Wednesday, 12 September 2012

Life is pain, princess.

Well, it's been a rough few weeks.

I didn't have a lot of energy after returning from Florence, and then there was the Olympics, and then I got some kind of gut bug and was in pain for ages.

Another irritating mishap was having a molar disintegrate on me. Turns out I'm going to need a crown. Meh.

Due to a coincidence of timing, I also was exercising my reproductive freedom and got a copper intrauterine device (IUD) inserted on Monday.  If you're squeamish about girl cooties, don't follow the jump (men being disturbed by such things is more than a little silly, but hey, that's a rant for another day. Women being disturbed by such things is only excusable on the same level as a guy wincing when another guy gets kicked in the crotch).

For various reasons, I'm not unfamiliar with abdominal pain, be it period cramps, gut pain, or back pain triggered by either or both of the former.

The pain during the insertion was profoundly strange. It was also pretty intense. Using this very helpful scale, it peaked at around 8 during the sounding and the insertion itself, which where both rather brief, fortunately. Most women, who haven't had major injury or other things which cause pain, would probably rate it around 11, I think, in part because it is so very strange having something poking you in a place that doesn't get poked.

I've had some interesting experiences with pain over the years; long term migraines, falling in a chip fryer, a sinus infection that was dense as the surrounding bone on the CAT scans, long term gut pain. I remember the doc looking at the scans, looking at me, looking at the scans, then blurting 'How the hell are you even upright?' (For people who were at LCA 2009, that's why I was a little listless, by the way). I wouldn't say I have a high tolerance for pain; I do have a high familiarity with pain. And I know how to do things despite being in the kind of agony that floors a lot of people, because I've had enough practice.

In any case, it's been about 40 hours since I had the IUD put in. Monday evening it was like being kicked between the navel and the crotch with a very pointy stiletto shoe (unlike normal period pain for me, which is like being kicked with just a foot, or maybe punched). Tuesday it was more like a bruise that was under constant pressure, about on level with bad period pain. Today, I've got twinges, and can function more or less normally, although I am not going to be going to the gym.

Why did I put myself though this pain, though? Taking the pill is painless, as are most contraceptive methods. I've got three main reasons.

Hormonal contraception tinkers with the female body in ways that I personally think are not fully understood. It changes emotional state, weight gain, retention, and loss patterns, and interferes with sex drive.

That's one reason. I'm fed up with being fucked around with.

Then there's the effectiveness of the various methods. A quick look at the table on this page, or the one here, shows that for many methods, there's quite a difference between typical use and perfect use for many types of contraception (the wikipedia one is even coloured!). Summarised, an IUD, once inserted properly, just does its thing. Aside from an appointment to get the old one out and a new one in (September 2022, in my case), there is no user interaction. Discrepancy between perfect and typical rates for an IUD related to improper insertion or spontaneous rejection. Unlike the pill, which has to be taken at the same time every day. I can't reliably wake up every day, much less at the same time every day, much less take any kind of medication at the same time every day. Which brings me to my last reason.

The medication I take for idiopathic hypersomnia, Modafinil, this is what the PI sheet has to say, under the heading 'Hormonal contraceptives':
"You will need to consider other birth control methods while taking Modafinil, and for two months after stopping treatment, because Modafinil reduces their effectiveness."

That's pretty clear, I think. From experience, I can say the effect of a pill is reduced to the point where it doesn't control my cycle. I wasn't about to experiment with seeing if I could get pregnant in the interests of scientific curiosity, either.

It's not all rainbows, though. The pain I'm in now is going away. So, for the price of a long GP appointment, and a few days of pain, why don't more women have IUDs? Why isn't it the first port of call for any woman asking her GP for a long term contraceptive plan?

Well, firstly, the insertion doesn't always go as smoothly as mine did, especially in nulliparous (never given birth) women. Whilst most women can lie still for a pap smear, having your cervix opened and something poking your uterus is quite another story. Many women, at that point, try and jump off the couch. My doc used a topical anaesthetic, and it helped ... but it wasn't just the surfaces that were objecting. It was still excruciating. If the woman balks, or panics, well, it's going to take longer. And be more painful. Fortunately (kind of), I've had a lot of experience at sitting still through pain.

Some women don't experience any pain, though. Lucky them.

