The Experiences of Women Who Have Used Intrauterine Devices for a Long Time

ABSTRACT

The intrauterine device (IUD) is an effective and reversible contraceptive method that provides long‐term protection. This study aims to analyze the experiences of women who exceeded their IUD use period. This study was conducted employing the phenomenological method, a qualitative research approach. This study was conducted with a sample of 15 women who applied to the Family Planning Outpatient Clinic of a hospital in Istanbul between February 2024 and April 2024 and used IUDs for at least 11 years. Interviews were conducted individually using the semi‐structured in‐depth interview technique. The data were analyzed with a descriptive analysis technique using the MAXQDA Plus Program. Based on women's experiences of exceeding the recommended duration of IUD use, three main themes were identified. These themes were: 1—Locking from anxiety to fear, 2—continuity of reliability, and 3—from attachment to neglect. This study concluded that women's prolonged IUD use was associated with negative experiences, insufficient information, and inadequate health care services.

Summary.

• Prolonged IUD use is known to be associated with many emotional, psychological, and social factors.

• Although prolonged IUD use is associated with various complications, women continue to use it. However, the emotional, social, and psychological factors influencing this behavior have not been examined in depth.

• This study examined the experiences of women with prolonged IUD use and highlights the importance of understanding their physical, emotional, and social experiences to improve health care quality and processes.

1. Introduction

Intrauterine devices (IUDs) are among the effective and reversible contraceptive methods (Sundaram et al. 2017). IUDs prevent sperm from reaching the ovum or the fertilized ovum from implanting in the uterus by disrupting the inner and outer wall structure of the uterus. IUDs are among the most commonly used contraceptive methods worldwide because they are Callahan (2019). It is used by approximately 14% of women worldwide and by about 27% in certain regions (Buhling et al. 2014; Callahan et al. 2019). When current national research on IUD use in Turkey is examined, it is determined that 14% of married women between the ages of 15 and 49 were using IUDs in 2018, while the IUD use rate decreased by 3% compared to the statistics in 2013. When population studies of the last 15 years are examined, it is determined that IUD use was 20% in 2003 and 14% in 2018 (TDHS 2018).

IUDs are divided into two groups: copper and hormonal. Copper IUDs are thought to prevent fertilization and implantation by interfering with sperm transport. The hormonal form is generally used for treatment to control irregular excessive bleeding and for protection (Ti et al. 2020). In addition, copper IUDs are also the preferred method of emergency contraception (Fok and Blumenthal 2016).

There is some debate in the literature about the duration of use of IUDs. The average duration of IUD use is 10 years (Tilahun et al. 2023). In addition, there are cases where IUDs are used for longer than the indicated duration. For example, a literature review conducted in 2014 reported that some IUDs provide protection beyond the approved duration of use, but this situation cannot be generalized (Wu and Pickle 2014).

When the literature was examined, it was determined that there were many factors associated with women's prolonged IUD use. In a case study conducted by Tilahun et al. (2023), prolonged IUD use was associated with inadequate counseling during application. In their study, Kaller et al. (2020) stated that women using IUDs exceeded their IUD use period due to prejudices such as pain and cramps (Kaller et al. 2020). In addition, women's fear of pain, negative experiences, and false beliefs result in prolonged IUD use (Gomez et al. 2020).

Prolonged IUDs are known to be associated with numerous complications (Committee on Practice Bulletins‐Gynecology, Long‐Acting Reversible Contraception Work Group 2017; Tilahun et al. 2023). These complications have been reported as infection, abnormal uterine bleeding, pelvic pain, uterine and intestinal perforation, ectopic pregnancy, and infertility (Rubin et al. 2020; Argaw et al. 2020; Tilahun et al. 2023; Yaşar et al. 2024).

IUD procedures worldwide are performed by healthcare professionals who have received certification training (Kaller et al. 2020). In Türkiye, according to the Midwifery Regulation published by the Ministry of Health in 2024, midwives are responsible for monitoring women of reproductive age. In addition, it has been stated that midwives who hold an IUD authorization certificate issued by the Ministry of Health are authorized to perform IUD procedures. Accordingly, it is emphasized that midwives play a significant role and hold key responsibilities in IUD procedures (implantation, follow‐up, and removal) in the country where the study was conducted (Official Gazette of Turkey 2024).

This study aims to examine the experiences of women who have used a prolonged IUD. Understanding the physical, emotional, and social experiences of women who have used a prolonged IUD is important to increase the quality of health services and improve counseling processes.

