Thursday, May 13, 2010

Contraceptive Confections—IUDs, you are so sweet

Disclaimer: These cookies do not prevent pregnancy.

In my last post I celebrated the birth of oral contraceptives.  Today I will salute another favorite form of birth control, the intrauterine device, or IUD.  IUDs have an interesting history of their own.  They have a very bad reputation among many of the lay population, but in fact, they are an extremely effective and safe form of birth control.  I would say that IUDs are a great form of contraception because they are very popular for OB/GYN docs [1].  If that doesn’t speak for itself!

The bad reputation of the IUD comes from a previous form of the IUD called the Dalkon Shield released in the 1970s.  The Dalkon shield caused a lot of controversy because it was blamed for causing an increased rate of pelvic inflammatory disease and infertility. A 1981 study showed that woman were 5 times more likely to have pelvic inflammatory disease from the Dalkon Shield than from other IUDs [2,3]. The Dalkon Shield is banned, but won’t be forgotten because it’s also a bandAlthough, not a very good band.

In the US currently, there are two FDA approved IUDs--the Mirena and the Paragaurd.  The Mirena is impregnated with progesterone and is effective for five years, and the Paraguard, the more traditional device wound with copper wire, is effective for ten years.  The Mirena works by secreting progesterone into the uterine cavity and makes the uterus inhospitable to implantation as well as thickening cervical mucus (yeah I know, cervical mucus…kind of gross to some).  The copper in the Paraguard reacts with the uterine cavity to inhibit implantation.

The IUD is an highly effective form of contraception, more effective than birth control pills, with a pregnancy rate of <0.5% over 5 years [4].  The side effect profile is low; women are at a minimally increased risk of PID if they have an STD at the time of insertion [5,6].  Women can experience cramping, abnormal bleeding, and expulsion. The IUD does not affect fertility, and fertility returns once the device is removed [7]. 

Along with the birth control cake for my contraceptive confections series, I made IUD cookies.  What could be more delicious than a simple sugar cookie decorated to look like a plastic device inserted into the uterus?  Nothing really.  My fiancĂ© ate them all.  I used my favorite childhood sugar cookie recipe straight from nothing else but the Betty Crocker Cookbook.  I fashioned up some simple royal icing and with my two surgeon gal pals, we delicately iced the ladylike cookies.  So thanks girls and I’m so proud of you!

IUD Cookies
Sugar Cookies from The Betty Crocker Cookbook
Makes about 50 IUD cookies

T shaped cookie cutter (purchased at Sur La Table and the only thing in the ENTIRE store that costs $1)

Cookie dough
1 ½ cups powdered sugar
1 cup (2 sticks) butter softened
1 tsp vanilla
½ tsp almond extract
1 large egg
2 ½ cups all purpose flour
1 tsp baking soda
1 tsp cream of tartar

Royal icing
4 cups powdered sugar
6 tbsp heavy cream or 4 egg whites

Beat powdered sugar, butter, vanilla, almond extract and egg in large bowl.  Stir in remaining ingredients, cover and refrigerate for at least 2 hours.  Heat oven to 375.  Roll dough to ¼ inch thick on floured surface, cut into T shape.  Bake 7-8 minute or until edges are light brown. 

Combine icing ingredients until smooth.  Color some and leave some icing white.  Pipe shape with pastry tube.

If you are interested in an IUD, please discuss with your doctor.  I might be a doctor soon, but I’m not yours.  There are other risks and side effects not discussed above. 

1. 2003 ACOG News Release. Gallup Survey of Women
OB/GYNs. Available at:
publications/press_releases/nr12-09-03.cfm. Retrieved February
3 Burkman RT. Association between intrauterine device and pelvic inflammatory disease. Obstet Gynecol 1981;57(3):269-76.
4. Thonneau, PF.; Almont, T. “Contraceptive efficacy of intrauterine devices.” American Journal of Obstetrics & Gynecology, v. 198 issue 3, 2008, p. 248-53.
5. Mohllajee, AP.; Curtis, KM.; Peterson, HB. “Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review.” Contraception, v. 73 issue 2, 2006, p. 145-53.
6. Shelton, JD. “Risk of clinical pelvic inflammatory disease attributable to an intrauterine device.” The Lancet, v. 357 issue 9254, 2001, p. 443.
7.  Hubacher, D., et al. “Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women.” New England journal of medicine, v. 345 issue 8, 2001, p. 561-7.


  1. I love the Mirena! Hurt like a b*tch to put in, but totally worth it in the end. The other big benefit--I barely have a period anymore. It's awesome.

  2. You crack me up! Nice cookies and great info on IUDs.
    I did get a chuckle though when you said that the Mirena is IMPREGNATED with progesterone. Pun intended?

  3. Is the gummi Nuva Ring next???

  4. Yummy cookies.

    Interesting story about the research that showed IUDs to be associated with PID.

    There were over 20 studies that showed that IUDs were associated with PID, and many of them did _not_ involve Dalkon shield. For a long time, these studies were the basis of a general disdain for the device. In aggregate, these studies showed a 3-10x relative risk for PID for IUD wearers versus non-wearers.

    Each study was a case control, that compared women admitted to the hospital with PID to women admitted to hospital for other diagnoses. They then looked at how many of each group had IUDs, and found that the group that had PID were far more likely to have IUDs than women admitted for other indications.

    This study got re-done in a zillion different environments, and each time showed that PID was associated with IUD use.

    The problem was that this study design was very flawed, and even though the study was repeated over 20 times, the ultimate result was incorrect.

    The study design had a great deal of selection bias. Women who presented to the ED were often evaluated by the ED physician, and if they had simple PID they were often sent home. They were only admitted if they had 'complicated' PID. And guess what was considered a criteria for 'complicated' - IUD use. As such, the women in the hospital with PID were far more likely to be wearing IUDs than the general population of women with PID.

    The moral here is that one really had to read the study design before you decide if the results are reliable. The secondary moral is that if the same bad study is repeated, you will get the same wrong answer. Repeating an incorrect study design 20 times does not make a more correct answer. Bias is not eliminated by power.

  5. Dr. Fogelson, thanks for such a thoughtful response! I wanted to talk about this but I honestly didn't understand enough background to explain thanks for being an "attending" of sorts to make sure that I dispel correct information. Hope you're having fun at ACOG!

  6. It's very interesting. Thanks to the author.

  7. Bahahaha... this is cute. I got a Mirena put in not too long ago. 'Installation' hurts like a motherfucker... totally don't get why they don't use local anesthesia.

  8. Hi! I just found this. SO cute! I got an IUD put in yesterday. It hurt a lot to put in, but I feel fine today!

    Also! I asked my doctor about anesthesia, and she said the reason they don't use local anesthesia is that it hurts as much to stick a needle in your cervix to numb it as it does to put the thing in- i.e. why add an extra step?

  9. I am presenting IUD information for patients and providers tomorrow as part of my Nurse Practitioner program. I can't wait to share these cookies. Thank you for the idea and included blog on contraception.

  10. Love it. May I use your cookie pic with a link to this page on my blog?