The IUD: A History

IUDs are under the umbrella of long-acting, reversible contraceptives, and they’re the oldest one of these in use today.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

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• 2:42Holly Frey?

  Welcome to Stuff You Missed in History Class, a production of iHeartRadio.

• 2:53Tracy V. Wilson?

  Hello and welcome to the podcast. I'm Tracy V. Wilson.

• 2:56Holly Frey?

  And I'm Holly Frey.

• 2:59Tracy V. Wilson?

  This is one of a number of episodes that I've done on the show that was inspired by internet behavior that I've been witnessing. Today, it is the history of the intrauterine device. Intrauterine device is how it's technically pronounced, but it always is going to come out of my mouth, intrauterine, sort of slurred together, probably. We will be getting into the internet behavior inspiration at the end of the episode. IUDs are under the umbrella of long, long-acting reversible contraceptives. They are the oldest one of those that is in use today. And an estimated 160 million people around the world use them, but their popularity

• 3:44Tracy V. Wilson?

  really varies from place to place. Some of that is connected directly to its history.

• 3:53Tracy V. Wilson?

  This whole episode of our podcast is about inserting devices into the uterus to prevent pregnancy. I'm a person who feels pretty comfortable with my body. I have watched my share of gory medical dramas on TV. Sometimes Patrick will walk in the room and he will watch sort of the, you know, the talking scene of doctors happening. And then there will be blood on screen and he goes, nope, and he leaves. I keep watching. Um, but some of the history that we are going to talk about is like right on the edge of body horror to me, even with all that context. Huh. Uh, also, um, this is not medical advice.

• 4:35Tracy V. Wilson?

  We are not going to be talking in any kind of great detail about like the benefits and risks of IUDs from today's understanding. It is about history, not like current medical thought on them.

• 4:46Holly Frey?

  There are a couple of probably apocryphal stories about the beginnings of IUDs that show up pretty regularly in articles about their history. One is that hundreds or thousands of years ago, nomadic peoples would put stones into the uteruses of camels so they would not become pregnant during long journeys through the desert. The origins of this factoid are pretty unclear, but it only seems to show up in writing about IUDs, but that's generally writing that comes from North America or Europe.

• 5:19Tracy V. Wilson?

  Yeah, I guess it's not completely impossible. It doesn't seem like something that's documented outside of this.

• 5:27Holly Frey?

  Yeah.

• 5:28Tracy V. Wilson?

  This conversation. Also, you can say it uteruses or uteri, either way is fine. It's all good.

• 5:37Tracy V. Wilson?

  There are also vague references to Hippocrates having written something about IUDs. The Hippocratic corpus dates back more than 2,000 years. It encompasses roughly 60 different Greek medical texts. Those were written over the course of about two centuries. I don't want to judge anybody too harshly for shorthanding all of that to just Hippocrates. I'm sure we have done that at some point, but in these IUD discussions, nobody really cites a specific source for whatever it is that Hippocrates supposedly specifically said. Classicists and medical historians Rebecca Phyllis and Helen King traced the probable

• 6:21Tracy V. Wilson?

  origin of this to a passage in book two of the Hippocratic text known as Diseases of Women. That describes a method for opening the cervix. It does not describe placing anything in the uterus. And this also was not something that was described as being done to prevent pregnancy. So something else has been sort of misstated as being Hippocrates talking about IUDs.

• 6:51Holly Frey?

  So the most likely precursor to the IUD is not Hippocrates or stones in the uteruses of camels. It's the pessary, which is one of the oldest medical devices still in use today. A pessary is used in the vagina to support the uterus. Today's pessaries are typically made from soft, flexible materials like silicone or silicone coated rubber, and they come in a variety of shapes depending on exactly what they're intended to do.

• 7:20Tracy V. Wilson?

  Historically, before we had those materials, pessaries were made with a range of other materials. In the 16th century, past podcast subject, Embois Paré used hammered brass and waxed cork, as well as gold and silver. Other materials included sponges and wax. There is apparently a description of using half a pomegranate as a pessary in Book Two of Diseases of Women. I was not able to directly confirm that, though. It's not impossible that that's in there.

• 7:51Holly Frey?

  That seems so problematic.

• 7:53Tracy V. Wilson?

  That seems large to me, unless it was a very small pomegranate.

• 7:57Holly Frey?

  I'm also just thinking that, like, pomegranates have a lot of crevacy surface area?

• 8:04Tracy V. Wilson?