2. Materials and Methods

2.1. Methods

In this study, a phenomenological research design, one of the qualitative research methods including content analysis, was used. The study was guided by the constructivist paradigm, which highlights the active role of individuals in shaping their perceptions of reality. The paradigm is grounded in the notion that people develop their understanding of the world through personal experiences and social interactions (Creswell and Creswell 2022). This study follows the Criteria for Reporting of Standards in Qualitative Research (SRQR) guidelines (O'Brien et al. 2014).

2.2. Reflexivity

The researcher in charge of the study is a midwife who works as an expert in the academy. The research team consists of a midwife working in the field and midwifery students. Women who applied to the hospital's family planning clinic and met the inclusion criteria were referred to the researchers by a midwife who was not part of the research team. The fact that women were referred by an independent midwife during the research process is a critical step in ensuring impartiality. To minimize bias, the data collection process was carried out by two researchers, and immediate field notes were taken of the interviews. The triangulation method was used to ensure reliability and objectivity, and data were analyzed independently by more than one researcher. The collected data were coded regularly using thematic and content analysis to increase the reliability of the study.

2.3. Context

This study was conducted in a Family Planning Polyclinic in a city hospital within the borders of Istanbul Province. The hospital was selected because it was thought to provide a suitable environment for the study due to the sufficient and diverse patient population in the region.

2.4. Participants

Simple random sampling, one of the probability sampling methods, was used to select the sample. Women who presented at the Family Planning Polyclinic between the study dates and who had used the IUD for at least 11 years were invited to the study by an independent midwife. Semi‐structured in‐depth interviews were conducted with women who agreed to participate in the study by the researchers (S.N.B. and E.A.) in a room at the polyclinic where individual interviews could be conducted.

2.5. Data Collection

Data were collected between February 1, 2024, and April 1, 2024, using a personal information form (nine questions) created in line with the literature (Merghati Khoei et al. 2019; Puri et al. 2020; Firoozikhojastehfar et al. 2021) and a semi‐structured interview form (four questions) created for women's long‐term IUD use experiences. In order to evaluate the internal validity of these questions, expert opinions were obtained from two researchers who were not included in the study and had qualitative research experience. In this regard, a pilot study was conducted with three women who were not included in the study. Since the feedback received from the women determined that the research questions were clear and easy to understand, no changes were made to the original version of the questions.

The questions asked to guide this research are as follows:

1. Could you explain your reasons for preferring IUD?

2. What experiences influenced your decision to extend the duration of IUD use?

To collect data, face‐to‐face, semi‐structured, in‐depth interviews were conducted by the researchers (S.N.B. and EA). Verbal and written consent was obtained by the researchers at the beginning of each interview. The interviews lasted approximately 15 min and were recorded with a voice recorder. In order to protect the data, the interviews were deleted immediately after being transcribed.

2.6. Data Analysis

In this study, thematic analysis was employed to process qualitative data. Feedback comments were transcribed verbatim and analyzed using thematic analysis, a flexible and rigorous qualitative method that allows for both inductive and deductive approaches (Kiger and Varpio 2020). After the interviews were completed, the researchers reviewed the relevant literature for guidance. The data obtained from the interviews were transcribed immediately after each interview to ensure completeness. Line‐by‐line coding was performed by the researchers following each interview. The codes were subsequently merged into themes, with the analysis being inductive at this stage, as the researchers grouped their codes into broader themes.

Thematic coding was carried out using MAXQDA Plus qualitative data analysis software. Coding was carried out manually by the researchers. The themes identified were discussed and supported by direct quotes from the participants.

Guba and Lincoln (1994) outline four criteria for ensuring trustworthiness in research: credibility, dependability, confirmability, and transferability. To enhance credibility, the researcher employed the triangulation method. Dependability was maintained by adhering to established qualitative analysis standards and conducting regular meetings. To strengthen confirmability, the authors engaged in detailed discussions over several months, focusing on critical reflection (Guba and Lincoln 1994). Additionally, feedback was obtained from an independent qualitative researcher not involved in the study to ensure transferability, allowing the findings to accurately reflect participants' narratives while minimizing the influence of the authors' personal perspectives and potential biases (Cypress 2017).

2.6.1. Ethical Aspects of the Study

This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval for the study was obtained from the Non‐Interventional Clinical Studies Ethics Committee of the Faculty of Health Sciences at Marmara University (25.01.2024/34). In addition, permission was obtained from the city hospital where the study was conducted.

3. Results

The mean age of the women (n = 15) who participated in the study was 42.8 ± 7.07 years, the mean duration of education was 9 ± 4.53 years, and the mean years of IUD use was 13.29 ± 1.89 years. The detailed participant information and characteristics are presented in Table 1.

TABLE 1.

Sociodemographic data of participants.

