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0:24

this is a a cbc

0:27

podcast

0:30

hi i'm doctor brian goldman

0:32

welcome to the dose ensure

0:34

you to ride devices are devices you these have been

0:36

around for more than than they've

0:38

emerged as one of most effective methods

0:40

for long term birth control this

0:43

month or sister show like oh black are took a

0:45

close look at the things women who get i

0:47

you these complain about so this

0:49

week we're asking what do i need to know about

0:51

i about d hi renee welcome

0:53

to the dose hello thank for

0:55

having me i hear your

0:57

called the i u d whisper

0:59

the nurses

1:01

, indeed told me the a d with for

1:04

which is that very sweet and i

1:06

appreciate that moniker for sure why

1:08

do they call you that well as

1:10

it is meant to be very simple and

1:12

quick procedure in the office but honestly

1:14

it has taken me the twenty

1:16

years to really really hone the

1:18

skill of gentle technique

1:21

and informed consent doing that properly

1:23

as well and being able to do it quickly

1:25

and carefully i'm at

1:28

it's it's not the easiest skill per

1:30

se particularly for are difficult

1:32

insertions and eventually we get to point

1:34

to we know this from literature to that

1:36

are complications to secrease and decrease

1:38

in decrease over time and thought way here

1:40

in our to be able to say i have very low complex

1:43

missionary of

1:44

sounds like you're the perfect person to

1:47

to be our guest this week on the dose to wanted

1:49

to give us hi my name is tell us what to

1:51

do and where he do it just sadly

1:53

absolutely must oh my name is in a hall

1:55

and i'm cynical associate professor the university

1:58

of british columbia and they

2:00

have been working in the area family planning here

2:02

for the twenty years work at to

2:04

hospitals and three clinics which

2:06

sounds chaotic but it's all the same topic

2:08

is contraception and abortion care and

2:11

i'm also a big teacher so i teach

2:13

our doctors to insert are you these and

2:15

give them bunch tools interesting things

2:17

that they can do to decrease pain as

2:20

well you sound like an incredible resource

2:22

so we're grateful to have on dose

2:24

of we are talking to you because

2:26

as you said you've you've got a ton experience

2:29

putting , you d's d's

2:31

i you these teaching ah healthcare

2:33

providers how to do it let's start

2:35

with the most basic question of all

2:38

what exactly does and

2:40

i you do oh i see

2:42

i'm before even talk about what and i he

2:44

does i do just want to briefly mention

2:47

why are you these are

2:49

just stay a bit about the canadian

2:51

contraceptive context really

2:54

and we know inadequate contraception

2:56

is major public health concern canada

2:58

because it leads to such high number of

3:00

unintended pregnancies and a

3:02

lot this work in the data that we have

3:04

is from doctor amount of black your system to

3:07

see interviewed on canadian

3:09

server the becoming pregnant or their partners

3:12

and they self report and thirty five percent

3:14

and not easy for interception the or

3:17

i'm having lot difficulties hearing

3:19

contraception basically

3:21

of all pregnancies in canada forty percent

3:23

or unintended on and

3:25

we do seventy five hundred thousand abortions

3:28

in canada every year and we know we

3:30

can do better we know that when we council people

3:32

to contraception that they do tend

3:34

to choose this are you dms it or some

3:36

of these long acting messes ah

3:38

and ah when we have

3:41

studied at about fifty six and

3:43

people after good contraceptive counting that

3:45

method in canada and an additional sixteen

3:47

percent use it or if they had

3:49

the money though it's close to seventy percent

3:51

of people interested in these long acting message

3:54

and right now we're probably

3:56

close to maybe swans twenty sixteen

3:59

it was it was for using id

4:01

than canada and eighty were up to twenty

4:03

percent at this point so there's a

4:05

huge unmet need and why

4:07

are we nowhere near that seventy percent

4:09

and new touched on one thing pain as

4:11

big thing we want to deal with that earth but

4:13

there's many of us dedicated to this practice

4:16

of hurting eighties and so

4:18

are we are trying so hard across

4:20

the country to share a test and our trip

4:22

to make this as easy as possible for those people

4:24

interested in it after good contraceptive

4:27