  Yeah.

• 8:05Holly Frey?

  Where, like, bacteria could move in.

• 8:08Tracy V. Wilson?

  Questions I have.

• 8:09Holly Frey?

  Yeah, many. Listen, we don't know. Today and historically, pessaries have primarily been used to treat a pelvic organ prolapse. Depending on their shape, pessaries can also treat some kinds of incontinence, or they can be used as part of the preparation for a pelvic surgery. Since a pessary can sit at the top of the vagina next to the cervix, they've also been used as contraceptives, either alone or in conjunction with some kind of spermicide. So today, most people call these kinds of devices diaphragms or cervical caps, but some of the earliest ones were billed as occlusive pessaries.

• 8:49Tracy V. Wilson?

  While pessaries are used in the vagina, in the late 19th century, there were also intra-cervical pessaries. These had a flattened out part like a disc or a button that was attached to a rounded stem. That stem went into the cervical canal and the disc rested against the outer surface of the cervix. And then there were intrauterine pessaries, which had a disc connected to a longer stem that went all the way through the cervical canal into the uterine cavity.

• 9:23Holly Frey?

  In the simplest intrauterine pessaries, the stem was about five centimeters, it's about two inches long, and it was wider at the far end to keep it from slipping back out through the cervix. More complex intrauterine pessaries had a loop that rested inside the uterus or a pair of legs, kind of picture a wishbone. These parts would be squeezed together and encased in a gelatin capsule for insertion, and then that capsule would dissolve in the uterus, so those legs could expand out.

• 9:53Tracy V. Wilson?

  We've been assuming that everyone in the audience right now has a basic understanding of the anatomy of the female reproductive system, but we're gonna pause for a second here, because I realized while working on this that my mental image of the cervix does not line up with reality. And that made the size of these intra-cervical and intrauterine pessaries really confusing, because I thought that the cervix was sort of like a dense muscular valve, maybe a centimeter or two thick. And that meant that the stems on these pessaries seemed like they were way too long. The cervix, though, is really more like a tunnel. It is closer to three centimeters or a little over an inch long,

• 10:35Tracy V. Wilson?

  although that changes significantly during portions of pregnancy. I mentioned my confusion on this to some friends, and they were also confused. Basically, the only person in the group chat who had a correct understanding of the cervix was the midwife. So it sort of seems like it might be a common enough misconception to clear up here, since it would not otherwise really make sense in the context of these pessaries. I blame... Vague illustrations that don't really differentiate between the cervix and the lower part of the uterus.

• 11:10Holly Frey?

  Like other pessaries, in the 19th and early 20th centuries, intracervical and intrauterine pessaries were primarily used to support the uterus. They were also used to treat conditions ineffectively, uh, for things that they just would not have had any kind of impact on, like irregular menstruation and conditions that have no foundation in medicine, like our good old favorite hysteria. And since they blocked the cervix and in the case of intrauterine models occupied the uterus, people used them to try to prevent pregnancy, or in some cases to try to terminate pregnancies. Gynecologist, surgeon, and pathologist Mary Halton, who is the only woman doctor

• 11:53Holly Frey?

  in this whole episode, was regarded as the foremost expert on these devices for contraception in the US in the early 20th century. She said she had used them on more than 700 patients in her practice in New York.

• 12:08Tracy V. Wilson?

  So whatever these are being used for, uh, in most cases, not very effectively. They apparently weren't that great at preventing pregnancy either. In my opinion, these sound terrible. Most of them were made from gold, silver, aluminum, or hard rubber, and then they sat in the cervical canal or went all the way through it. So having experienced like the temporary sensation of an IUD insertion and the discomfort of many years' worth of pap tests, I just can't imagine that having a piece of metal going all the way into or through my cervix would be comfortable at all, especially since the stems on some of these things were not smooth. They were shaped like springs or coils.

• 12:53Tracy V. Wilson?

  Also, a lot of these were meant to be used for a month or two at a time and then removed and cleaned and reinserted. Halton talked about having to let the cavity heal before it could be reinserted. The intracervical model that we described here was placed by a doctor at the end of someone's menstrual period, and then the patient was supposed to remove it just before the start of the next one. But the intrauterine models had to be inserted and removed by a doctor. So there was just like, a lot of very uncomfortable seeming doctor visits involved with this.

• 13:28Holly Frey?