Participant	Age	Marital status education	Duration of education	Employment status	Duration of IUD use (years)
Female‐1	44	Married	5	Not working	13
Female‐2	42	Married	12	Not working	12
Female‐3	50	Married	5	Not working	14
Female‐4	33	Married	16	Working	11
Female‐5	37	Married	12	Not working	13
Female‐6	32	Single	5	Working	12
Female‐7	38	Married	5	Not working	13
Female‐8	46	Single	16	Working	15
Female‐9	46	Married	8	Not working	18
Female‐10	44	Married	12	Not working	13
Female‐11	53	Married	8	Not working	12
Female‐12	35	Married	16	Not working	11
Female‐13	48	Married	5	Not working	15
Female‐4	55	Married	5	Working	1
Female‐5	39	Single	5	Working	15

In the descriptive analysis of the interviews, three main themes were identified after the codes were determined. These themes are “Locking from Anxiety to Fear,” “Continuity of Reliability,” and “From Attachment to Neglect.” The participants' statements were presented separately under each theme, accompanied by direct quotations (Figure 1) (Table 2). The theme “Locking from Anxiety to Fear” reflects the physiological and psychological reactions that women experience with the use of prolonged IUDs, and includes codes such as anxiety, fear, pain, uncertainty, and bad experience. The theme “Continuity of Reliability” highlights women's continued confidence in prolonged IUD and their ease of use, with codes like trust, protection, easy, applicable, and comfortable. Finally, the theme “From Attachment to Neglect” represents the spectrum of women's attitudes toward prolonged IUD use, ranging from commitment to indifference, and includes the codes attachment, ignoring, and neglecting (Figure 1) (Table 2).

FIGURE 1.

Theme‐code hierarchy.

TABLE 2.

Theme and code.

Theme	Definition	Code
Locking from anxiety to fear	It is about the physiological and psychological reactions that women experience with the use of prolonged IUD.	• Anxiety • Fear • Pain • Uncertainty • Bad experience
Continuity of reliability	It is about women's continued confidence in the prolonged IUD and its ease of use.	• Trust • Protection • Easy • Applicable • Comfortable
From attachment to neglect	It is related to women's attitudes toward prolonged IUD use, varying between commitment and indifference.	• Attachment • Ignoring • Neglecting

3.1. Theme 1: Locking From Anxiety to Fear

Women expressed concerns about experiencing pain during their IUD insertion or removal. As a result of these worries, they delay seeking healthcare services for IUD removal within the recommended time frame. These concerns were articulated by the participants as follows:

I was very anxious when the IUD was inserted. That's why I couldn't come for its removal. Of course, I can also say that I was worried and afraid of experiencing pain. (Woman‐1)

I was a little scared when it was inserted, and I was afraid of feeling pain when it was removed. That's why it has been standing for 13 years. (Woman‐10)

Women reported experiencing fear due to negative past encounters with healthcare services. This fear restricts their access to healthcare and contributes to delays in seeking treatment.

This fork scared me a lot, my birth was difficult because of it, I don't know if it traumatized me anymore, I don't know if it traumatized me anymore, it haunts my dreams. That's why I'm a little late. (Woman‐11)

Going up to the fork makes me very nervous. I remember what I went through before, and now I came because I had to; otherwise, I would never have come. Nothing happened anyway, so what if I came, so what if I didn't. (Woman‐14)

I was afraid to put it on. Besides, I am sick and I already have high blood pressure. I am now very afraid of the hospital and doctors. I can't do it. I don't even want to come here (Woman‐9)

Women who have not undergone the IUD removal process may experience fear due to uncertainty about how the procedure will unfold. The lack of knowledge regarding the process is a primary source of fear. Additionally, uncertainty about whether the procedure will be painful or uncomfortable can contribute to this fear. Women articulated their concerns regarding the uncertainty of IUD removal as follows:

I didn't come because I was too scared to have my spiral removed. (Woman‐3)

I didn't come to get it removed because I was scared. I made two appointments, but I always canceled them. Now I'm here because I'm getting married. Otherwise, I wouldn't get it removed again. (Woman‐6)

There was also fear. I did not want to remove it because I did not know how it was removed before and I was afraid. (Woman‐7)

3.2. Theme 2: Continuity of Reliability

The average duration of IUD use is 10 years, and the long‐term nature of this method contributes to women's preference for it as a contraceptive option. Women continue to use the IUD because they believe it will remain effective over time. In addition, the absence of problems with IUD use and satisfaction with the method have encouraged continued use. In this context, the reliability of the IUD as a long‐term method of contraception is a key reason why women continue to use it beyond the recommended duration. Women described the situation as follows:

