Australian gynaecologists and obstetricians have this week defended long-acting reversible contraceptives (LARCS) after some users described severe side-effects they had suffered.
Patients told the ABC they had experienced anxiety, chronic pelvic pain, non-stop bleeding and scarring after removals. A subsequent Fairfax Media article detailed the experiences of more women who described acne, hair loss and mental health issues.
"I had headaches, sweats, the shakes, nausea continuously pretty much 24 hours a day," one woman told ABC.
"I never wanted it in the first place and then once I wanted it out, I felt like I had this thing stuck inside me without consent," another patient told Fairfax Media.
The head of the Australian Medical Association Michael Gannon defended LARCs and said in most cases they were a safer option than the combined oral contraceptive pill.
"[LARCs} are not perfect and they do have side effects, but the beauty of them is that they are reversible and the hormonal effects are out of the body within 48 to 72 hours of removal, and in the vast majority of circumstances, that removal is simple and takes either seconds or minutes," Gannon said on Sky News.
"They are overall — appropriately used — extremely safe, and they've been an absolute bonanza for women in Australia over the past 20 years."
Family Planning NSW told BuzzFeed News there were a "significant number of cancellations from clients who had been booked in for either an IUD or an implant" after the ABC report.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) released a statement reminding Australians that "large patient trials had demonstrated that these devices are very safe and effective at preventing pregnancy."
"I was very distressed about the negative coverage because some of the side effects these women talked about were in no way related to the devices and had no support from a clinician," RANZCOG's spokesperson, associate professor Dr. Kirsten Black, told BuzzFeed News.
"The [hormonal IUD Mirena] has far fewer side effects than [the hormonal implant Implanon] and that wasn't made clear; they were both demonised and it was said they could cause pelvic adhesions, which is misinformation."
Black said she treated patients "at the coal face" and that for the "vast majority" of women, LARCs "transform their lives".
"We know that everything has documented side effects but the discontinuation rate for LARCs, which are the most effective form of contraception, is lower than with the oral contraceptive."
Here is everything you need to know about LARCs.
What the bloody hell are they?
There are three types of LARCs. All provide contraception for a number of months or years.
Other than the copper IUD, all LARCs are listed on the Pharmaceutical Benefits Scheme (PBS) in Australia and work out more affordable than oral contraceptive pills.
You can find the full list of adverse side effects for all contraceptives on the TGA's website.
Contraceptive implants
The contraceptive implant is a 4cm–long flexible rod inserted just under the skin (under local anaesthetic) on the inner arm just above the elbow, where it continuously releases a low dose of the hormone progestogen into the bloodstream.
Progestogen stops your ovaries from releasing an egg each month and thickens the mucus in your cervix, which makes it difficult for sperm to penetrate and fertilise an egg. It is 99.9% effective and lasts up to three years.
Dr Charlotte Elder of RANZCOG said the most common side effect, especially in the first 6–12 months, was a change in bleeding patterns — less bleeding, some spotting, and a fifth of patients don't have any bleeding at all.
"Around 90% of patients will get a change in their bleeding patterns and about 70% of them will find that change acceptable," Elder told BuzzFeed News.
Family Planning NSW medical director Dr Deborah Bateson said the implant was a "very safe form of contraception", and that over a million have been inserted over the past 10 years in Australia.
"There were only 680 reports to the Therapeutic Goods Administration for adverse side effects, two-thirds of which were pregnancy-related," Bateson told BuzzFeed News.
"Women may experience other hormonal side effects such as mood changes or a headache, and insertion and removal of the implant is generally very straightforward, with a minimal risk of a small scar."
Intra-uterine devices
There are two kinds of IUDs available in Australia and both prevent pregnancy by stopping sperm reaching the egg to fertilise, and changing the lining of your uterus so a fertilised egg won't stick to it.
The copper IUD is a small device made from plastic and copper that is fitted inside the uterus and works by blocking sperm from reaching the egg, and stopping any fertilised egg from sticking to the wall of the womb (uterus). It is 99.2% effective and lasts for up to 10 years.