counseling okay is so now that

4:29

you've explained the preamble what does an id

4:31

do the are you d is

4:33

a device that fits within your

4:35

uterus and they act in couple

4:37

a different ways so the hormonal

4:40

ones will decrease the

4:43

risk of becoming pregnant by sickening

4:45

the cervical mucus as well

4:47

as i'm by changing the

4:49

endometrial lining of the uterus

4:51

and the beginning of cervical mucus

4:54

basically the act as a block from

4:56

so most of their theft is pre

4:58

fertilization but though it

5:00

would be difficult for an ageing from to actually

5:02

implants into the wall because the lining of the

5:04

uterus has altered so because they work in these

5:06

multiple way they were affected mr super

5:09

high spots in typical used

5:11

and imperfect you the

5:14

copper are you details from as well

5:16

copper is like little shooting

5:18

then you as well i think about settling

5:20

this burn as they come by and

5:23

are also affects the endometrial lining

5:25

as well and to that's how they work and they're

5:27

just like a little device sitting in the uterus would

5:29

been made of all kinds of things the years

5:32

did you take about the main types of ideas well

5:35

there are two main types

5:37

of ideas and when i'm talking

5:39

to a patient i'll often asked them about their cycle

5:41

first if they have have year like period

5:44

none of the me an idea of which way

5:46

talk about some the you these to

5:48

copper ones tend to increase

5:50

your bleeding and increase your around and

5:52

but they do have no hormone at all

5:54

and they're still a lot people quite interested

5:56

in that option and they don't mind little the heavier

5:59

bleeding the cramping other

6:01

people put the copper idea and very

6:03

much disliked that feature of it would

6:06

be hormonal i do however decreased

6:08

pain and bleeding and bleeding fact the marina

6:11

have the indication by health canada

6:13

to act as treatment for people

6:15

who have terrible pain and bleeding we've

6:17

seen a lotta help for people in

6:19

this area in fact lot of the campaign

6:21

or surgeries are hysterectomy and things like

6:23

thoughts and what i

6:26

say about that one is that it does have

6:28

formal in it you can have

6:31

that hormone in your sitting and there's

6:33

about twelve percent people who remove

6:35

the hormonal idea because

6:37

farm on the side effects comparing

6:40

that to the pill after a year

6:42

it's about forty five percent of people who

6:44

stop the pill for hormonal died of exos

6:46

it's definitely better and how

6:48

it react in each individual person's

6:50

body we don't til we give it try

6:52

so usually say you hate it for

6:55

five months hormonal e speaking, we can can

6:57

take get it out you you hate it it for bleeding reasons,

6:59

or

7:00

pain, reasons by about 6 months, then, absolutely

7:02

we can can take it it out anytime, how much

7:04

more effective are, the

7:06

hormonal i iuds compared to said the pill

7:09

yeah so this is a really good

7:11

question in this in this the society obstetricians

7:14

and gynecologists as well as the canadian

7:16

pdf a tidy sum

7:18

that was is why they were

7:19

london first line meaning if

7:21

you see a fifteen year old and she comes to talk you

7:23

about birth control as health care providers

7:26

we've been asked to discussed these long

7:28

acting message first so are you these

7:30

and implants and that reason is threefold

7:33

one is effectiveness as you mentioned

7:35

so with effectiveness it's

7:37

an interesting thing when you look at the passage

7:39

of of control pill it says zero

7:41

point three percent chance of pregnancy fabulous

7:44

when you look at package of condom two

7:46

percent again fabulous

7:49

however if you actually look

7:51

at typical used failure rate

7:53

meaning you take one hundred people using condoms

7:56

eighteen percent get pregnant if you

7:58

take a hundred people using pill nine

8:00

percent actually get pregnant because there's a huge

8:03

human error component whereas

8:05

the i you these the typical use

8:07

sale and the perfect you silly are

8:09

very very close to the same so in

8:11

fact the same for the marina ideas

8:14

point the percent chance if use

8:16

a perfectly and point two percent chance

8:18

of pregnancy if you in a

8:20

in a typical population using it so

8:23

that's the first reason that they recommended and

8:25

second reason is can quit continuation

8:28

about eighty to eighty five percent of people

8:30