I didn't actually take it off because it protected me from pregnancy for a long time. And, of course, I never thought about the second child in God's power. I never came because it protected me for a long time. Thank God I haven't had any problems so far, thank God… (Woman‐5)

I preferred the spiral because I knew it would protect me from pregnancy for a long time. I didn't want to remove it afterwards. (Woman‐7)

IUDs are one of the most widely used contraceptive methods in the world and are reliable and easy to use for almost all women. The women who took part in the study said that IUDs are easier to use than other contraceptive methods, such as oral contraceptives or male condoms, and that this situation ensures the continuity of IUD use:

I thought that the spiral would be, how should I say, more protective and easier to apply, and you forget to take the pill, I don't know, condoms are risky things… so I never thought of such things. (Woman‐8)

I use it because I find it more comfortable than other methods. I believe it is the most comfortable and reliable method. I've been using it for so long and nothing happened. (Woman‐9)

One of the women who participated in the study stated that although the period of use of the IUD had expired, she did not want to remove it because she trusted this method and it was easy to use. The patient also stated that the long‐term protection provided by the IUD played an important role in her decision to continue using this method. She stated that the security provided by the method was the main factor in her preference for IUD.

I did not want to remove it too much because it has high reliability and is easier to use. (Woman‐10)

3.3. Theme 3: From Attachment to Neglect

The women who participated in the study reported that they generally preferred the IUD for its long‐term protection and that they developed an emotional attachment to the method throughout this process.

I wanted protection for a long time. I didn't want to take it off because I think I'm attached to him. I don't want to break up with him. I still don't want to take it off, but you know. (Woman‐13)

This attachment results in the IUD not being removed despite the expiration of its recommended usage period, as women rely on its protective effects and do not wish to separate from it. One of the women who participated in the study described the IUD as a reliable method of pregnancy prevention and explained that a trust relationship developed between her and the method throughout this process, as follows:

Actually, I wanted to take it off, but my husband told me to leave it on if it does not harm you, so I left it on thinking that nothing would happen. I thought it would continue to protect me anyway, and I didn't think anything would happen if it stayed in my womb. I think I trusted it to protect me from pregnancy. (Woman‐12)

Many people prefer to ignore situations that bother them rather than confront them. Although ignoring provides temporary relief for the individual, it causes problems to grow and become more complicated in the long run. One of the women who participated in the study, although she was aware that she had exceeded the period of use of IUD after separating from her husband, she thought that there was no harm and ignored the situation until she started bleeding. The woman expressed this situation as follows:

It's been 8 years since I left my wife. After we had separated, I don't know. I mean, nothing like that ever happened. There was no harm to me at all. There are no problems with my periods. And when that didn't work, I thought I would stop. Lastly, I bled profusely at work and returned home. I'm an idiot. (Woman‐8)

The women participating in the study reported that they neglected to seek healthcare services to avoid complications and pregnancy, which led them to continue using the IUD despite its expiration, as follows:

It was delayed because of the pandemic. Of course, my negligence was also the reason for both. I am structurally negligent in doctor's work. I mean toward myself. I don't like going to the doctor too much. (Woman‐5)

Actually, that was my negligence. I have neglected to do so. Normally, I should have come, but I neglected. I didn't know that it could be inserted directly when it was removed, so I neglected to come in case I got pregnant again…(Woman 15)

4. Discussion

In this study, the reasons why women continue to use this method despite the end of their IUD use period were evaluated, and their experiences in this process were revealed.

The duration of IUD use of women was found to be 13.29 ± 1.89 years. In addition, a recent case report reported that IUD use had been going on for 40 years (Tilahun et al. 2023). When the reason for this situation is examined, it is seen that the woman forgot to have the IUD removed. Parallel to this study, Zhu et al. (2013) found that the average IUD usage time was 10.29 ± 5.4 years (Zhu et al. 2013). In a study conducted by Bahamondes et al. (2005), it was observed that the rate of IUD use among women was 67% at the end of 10 years and 21.2% at the end of 16 years (Bahamondes et al. 2005). Based on these findings, it was determined that women continued to use IUD for many years.

There are several reasons why women who participated in the study continued to use IUDs despite their expiry date. These reasons include fear, pain, insufficient information, concerns about the gynecological table, and negative health experiences in the past. Stimmel et al. (2022) reported that women who had a bad birth experience and did not trust health services did not apply to the hospital to remove the IUD (Stimmel et al. 2022). In a case study conducted by Koh (2023), it was determined that women were unaware of the presence of IUDs and therefore did not go to the control (Koh 2023). These findings show that women's behaviors in benefiting from health care services are affected by many individual and social factors.