The hormonal IUD is a T-shaped plastic device fitted inside the uterus, which slowly releases a progestogen hormone into the womb and thickens the mucus in the cervix. It affects the implantation of the egg, is 99.8% effective and lasts around five years.
"The IUD has a much lower dose of hormones than the pill or the implant, so we see fewer mood changes, and there are more predictable bleeding patterns — you'll get between three to six months of spotting and periods that are progressively lighter and eventually can disappear," Elder said.
The most popular hormonal IUD in Australia is the Mirena.
There were 968,000 Mirenas inserted over the past 10 years, with 754 reports to the TGA, of which 205 were pregnancy-related reports.
Here are some things you should know before getting an IUD, and what it is actually like to have one removed and inserted.
Hormonal injections
DMPA (Depot medroxyprogesterone acetate) is a long-acting progesterone hormone that is given as an injection every 12 weeks. The hormone stops your ovaries from releasing an egg each month and changes the lining of your uterus so that a fertilised egg won’t stick to it. It is between 94% and 99% effective which means that between one and six women in every hundred who are using the contraceptive injection will become pregnant in a year.
How do LARCs compare to the oral contraceptive pill?
There are obvious differences which affect how well each contraceptive prevents pregnancy. The pill's efficacy is dependent on the user taking it every day while LARCs can be inserted and forgotten for the period in which they're active.
But the types of side effects also differ.
"The combined hormonal contraceptive pill which contains only oestrogen is associated with a small increased risk of blood clots while the progestogen-only methods including the Mirena and Implanon are not associated with blood clots," Bateson said.
"A recent Danish national database study looking at the association of depression and hormonal contraception found similar outcomes for the combined pill and the hormonal IUD.
"Neither the LARC methods nor the contraceptive pill have an effect on future fertility."
Do Australians use LARCs more than other countries?
No.
Family Planning Australia found the nation's LARC uptake had increased from 9.2% in 2014 to 12.1% in 2016, however, rates are higher elsewhere.
United Nations 2013 data found the IUD (the most common form of LARC in Australia) was used by 14% of women of reproductive age who are married or in a union and was the second most widely used contraceptive method in the world after sterilisation.
It was most commonly used in Asia (18%) and its prevalence is highest (over 40%) in China, the Democratic People’s Republic of Korea and Uzbekistan and upwards of 30% in Israel and Vietnam and above 20% in much of northern Europe.
A survey by the Australian Healthcare and Hospitals Association (AHHA) last year found more than 70% of Australians said they would not consider using LARCs.
Yet this year the nation's peak hospital and women's healthcare organisations rallied together to fight for Australian women to have better access to the contraceptives.
A statement was endorsed by all major reproductive health and hospital bodies, including the Australian College of Midwives, state family planning bodies and RANZCOG, calling for LARC insertions and removals to be covered by Medicare.
"Around 60% of Australian women who have had an unintended pregnancy were using contraception — most notably the pill (43%) and condoms (22%)," AHHA chief executive Alison Verhoeven said when launching the statement.
"Although they will not suit everyone, LARCs are a more effective, less user-dependent method of contraception."
What should I do if I'm worried about my contraception?
The medical professionals who spoke to BuzzFeed News for this story unanimously said patients should talk to their doctor about their birth control options.
Black and Elder stressed that pregnancy posed greater risks, and adverse mental health effects, for women than contraceptives.
"We see the fall out from unplanned pregnancy with women who have to carry a pregnancy which interrupts their education and wellbeing, sometimes in states like NSW where there is virtually no public abortion access," Black said.
Elder suggested Australian doctors should take a "tiered counselling" approach when it came to contraception.
"If women are presented with contraceptives from most to least effective they are more likely to choose LARCs," she said.
"But in Australia doctors say: 'Well, if you don't like condoms you can go on the pill and if you don't like that you can get an implant or an IUD'."