continue using the long acting methods

8:32

after a year world will sort

8:35

as and methods like the pill and the patch the

8:37

ring are as mentioned it's

8:39

a good forty five percent of people were

8:41

you gonna have to talk about birth control all over

8:43

again because they don't like it enough not marry

8:45

pandemic proof or politics proof

8:47

her folks to the south and on the

8:49

final reason as they're super reversible because

8:51

of their low low dose of hormones they

8:54

are you take them up didn't get pregnant right away

8:57

what do you recommend people ask their healthcare

8:59

provider when they're interested in getting id

9:01

i think one the first things particularly

9:05

if people have lot of here are a variety

9:07

around the i you the insertion if

9:09

how often the person inserts i judy's

9:11

there are specific clinics that you can

9:14

the two that are where we're passionate about

9:16

these things and insert i you do all day

9:18

long and their call and can go to raised

9:20

stuff to gay are a he

9:22

does he a click on your province and it has

9:24

places that are you did all the time

9:27

i'm however it so many family

9:29

doctors and nurse practitioners and in

9:31

some provinces midwives are perfectly capable

9:33

of inserting er you do

9:34

then you wanted to ask them how often they do

9:36

it and on what you want

9:38

to ask is how it might have

9:40

you in your situation so

9:43

your doctor will take full history to try

9:45

to understand your uterus

9:47

what history is has a in with

9:49

regards to having had c section before or

9:51

not if you have any other conditions

9:54

that may affect your response to both

9:56

insertion and just having the id

9:58

and then ultimately together you're

10:00

both making your best guess as

10:02

to what would work best for your body authentic

10:05

tix ongoing communication with

10:07

that helped her provider to

10:09

make sure that this is the right option

10:11

for you to be able to change

10:13

quickly if you're not happy with

10:15

the result

10:17

as a provider how you decide

10:19

whether and i u d is right for one patient

10:21

and maybe not right for another what is some of the

10:24

decisions or or at some the

10:26

conditions are criteria that you're looking for

10:28

the first thing of course

10:30

is that medical contraindications which

10:32

contraindications mentioned very few with the idea

10:34

for that usually the cricket part of the congress

10:36

do you have any liver disease do you have like

10:38

very few things that would actually

10:41

exclude someone and then

10:43

for example of someone has very low iron

10:45

in the first place first don't have the copper

10:47

i you do such great idea because

10:49

we're about to increase your bleeding for

10:52

that i would start tearing toward

10:54

our maybe the ah hormonal

10:56

i used might be better option for them having

10:59

said that having a going through

11:01

their medical history and helping them to decide

11:03

at the end the day it's still the patient choice

11:06

and what they want to do as

11:08

long as it's not medically contraindicated

11:10

i'm happy to proceed of for

11:12

them as with what they would like

11:14

the other thing is is save had

11:17

and and nor is they do have that normal years the

11:19

who happy double uterus is and so then

11:21

in that case maybe the arms

11:23

contraception the army contraceptive

11:25

and plant a be a better choice or we

11:28

have those have had history of sexual trauma

11:30

or have had a have a very difficult

11:32

time with pelvic exams so

11:35

it's a lot about their medical history and

11:37

their preferences of had some patients

11:39

who just absolutely would love not to

11:41

have period and co for sure that i'm happy

11:43

to talk about the hormonal as it's with them and

11:46

those who are really uncomfortable

11:48

with the idea of nope the it at all

11:50

they've just feel like it's just not natural

11:52

and i try to reassure them and addressed

11:54

the myth that if they still would prefer a period

11:57

than we lean more towards a lower dose

11:59

hormonal one or the

12:01

hi i'm jamie for cel host of front

12:03

burner the cdc sailing

12:04

podcast is

12:07

, first one damage caused

12:10

by a coroner bite us involvement

12:12

that i'd had should have had me

12:14

remove myself from this discussions every

12:16

weekday morning meeting you one important

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that there's whole world out there and we bring