Informing the public about contraceptive methods provided by health care providers is an important factor affecting the timing of IUD removal. The fact that women are not sufficiently informed about the procedure and timing of IUD removal may lead them not to apply for the removal procedure even when the period of use has expired. In this study, it was stated that women had inadequate information about the IUD removal procedure and therefore experienced fear and did not apply to health institutions. When the literature was analyzed, it was found that women generally received information about the removal time of IUD from health care providers and applied to the hospital because of this information (Stimmel et al. 2022; Zong et al. 2022; Jiang et al. 2023).

Women prefer IUD because it is a hormone‐free, inexpensive, effective, easy‐to‐use, and long‐term treatment method (Bateson et al. 2016; Callahan et al. 2019). However, in this study, no findings were found regarding the content of IUD that affects women's preferences. This indicates that women do not have enough information about IUD or cannot get information.

Delays in accessing healthcare services due to factors such as migration, war, or the Covid‐19 pandemic, neglect of annual gynecological examinations, lack of medical records, and inadequate awareness of individuals about IUDs lead women to continue using this method for a long time and neglect their regular check‐ups. In a case study conducted by Koh (2023), it was observed that the woman continued to use IUDs despite being 2 years postmenopausal, skipped check‐ups, and neglected to apply to the health institution despite the expiration date (Koh 2023). When the literature was reviewed, it was reported that forgetting to remove the IUD was the most common reason for neglect (Aniulienė and Aniulis 2014; Christodoulides and Karaolides 2020). In this study, it was observed that women postponed and neglected this procedure even though they knew that the IUD should be removed. In addition, a recent case report reported that IUD use had been for 40 years (Tilahun et al. 2023). When the reason for this situation is examined, it is seen that the woman forgets to have the IUD removed.

This study concludes that having an IUD inserted can be perceived as a painful and negative experience for women. The fact that women are reluctant to have it removed or postpone it despite the expiration date may be related to previous negative experiences. When the literature is reviewed, it has been stated that bad hospital experiences have negative effects on women. In addition, it has been determined that some women prefer to do the removal themselves (Stimmel et al. 2022; Muna and Mahiti 2022).

The decline in the use of IUDs in recent years suggests that women are not receiving sufficient information on the subject and that there are inadequacies in the counseling provided by health professionals. This situation highlights the need for a more effective counseling approach in women's health services. Health professionals, especially midwives, should receive more comprehensive training on the use of IUDs, and women should be made aware of this method. In addition, increasing the authority and responsibility of midwives in this area through the Midwifery Regulation 2024 may improve the effectiveness and safety of the practice. This policy will be an important step in ensuring that women have access to correct and safe family planning methods.

4.1. Limitations

Limitations of this study include that the sample was drawn from only one geographic location (one hospital in Istanbul Province), which may limit the generalizability of these results. Furthermore, a study of women's self‐reported experiences may have influenced responses by social expectations or individual biases. Although this study adopted a qualitative approach, it is thought that it may be difficult to generalize the findings without confirmation by larger‐scale quantitative studies.

5. Conclusion

These results show that women's experiences of IUD removal are influenced by many factors. In general, previous negative experiences are reflected in the IUD removal process. Therefore, women delay or do not receive health care services. In addition, removal is prolonged because women are not sufficiently informed about the IUD. In addition, inadequate health care services for women result in the forgetting of IUDs.

Health care providers should ensure that women are sufficiently informed about IUDs. This will prevent women from prolonged IUD use. It is also important that midwives check the women intermittently. Thus, complications that may occur are prevented. In future studies, it is recommended to create a “IUD Follow‐up Card” so that women can follow the duration of IUDs.

Technological solutions, such as digital tools and mobile health applications, can prevent prolonged IUD use by providing women with faster access to accurate information. In addition, increasing public awareness through health education campaigns can help women make more informed decisions about their health. It is recommended that future studies evaluate the effectiveness of such interventions.

Author Contributions

Zeynep Dilşah Karaçam Yılmaz: conceptualization, investigation, funding acquisition, writing – original draft, methodology, writing – review and editing, formal analysis, supervision. Ceyda Şapoğlu: conceptualization, methodology, writing – original draft, writing – review and editing, supervision. Sena Nur Bülbül: conceptualization, methodology, formal analysis, writing – original draft, investigation, data curation. Eda Aydoğan: conceptualization, investigation, formal analysis, data curation, writing – original draft.

Ethics Statement

Ethical approval for the study was obtained from the Non‐Interventional Clinical Studies Ethics Committee of the Faculty of Health Sciences at Marmara University (25.01.2024/34).

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.