  James Friar Cooper's 1928 Technique of Contraception: The Principles and Practice of Anti-Conceptional Methods describes the disadvantages of intracervical pessaries as including infections, irritation, being extremely difficult to adjust except by a doctor, and, quote, "It does not entirely occlude the cervical canal, so that pregnancy may take place." So, also ineffective. He describes the intrauterine pessary as unreliable as a contraceptive and says that reports from both London and New York associate them with infections and even deaths. So, quote, "From a health viewpoint, this type of pessary

• 14:11Holly Frey?

  is therefore undesirable." Even so, these pessaries were in use as contraceptives until around the 1930s.

• 14:20Tracy V. Wilson?

  At this point, these concerns about infections were well-founded. Antibiotics had not been invented yet. If one of these pessaries was inserted in a non-sterile way, or if pathogens traveled along it from the vagina to the uterus, or if it caused injury to one of these organs, any infection that developed could be life-threatening. But this association with infections would continue after the development of true IUDs, and it was initially because of their connection to these pessaries.

• 14:52Holly Frey?

  We will get to the first actual IUDs without a part that stayed outside the cervix after a sponsor break.

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• 17:40Tracy V. Wilson?

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• 19:40Tracy V. Wilson?

  The first published description of an IUD was by physician Richard Richter in an article in the German Medical Weekly magazine in 1909. Its title translated to "A Means of Preventing Conception." Richter described using two threads of silkworm gut tied in a simple loop, like a very loose overhand knot. The free ends of the silkworm gut were encased in celluloids so that they would not damage the lining of the uterus. A bronze wire was connected to the bottom of this loop that held the two threads together, and it also made the device visible on an X-ray and facilitated its eventual removal.

• 20:23Tracy V. Wilson?

  This loop was inserted into the uterus using a hollow probe, and the end of the wire was snipped off close to the outer surface of the cervix.

• 20:33Holly Frey?

  Richter said he had been testing this for several years, and that the silkworm threads irritated the mucous membranes of the uterus enough to keep an egg from implanting, but not so much that the patient could feel it. He said the longest that one of his patients had kept one in place was four years, and that after the device was removed, his patients were able to conceive and had uncomplicated pregnancies. He didn't give any specific details about how many patients he had treated this way or data on how effective this method was.

• 21:06Tracy V. Wilson?

  In 1923, Carl Pust published an article in the same journal with a title that translated to "A Useful Protection for Women." He said that he had treated more than 400 patients with a similar device that also had some of the traits of an intrauterine pessary. Pust described it as a pessary in the paper. In addition to a loop of silkworm gut that sat inside the uterus, this device had a tail made of silk that extended out through the cervix. The tail was attached to a button made of borosilicate yena glass, which is heat and shock resistant. This button rested against the surface of the cervix. Pust claimed that there had been no serious complications

• 21:51Tracy V. Wilson?

  in any of those 400-plus patients, and that more than 20,000 of these devices were in use.

• 21:59Holly Frey?

  Around the same time, also in Germany, gynecologist Ernst Grafenberg started experimenting with intrauterine contraceptive devices in his private medical practice. Like Richter and Pust, his first attempts involved a loop of silkworm suture, although he doesn't seem to have been aware of their earlier work. His loops were prone to being expelled from the uterus, so he tried wrapping the suture in silver wire, creating a flexible ring. Pure silver was absorbed by the patients' bodies, causing them to develop argeria, or a blue tinge around their gums. He switched to an alloy of copper, nickel, and zinc that's known as German silver.

• 22:42Holly Frey?

  The copper probably provided at least some of the contraceptive effect of this ring, although that connection wasn't discovered until much later.

• 22:50Tracy V. Wilson?

  Grafenberg gave a presentation on his intrauterine ring at a course presented by birth control advocate Margaret Sanger in 1928, and then at the 1929 International Sexual Reform Congress in London, and then at the 1931 German Congress of Gynecology in Frankfurt. He published his work on this device in 1931 as well, reporting a failure rate of only 1.6%. But other gynecologists denounced the Grafenberg ring as unsafe. Grafenberg was using sterile procedures when inserting these rings, and they didn't have a portion that extended through the cervix, but they were still associated with

• 23:32Tracy V. Wilson?

  the infection risks of intracervical and intrauterine pessaries.

• 23:37Holly Frey?