12:27

he those stories

12:28

you can subscribe to front burner wherever you get

12:30

your podcasts or get front burner on

12:32

the cbc listen

12:35

i'm going to talk about the procedure itself but

12:37

first all i want to ask you how much

12:39

do these devices cost on average

12:41

so the copper ones are quite

12:44

affordable other between seventy two hundred

12:46

dollars a lot of his extended

12:48

health programs to

12:50

cover our whereas the

12:52

hormonal you need an arc

12:54

of in the range of about four

12:55

the dollars and there's some pharmacies

12:57

you can shop around to i always like tell

13:00

my patients

13:00

shop around because there are differences and soon

13:02

he sees for sure and from one place

13:04

to another but somewhere in the order of around

13:07

four hundred dollars on white or black aren't

13:09

we heard how few proven medications

13:11

there are for pain control so how do you

13:13

handle that were you practice slow

13:15

the first thing we do is have a conversation

13:17

with the person

13:18

how did time so that we can

13:20

see if we can get some indication

13:22

some kit some hints ahead of time of

13:24

how difficult conclusion going to be

13:27

and though the first thing i'll talk to them

13:29

a bow is all the tools that we have

13:31

each individually may not have shown

13:33

a lot of improvement but some of them do show

13:36

a little and then together i'm

13:38

they tend to do quite a good job

13:41

even just the informed consent

13:43

and information ahead time for that people are

13:45

aware and are councils as preseason

13:47

so i'll offer pieces

13:49

the option of medication ahead of time

13:52

help with their anxiety we offer patients

13:55

we do ultrasound at our office which helps us

13:57

not poke around to too much we know exactly

13:59

what direction we're we're going and

14:01

we offer local anesthesia pretty

14:04

much as as to everybody even know

14:06

the data hasn't really helped

14:08

us we sound that it's been very

14:10

helpful in our practice and patients told

14:12

to tell them a lot and in

14:14

addition with the gentle technique and

14:16

informed consent and what i like to refer

14:19

to as verb mccain chatting with people

14:21

through the procedure some and

14:23

at using all these different tools we can get

14:25

about know and ninety nine and a half percent

14:27

of people through in an office setting

14:29

so we have till about half percent people

14:31

that we think you know you

14:34

may be back in sedation setting and setting know for

14:36

gynecologist to you've spoken to that easy

14:38

access for them but for those of us out in community

14:40

that's not super easy access which has made

14:42

force the in a good way to

14:45

improve our skills and

14:46

little tips and tricks like even modified

14:49

cervical blocks that arm much less

14:51

painful than the typical once and

14:53

that we've been sharing as much as we can widely

14:55

as we can with people to the got lots tools

14:57

and toolbox to help with pain you've

15:00

touched on the experience of

15:02

the provider and and certainly

15:04

you have lot of experience and want you to

15:06

address this in a question all

15:08

by itself how important is

15:10

the experience of the provider in

15:13

in making it as as

15:15

pain free or as smooth and insertion

15:18

and getting the confidence patience nurses

15:21

the

15:21

relationship that you have with the

15:23

provider is so important

15:25

and that's why those of us who passionate

15:28

about the topic worked so hard

15:30

to try to figure out the best

15:32

ways to communicate with patients

15:34

to train ourselves and trauma

15:36

informed care and making

15:38

this the entire scene comfortable

15:40

even talk about in our training programs

15:42

to make the room comfortable make

15:45

it warm in there make the

15:47

let him use some headphones

15:50

and music is that helps them we've had people come

15:52

in with flippers and blankets and and

15:54

cuddly toys every tool we can

15:56

possibly we are trying to help people

15:58

out the nearest sense

16:00

tonight and open to them are

16:02

being as comfortable as they possibly can

16:04

be as well as trying to hone your

16:06

yo i'm it makes huge

16:09

difference to their experience i hadn't i

16:11

am by no means perfect there are times

16:13

when i assumed a procedure would

16:15

be very very difficult than it was simple and