In terms of pain, it's one of the few contraceptive methods that involve such an upfront investment of pain. The shot and the stick-in-arm don't involve anywhere near that much pain. Also, at some point it has to come out ... and that's probably also going to be quite uncomfortable, moreso than the other methods (although, it did take an hour of digging around in my arm to get the stick out the second time).

Related, if it isn't working out, it's not a matter of simply stopping. You have to make an appointment, and go through the process in reverse. There may or may not be some cost involved. I'll talk about cost in a bit.

On the point of not working out, a lot of women report heavier, longer periods, and cramps. That's the main reason women choose to go for something else after having one.

Last comes cost. In Australia, a copper IUD will cost around $100, plus a visit to someone trained in insertions. The cost of the visit may be defrayed in part by medicare. For comparison, a 3 month supply of contraceptive was costing me $70, and I was seeing my doc for extra long appointments fairly frequently as I went through different contraceptives anyway. In the UK, it was free under NHS. In the US, it costs between $40-140, and insertion costs may or may not be covered by insurance, and in any case, vary widely. Upfront, it isn't cheap. On the other hand, it lasts 10 years. For cost-over-time, it works out pretty economical.

So why has it taken me so long to get one, if they're so awesome?

Partially it's because every single doc has pushed me towards hormonal contraception of one form or another. Partially it has to do with other physical issues I have.

Mostly it's because I don't have children.

There is a medical reason for that - IUD insertion is more painful for women who haven't had children. But that's only a teensy tiny part of the story.

It's only been in the last year that I've had (in the eyes of the medical profession) a valid ethical reason to avoid pregnancy. (Apparently, being unable to tolerate the presence of even dearly loved people at times doesn't count, or children aren't people, or something). Being on stimulant medication which is untested in pregnancy and also even on that medication having difficulty performing normal daily routines is sufficient to override my relationship status and age. Not only that, the effective medication has a side effect of making hormonal contraception useless.

This is more compelling than me simply claiming I don't want to have children. It's irrelevant to the medical profession that I have never wanted children. My biological clock might go off at any time, especially since I'm in a long term, committed, happy relationship with a male. The fact that a risk of pregnancy makes me anxious enough to completely kill my sex drive to the point where sex is impossible is irrelevant. The fact that my medical history and various mental quirks point to having highly autistic children, and because of those same quirks, I can't handle children full time, much less autistic children, is irrelevant. I find it odd to say the least that the welfare of prospective children is irrelevant in the discussion of whether or not to prevent the arrival of said children.

From a strict religious angle (Roman Catholic), I should either be abstinent, or give the child up for adoption after spending 9 months as a semi-conscious vegetable. Neither celibate marriage or the walking (or more likely unconscious) womb scenario appeal (Tleilaxu tanks, anyone?). My opinion is that God can make me preggers if He really wants to (ref: Virgin Mary), so my using contraception shouldn't be a problem for Him.

There's a feminist rant in here somewhere about how I'm bloody old enough at 31 to decide my body's future.

So how does this figure into getting a copper IUD specifically?

It's long term contraception. 10 years. I'll be 41 when I get a new one. Pregnancy in the 40s generally requires fertility assistance, amongst other things, which is covered to a greater extent in Australian socialised healthcare (and private insurance, for that matter) than IUD use. So at the time my first one is coming out, if I decide to have children between now and then, it will suddenly be much more expensive in taxpayer dollars to support my reproductive choices. Far easier for me to have an oops in my 30s.

It requires a non-zero amount of effort to stop, if I want to get pregnant before it expires, and it's a bit less trivial to remove than a stick in the arm. There's a pain barrier, and a potential cost barrier.

Also, doctors kept pushing me towards Mirena (progesterone) rather than the copper IUD. I had some pretty horrific responses to progesterone-based contraception, and the copper IUD is the last resort for doctors, it seems. Try a dozen different types of pill (literally), the stick, the ring, and well ... going through all that has taken as many years as it has. Even now, without the Modafinil, I'm not sure I could successfully get a copper IUD, without a lot of fuss and bother and stuffing around. It'd be touch and go. I strongly suspect it was one of the breakdowns I had in front of my doctor when we were discussing my contraceptive choices that helped avoid some of said fuss.

I can't imagine how challenging it is for a woman without reasons as comprehensive as mine for avoiding childbearing.

Alright, this is in danger of turning into a rant. I'll let it go there, and think some more. And have some nearly-paleo chocolate psuedo-icecream.