  Grafenberg's work was happening alongside a movement for birth control and sexual reform in Germany. This was during the period that's known as the Weimar Republic. We've talked about it a few times lately. It was a time of both political turmoil and social and artistic freedom. This was also when Magnus Hirschfeld was operating the Institute for Sexual Science in Berlin, which conducted research and training on sex, sexuality, and gender, and developed a massive library on those subjects. Many of Hirschfeld's patients would be described as gay, lesbian, bisexual, or transgender today, although most of those terms were not in use, or they were not used quite the same way at the time.

• 24:22Holly Frey?

  Our episode on Hirschfeld and the Institute ran as a Saturday classic in April of 2023.

• 24:29Tracy V. Wilson?

  The Weimar era ended with the rise of Nazi Germany. In 1933, Nazis raided the Institute of Sexual Science and burned its entire library of an estimated 20,000 books. Hirschfeld was both gay and Jewish, although he had not been observant since his childhood, and Nazi propagandists used him as an example of degeneracy. Ernst Grafenberg was also Jewish, and he was fired from his position at a hospital in Berlin for that reason in 1933. He remained in Berlin, though, until he was arrested in 1937. He was eventually released with the help of Margaret Sanger, and he fled to the

• 25:11Tracy V. Wilson?

  United States in late 1940. If you have been wondering, this is the same Grafenberg that the G-Spot is named for. That was based on a publication of his from 1944. Grafenberg continued to work as a gynecologist in the US, although because of perceptions of IUDs as dangerous, he shifted his contraceptive focus to diaphragms and cervical caps.

• 25:37Holly Frey?

  A somewhat similar trajectory took place in Japan, starting in the 1920s. Birth control advocate Margaret Sanger made her first of several visits to Japan in 1922. Contraception was both illegal and culturally taboo in Japan, and initially, the Japanese government barred Sanger from visiting. When it did happen, that visit was tightly controlled, and Sanger was banned from discussing contraception. But afterward, Japanese women started their own birth control movement. One of its key figures was Shizuekato, who had met Sanger in the United States in 1920 and who had acted as her guide during that 1922 visit.

• 26:20Tracy V. Wilson?

  In 1933, Japanese gynecologist Tenre Ota introduced an IUD he called the "Presia Ring," which was an English-Japanese neologism meaning "pressure." He had experimented with a range of contraceptive techniques, starting in the late 1920s. His first attempts at an intrauterine device were gold balls. Having heard a similar story to the one about the stones in the camels, he had heard that cows would not become pregnant if a gold ball was placed in their uterus. But he found that these gold balls did not stay in the human uterus well. When he learned about the Grafenberg ring, he combined these two ideas into what looked

• 27:03Tracy V. Wilson?

  kind of like a stylized wheel with an outer rim made of suture wrapped in wire and three spokes connecting the rim to a gold ball in the center.

• 27:14Holly Frey?

  He tried to market this as a contraceptive, which also became known as the Ota Ring, and had some initial success. But not long after he developed the device, the Japanese government started re-imposing restrictions on contraceptives. We have talked about connections between the eugenics movement and the birth control movement on the show before. Eugenists, including Margaret Sanger, thought contraceptives could keep the so-called "wrong people" from reproducing for the betterment of the human race. Japan's eugenics movement had a slightly different nuance. The easy access to contraception might mean the purportedly right people would not reproduce enough.

• 27:56Holly Frey?

  There were also concerns about IUDs specifically, including worries about negative health effects and claims that they terminated pregnancies rather than preventing them.

• 28:06Tracy V. Wilson?

  Japan defined the IUD as a harmful contraceptive in 1936 and banned contraception outright after allying with fascist Italy and Nazi Germany. Ota had to take on a new name and go into hiding. He returned to his work and opened a birth control clinic after the end of World War II, at which point the Japanese government started to promote contraceptives due to fears of overpopulation. IUDs were not licensed in Japan until the 1970s, though.

• 28:38Holly Frey?

  Although there were individual doctors who worked with IUDs, at this point, the medical community as a whole did not trust them. They were still associated with, and sometimes confused with, the intrauterine pessaries that we talked about earlier. Only one paper on IUDs was published in Western medical literature between 1934, after the fall of the Weimar Republic, and 1959, after developments in plastics led to innovations in the field. That 1948 paper was by Mary Halton, Robert L. Dickinson, and Christopher Tietzeh. It described the use of a gelatin capsule to insert a device made of sterilized silkworm gut into the uterus.

• 29:23Holly Frey?

  According to the paper, only 1.1% of patients using this device became pregnant. Later on, Tietzeh described the paper's content as so subversive at the time that he would not have put his name on it without Dickinson's encouragement. Dickinson had written numerous books and served as president or director of a whole collection of medical societies, so he had some safety to his credentials that Tietzeh maybe didn't.

