to see this as standard practice, "Oh, yeah. As much as it sucks, they're not gonna replace your IUD unless something is really wrong with it".
In part, I see the validity of that argument. My IUD hasn't punctured my uterus, it hasn't completely come out of my body, it hasn't caused an ectopic pregnancy, so there's no urgent need to get that thing out of there. Sure. But why does it have to be the case that the only time my uterus' needs are given credence by doctors is when I'm dying or hemorrhaging? Why is it that preventative care for women's health is only allowable when doctors (or men in general) find it appropriate?

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