16:17

the exact opposite is true when i

16:19

thought that the procedure would be no problem at

16:21

all and it was very very painful for the person

16:24

but it's also how you handle the situation

16:26

how you manage their pain afterwards the

16:28

conversation you had head so that they

16:30

can can expect that that could have happened

16:32

the first place i think what people

16:35

also really appreciate

16:36

but i'm able to tell them exactly the moment

16:38

where they'll feel pain and i'll

16:40

say you feel pension three two one you're going

16:42

to feel a crap and three to what so that they're

16:44

ready and kind of brace themselves for it

16:46

and lot lot of patience tell me that they appreciate

16:49

that knowledge of exactly when tickets

16:52

the prices never find when it comes to paying

16:54

know and i can you know

16:56

certainly as certainly as as an emergency

16:58

provider who who doesn't insert idea

17:01

is is true for the rest of medicine as well

17:04

have

17:05

interesting question for you or is

17:07

it better to wait six or seven months

17:09

to get an experience provider or get

17:11

an id right away from somebody

17:13

who's inexperienced

17:14

though it depends on what contraception you

17:16

are you are on now and

17:18

the am and how good you are at adhering

17:21

to that contraception and also

17:23

your level of concern anxiety and medical

17:25

situation so if you're someone is had

17:27

three babies and you've had an idea in the

17:29

past there's no need to be waiting

17:31

for a specialized care center

17:33

but as mentioned those race clinics aren't actually

17:35

a guy anywhere you have to wait six or seven months

17:37

there are you did clinics where you may have to wait maybe

17:39

one month or or less some i'm

17:42

or if someone has a lot as a

17:44

human experience per se is likely

17:46

going to be an easy procedure and

17:48

if someone is our wix the

17:50

in years old never had pact has never

17:52

had a pelvic that's

17:54

and then we're swaying

17:56

to how good are they out using

17:58

contraception right

18:00

the perceived as the experience

18:02

of the insert or as well so it's a balance

18:04

and trying to figure out the best place in the best

18:06

timing for each individual person okay

18:09

the i you the is in now what you'd expect

18:12

i always tell people it's maybe

18:14

three four minutes for this part of rest

18:16

is more the issue with some

18:18

people walk out and they go straight to work

18:20

and they're absolutely fine and continue on

18:22

with their day literally they do it at lunchtime

18:25

we've had that all the way up to people

18:27

literally ceiling like they having contractions

18:30

the end of the day so depends on just how

18:32

much the

18:33

uterus object to having an object

18:35

in it and it is more than friend

18:37

it does for some people feel literally

18:39

like contractions a , the

18:41

evening that they go home so i always tell

18:43

people before are you the insertion

18:45

just in case maybe don't plan anything

18:47

that night and i like to tell people worst case

18:49

scenario just because it's i'm

18:52

a it'll always just be positive if it

18:54

doesn't come out to be that bad though

18:56

i tell people if you are on that side

18:58

of things where the paint is really bad then

19:00

heating pads ibuprofen netflix

19:03

chocolate the usual p m

19:05

crap management is what

19:06

we would use and then first

19:09

let them know about any warning signs are things that

19:11

would be concerned be concerned i'd like to hear

19:13

about we have twenty four hour called number

19:15

for them for that suits and then there's

19:17

the length of time the thing because unfortunately

19:20

it's not a shot

19:23

deal boom you're done it over i you these

19:25

take settling it takes time to determine

19:27

if this is the right option the you so

19:29

i tell people if you're having severe

19:31

awful the

19:32

and bleeding and pain and cannot

19:34

go on of course let me know of course we can talk

19:36

about it and of course we can take it out

19:38

the idea going to three different doctors before

19:41

someone will take it out make sense that that's not

19:43

consent some are on

19:45

the other hand i also wanna make sure people

19:47

aware that it does take time to settle

19:49

for the brady i say the first couple

19:51

of periods tend to soccer they tend to very

19:53