• 29:50Tracy V. Wilson?

  Yeah, there were some new developments in the world of IUDs in the post-World War II years, and we will get to those after a sponsor break.

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• 30:31Tracy V. Wilson?

  Guess who's back in the house? The old gays return for season two of Silver Linings, their hit podcast from iHeart's Ruby Studio in partnership with ViiV Healthcare. Just wait until you hear what hosts Robert McMillan and Jess A. have in store this time around. They strut back down memory lane, navigating life, love, loss, and everything that shaped them along the way. And as usual, someone just might break into song. From leather bars to bathhouses, dance floors to drag brunch, nothing stays off limits. These are the kinds of insights that can only come from experience. So, listen to your elders, honey, and discover the silver linings you can take with you.

• 31:11Tracy V. Wilson?

  All sass, zero filter, and decades of perspective from four friends proving that queer joy only gets better with age on the podcast that never gets old. Listen to Silver Linings, available on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

• 31:31Speaker 06

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• 32:13Speaker 06

  This new Chicken Nugget, reinvented based on real feedback, is made with 100% white meat chicken and is now better than ever. You gotta try the new Burger King Chicken Nuggets and sauces today.

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• 34:13Tracy V. Wilson?

  In 1959, two papers helped lift some of the stigma around IUDs. Dr. Willy Oppenheimer, who worked at a hospital in Israel, published an article in the American Journal of Obstetrics and Gynecology, saying that he had used variants of the Grafenberg ring in 329 patients, changing those rings out every nine to 12 months, for a total of 866 rings. He said one of his patients had used rings for 20 years and another for 27. He had seen no pelvic inflammation of any kind among any of his patients and no cancer or endometriosis.

• 34:56Tracy V. Wilson?

  The devices had also been very effective, with a failure rate of 1.3% for silver rings versus 2.4% in the original silkworm design. The other paper was by Atsumi Ishihama in the Yokohama Medical Bulletin. He reported his observations of 973 patients that he had personally seen and more than 18,000 other patients across almost 150 hospitals in Japan. His results were similar to Oppenheimer's: only 1.4% of his own patients became pregnant and about 2.3% of patients across the other hospitals, and there had been no pattern of serious side effects.

• 35:39Tracy V. Wilson?

  These two papers did not flip some kind of light switch going from IUDs being condemned to being accepted, but they did spark some researchers' interest, and they made it a little easier for people to publish new research without it just immediately being dismissed.

• 35:56Tracy V. Wilson?

  In 1959, Dr. Lazar Margulis, a Polish immigrant to the United States, started experimenting with loops of silkworm gut inserted using a gelatin capsule, similar to what had been described in that paper that Mary Halton had co-authored. But he was disappointed in how often this was expelled from the uterus and how painful the insertion was for his patients. So he developed a spiral made from polyethylene tubing, filled with a solution that would make it visible on an X-ray and sealed. This spiral could be straightened out and inserted through a narrow tube, and it would return to its spiral shape in the uterus.

• 36:39Tracy V. Wilson?

  So what needed to be inserted was a lot smaller.

• 36:43Holly Frey?

  In 1962, gynecologist Jack Lippies of New York developed a polyethylene IUD shaped like a double S, larger at the top than at the bottom. And this was similarly straightened out for insertion. This shape approximately filled the uterine cavity, which reduced the likelihood that the uterus would expel it. It also had nylon strings that exited through the cervix, which could be felt to make sure that the IUD was still in place, and they could also be used to remove it.

• 37:13Tracy V. Wilson?

  The First International Conference on Intrauterine Contraceptive Devices, sponsored by the Population Council, was held from April 31st to May 1st of 1962. As that name suggests, at the time, the Population Council was focused on the purported dangers of overpopulation in the wake of the post-World War II baby boom. The book "Population Bomb" would be published later on in the decade. This was one of the driving forces behind research into IUDs at the time. There were multiple papers about the Grafenberg ring, the Margulies spiral, and the Lippies loop presented at this conference.

• 37:55Tracy V. Wilson?

  Participants included doctors from Japan, China, England, Israel, Pakistan, Egypt, Mexico, India, Chile, and the United States, including Puerto Rico, including several of the IUD developers that we have mentioned.

• 38:10Holly Frey?

  In 1969, Dr. Howard Tatum, who had a medical degree, as well as other multiple degrees related to medicine, like chemistry, tried to develop a smaller IUD with the hope of resolving issues with pain and cramping after the device was inserted. The general idea was that an IUD had to occupy the uterus to prevent pregnancy and to reduce the likelihood of it being expelled. But an IUD that was too big could cause ongoing discomfort or even injury to the uterus. Tatum thought that a T-shaped IUD with arms that could be folded flat for insertion and then spring back out inside the uterus might be more comfortable. Tatum's first designs did seem to be more comfortable,

• 38:55Holly Frey?

  but they were also less effective than other IUDs. Then he met physician and scientist Jamie Zipper while on a sabbatical in Chile. In 1968, Zipper had discovered that a copper wire had a contraceptive effect when placed in the uterus of rabbits. Tatum and Zipper developed the Copper T200, a T-shaped plastic device with copper wound around the central stem. This was the first copper IUD.

• 39:25Tracy V. Wilson?

  In 1970, Dr. Antonio Scomagna, who was born in Italy and first came to the US as a Fulbright scholar in 1954, developed Progestocert, which was a T-shaped IUD with a capsule that released progesterone.

• 39:41Tracy V. Wilson?

  One of the unwanted side effects of IUDs was increased menstrual bleeding, and he thought the progesterone would reduce that bleeding. This was the first hormone-releasing IUD, although its popularity was limited by the fact that it was only approved to be used for a year at a time.

• 40:00Holly Frey?

  So, we're not going to mention all of the specific IUDs that were developed at this point, because they fall into those two broad categories: copper or hormonal. At least in the US, some hormonal IUDs are FDA-approved to treat heavy menstrual bleeding. By the 1960s, IUDs were becoming more widely accepted, although there were still some questions about safety, especially about whether IUDs carried an increased risk of infections or pelvic inflammatory disease.

• 40:30Tracy V. Wilson?

  In the United States, IUDs really surged in popularity after the Senate held hearings on the safety of oral contraceptives in 1970. We covered the Nelson Pill hearings on the show on May 5, 2021. The first oral contraceptive had been approved in 1960, and those early pills had much, much higher levels of hormones than they do today. There were reports of blood clots and other potential health concerns, and reporting around these hearings led to increased fears of birth control pills among the general public.

• 41:08Holly Frey?

  One of the speakers at the Nelson Pill hearings was OB-GYN Hugh Davis, who developed an IUD called the Dalcon Shield with engineer Erwin Lerner. The Dalcon Shield had been introduced in 1968, and by 1970, more than 600,000 had been sold in the US. The A.H. Robbins Company bought the design from Davis and Lerner in 1971, and by 1974, more than 2.2 million of them had been sold.

• 41:38Tracy V. Wilson?

  The Dalcon Shield was made of flexible plastic with a membrane across the middle. So if you're looking at a picture, it looks almost like a solid thing. It was flexible, though. It had five downward pointing prongs along the edge meant to reduce the likelihood of it being expelled by the uterus. It looked a little bit like a horseshoe crab. By this point, it was common for IUDs to have some kind of strings that exited through the cervix, both for a person to be able to confirm that it was still in place and to eventually allow it to be removed. Because the Dalcon Shield was designed to be more difficult to dislodge, it needed a stronger string.

• 42:22Tracy V. Wilson?

  That stronger string was made up of multiple filaments within a sheath.

• 42:27Holly Frey?

  There were reports of health problems associated with the Dalcon Shield. It came preloaded in a sterile inserter that extended past the top edge of the IUD, and there were reports of this protruding bit perforating the uterus during insertion. There were also reports of infections and pelvic inflammatory disease, which were blamed on the unsealed multi-filament strings. The Dalcon Shield was blamed for at least 18 deaths, and more than 300,000 lawsuits were filed against A.H. Robbins. The company pulled the Dalcon Shield off the market in the U.S. in 1974 and suspended sales worldwide in 1975.

• 43:09Holly Frey?

  A.H. Robbins ultimately filed for bankruptcy.

• 43:13Tracy V. Wilson?

  In 1984, there was a widespread ad campaign encouraging anyone who still had a Dalcon Shield to have it removed. And then there was a 1989 legal settlement that created a $2.5 billion trust to pay off claims against the company. Multiple case control and cohort studies suggested that Dalcon Shield users had a much higher rate of pelvic inflammatory disease than other IUD users, but clinical trials weren't quite as definitive. Researchers also found that the Dalcon Shield had a higher failure rate than what the manufacturer had claimed, and those pregnancies had a higher risk of complications.