long and heavy and crappy and

19:55

then by but the fourth or fifth that's

19:57

about as good as it gets so his hero

20:00

with a level of bleeding wonderful

20:02

for five months and you're not liking it then

20:04

for sure come on dash to the marina

20:07

it's more that five six months so at

20:09

about six i'm earning highly know if

20:11

people are not happy the bleeding and pain

20:13

or it's unlikely to improve too too much

20:15

more maybe a little bit more up to one year

20:18

i'm but it's were com or

20:20

talking to people throughout their experience

20:22

to try that find out how they're doing

20:24

and see if they're ok to continue on

20:27

and bleeding for the morale anti lena

20:29

it's feels like you can bleeding all the

20:31

time the i've been on the other side of the the i had

20:33

all kinds of all his three kinds of eighties

20:35

myself so it's just santa want

20:37

to have panty liners with the all the time to to the

20:39

bleeding can be quite unpredictable it stretches

20:42

your period out so feels like you're spotting

20:44

lot the time and then each month the spotting

20:46

days start to disappear and disappear and

20:48

disappear so slowly but surely that a lado

20:50

period and left i'm

20:53

not your average there are of course people

20:55

who don't have that experience i'm describing

20:57

all and so on

20:59

that that's why it's important the communication

21:02

with your patience

21:03

if the person isn't satisfied

21:06

in a certain a we heard a my try to pull it out

21:08

a poet the idea like a tampon why

21:10

that not recommend

21:11

because if you get part way but not all

21:13

of it the are you the sitting

21:15

in service sinclair the what we call

21:18

is available reaction so there is

21:20

a nerve in your cervix that drops

21:22

your blood pressure if it simulated and

21:24

makes st so that can be quite dangerous

21:26

if you're on your own if you're trying do in your bathtub

21:29

and you hit your has so it's

21:31

not greatest idea and then if you do

21:33

get halfway out and have to the see physician

21:35

you've got this sort of device

21:38

sitting sitting vagina that has lots of bacteria

21:41

in it where the other half is in your uterus added

21:43

meant to be sterile both on their

21:45

to be risk of infection as well and it's such

21:47

quick and easy procedure generally

21:49

when we remove i u d that that

21:51

i would even say by all means go to your

21:53

local walk in clinic as well

21:55

dr renee harm i want to thank

21:57

you for answering all my questions and

21:59

making it

22:00

the town so clear my pleasure

22:02

structure , a hall is clinical

22:04

associate professor at the university of british

22:06

columbia in vancouver vancouver inserts

22:09

about two thousand are you days a days

22:12

here's you just a smart advice there are two

22:14

kinds of i you these copper i you

22:16

these work like these sperm hormonal

22:18

i you these work by causing the cervix to make

22:20

thicker mucus which blocks sperm from getting

22:22

into the uterus they cause

22:24

less leading and cramps and copper i u

22:26

d

22:28

canadian pediatric society and the society

22:30

of obstetricians and gynecologists of canada

22:32

recommend are you these as go to

22:34

method of birth control because they're

22:36

more effective and have fewer side effects

22:38

than the pill the cost of an id

22:41

varies from seventy dollars canadian for

22:43

a copper id to ,

22:45

four hundred dollars for a hormonal hormonal

22:48

mayberry so it pays shop around some

22:50

extended health plans cover idea in

22:53

general choose a provider who has experience

22:56

meaning they insert a lot of i you these

22:58

are regular basis they need to

23:00

do a careful assessment to make sure and

23:02

are you d is right for you

23:04

are you these can be painful to have inserted

23:07

your healthcare provider should anticipate and

23:09

deal with the likelihood of severe pain it

23:12

, around five minutes to put in

23:14

an id id takes longer

23:16

to see how will you tolerate having tolerate

23:18

consider having copper id remove

23:21

only if having severe cramps and

23:23

bleeding after for five months for

23:25

hormonal it's more like half year

23:27

contact your healthcare provider to have it removed

23:30

because of the risk of facing he should

23:32

not try to take it up yourself

23:34

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