• 43:55Tracy V. Wilson?

  All of this had an immense impact on the acceptance of IUDs in the United States. Multiple other IUDs were pulled off the market in the face of the Dalcon Shield's bad publicity. In 1976, Congress passed the Medical Device Amendments, which gave the FDA authority to regulate medical devices and established three risk categories for those devices. IUDs were placed in Class 3, which was the highest-risk category. In 1970, about 10% of women in the US who were using contraception were using an IUD. I have some questions about exactly how that number was derived, that it's just how it was described in the paper that I was reading.

• 44:40Tracy V. Wilson?

  In the year 2000, that number had plummeted. It was less than 1%. But in other parts of the world not affected by the Dalcon Shield, IUDs became a popular form of contraception. By 1985, an estimated 60 million people around the world were using IUDs, and 40 million of them, or about 2/3, were in China.

• 45:04Holly Frey?

  That brings us to one of the contradictions around IUDs. If you live in a place where you have autonomy over your own body and your fertility and access to a doctor and money, or health insurance, or universal healthcare, and you want to get an IUD, you probably can. And that might feel liberating, a long-lasting contraceptive method that you don't have to think about and a partner doesn't even have to know about. But if you live somewhere where that is not true, or if you are in an abusive or a controlling relationship, an IUD is something that can be imposed on you or refused to you. While it's at least theoretically possible for a person to remove their own IUD...

• 45:49Holly Frey?

  Most doctors do not recommend doing that, and not everyone is actually even able to.

• 45:54Tracy V. Wilson?

  China is one of the most populous countries in the world, which is part of the explanation for those numbers of how many IUD users are in China. But it's also because of the Chinese government's "one-child" policy, which was announced in 1979. Under this policy, couples who had more than one child faced fines and other penalties. After having a child, Chinese women were expected to get an IUD or to be permanently sterilized unless their husband got a vasectomy. China changed that to a "two-child" policy in 2016, and in 2021, that number was increased to three children.

• 46:34Holly Frey?

  This kind of coercion can happen on both a societal and an individual level. Another recent example is the Britney Spears conservatorship case. In 2021, she gave a statement to a probate judge in which she said she had an IUD that her team would not allow her to have removed.

• 46:55Tracy V. Wilson?

  As for the internet behavior that inspired this episode, it is the way that pain during IUD insertion has been reduced almost to a meme. That pain is absolutely real. A 2023 study in the European Journal of Contraception and Reproductive Healthcare assessed more than 1,000 patients and reported that 2.5% of them had no pain with IUD insertion. But 49.7%, or almost half, had intense pain. The highest pain scores were among people who had never given birth or whose children had been born via cesarean section. But this reality of pain

• 47:40Tracy V. Wilson?

  has gotten kind of condensed into a weird shorthand. Like, they don't even do pain management for IUD insertion. What do you expect? And this is thrown around in conversations about someone's actual painful IUD experience. Or about endometriosis, or pap tests, or uterine fibroids, or menstrual cramps, all kinds of other things that can also be painful. And then the comments also fill up with people saying that they are afraid to get an IUD, or to get their existing IUD replaced, or maybe to go to the doctor at all because of this. So here is a PSA to say, at least in the United States, doctors who are not discussing pain management with their patients, beyond recommending over-the-counter pain relievers

• 48:23Tracy V. Wilson?

  for an IUD insertion, are not following the current guidelines.

• 48:27Holly Frey?

  In 2016, the U.S. Centers for Disease Control published an updated version of its Selected Practice Recommendations for Contraceptive Use. That update included this statement, quote, "Paracervical block with lidocaine might reduce patient pain during IUD insertion." The World Health Organization's most recent Selected Practice Recommendations for Contraceptive Use, published in 2025, say that paracervical blocks can be routinely offered for IUD placement, as can topical anesthetics like lidocaine gels, sprays, and creams. That's in addition to recommendations for over-the-counter pain relievers. The most recent U.S.

• 49:10Holly Frey?

  recommendations are adapted from these, and they have the same basic language.

• 49:14Tracy V. Wilson?

  The current World Health Organization recommendations also say this, quote, "Before IUD placement, all patients should be counseled on potential pain during placement, as well as the risks, benefits, and alternatives of different options for pain management. A person-centered plan for IUD placement and pain management should be made based on patient preference. Barriers to IUD use include patient concerns about anticipated pain, with placement and provider concerns about ease of placement, especially among nulliparous patients."

• 49:51Tracy V. Wilson?

  That means somebody that hasn't had a baby. When considering patient pain, it is important to recognize that the experience of pain is individualized and might be influenced by previous experiences, including trauma and mental health conditions such as depression or anxiety. Although these recommendations for provision of medications for IUD placement are based on the best available evidence, not all populations or patient experiences are represented in the literature.

• 50:22Holly Frey?

  Additionally, the American College of Obstetricians and Gynecologists issued a new clinical consensus for pain relief in 2025, which covers IUD insertion and a range of other procedures involving the cervix and uterus. They include anesthetic sprays, creams, and pericervical blocks. Various medical bodies have also recommended anti-anxiety medications or sedation if patients are anxious about the procedure or have other factors that might necessitate that.

• 50:54Tracy V. Wilson?

  This shorthand of like, they don't even do pain management for IUD insertion absolutely grew out of medical sexism and decades of reports about pain not being taken seriously enough, not just with IUD insertions. Some of the slow evolution of these guidelines is because of a lack of clear evidence about what actually helps. But in my opinion, it took way, way, way too long to get guidelines that very clearly reference pain relief. While I was researching this episode, I found papers on the use of topical lidocaine and pericervical blocks to make IUD insertion more comfortable, going back to the 1980s, 40 something years ago.

• 51:37Tracy V. Wilson?

  The frustration around this is all incredibly valid, but I do personally wish that we had landed on an expression for that frustration that was empowering instead of scaring one another. And I will also talk about my own personal experience with IUD insertion in our Friday behind the scenes.

• 51:58Holly Frey?

  Do you have listener mail in the meantime?

• 52:00Tracy V. Wilson?

  I do. I have listener mail from Hannah, and Hannah wrote, "Hey, y'all." Which is honestly one of my favorite ways to open an email. I hollered with joy when I saw you release an episode about Francisco Menendez and Fort Mose. I was so excited, I almost started writing this email before actually listening to the episode. I'm a lifelong Florida resident who visited Fort Mose a few years ago after hearing about it on Florida Frontiers, the podcast of the Florida Historical Society. The museum has a small footprint, but it's one of the most well-designed and accessible exhibits I've ever seen. I remember how incredible Francisco's story was just from the brief overview given by an informational plaque. I highly recommend any St. Augustine

• 52:44Tracy V. Wilson?

  visitors to stop by, especially since it's only a 10-minute drive from the Castillo. On a completely unrelated note, this email gives me a chance to share a stuff you miss in history class Easter egg of sorts. In February of 2023, I got a free tote bag at a local festival. The artist included a small 1874 Kitty Knox button on the subject's backpack. This was only a month after you released Kitty's episode. This little addition adds so many layers to the scene depicting a black woman using public transit while watching a rocket launch over the mangroves of the intercoastal. I like to think she's an astronaut continuing Kitty's legacy on her way to Cape Canaveral.

• 53:26Tracy V. Wilson?

  In lieu of pet tax, I'm adding photos that represent the wildlife residents of Fort Mose may have encountered: a wrinkly baby manatee, two river otters, and the only bird endemic to Florida, the endangered Florida scrub jay. Scrub jays are highly specialized, intelligent birds with big personalities, hence why one landed on my head during an annual population survey. There's so much more to my home state than theme parks, wacky headlines, and beaches. I encourage anyone who visits to explore our natural and cultural heritage beyond the tourist hotspots. If y'all ever want outing recommendations around the Orlando area, let me know. Thank you so much for the work you do. It is truly an invaluable public service and has enriched my life for well over a decade. I wish you both nothing

• 54:09Tracy V. Wilson?

  but peace, good food, and laughter. Warmest regards. And then there's also a final episode request. Thank you so much Hannah for this email. We have a picture of a bird just hanging out on Hannah's head. I love it. We also have a picture of this tote bag, uh, which is decorated with, um, an illustration that says rethink your commute. And the commuting person has this backpack with the Kitty Knox button on it. Uh, baby manatee, also very cute. And then, uh, river otters, so favorite. And a picture from Fort Mose. So thank you so, so, so much, uh, for sending this, uh,

• 54:53Tracy V. Wilson?

  and all of these pictures and this great email. I loved it. And that's all I have to say about it.

• 54:58Holly Frey?

  We love a river otter.

• 54:59Tracy V. Wilson?

  Yeah, I would look at river otters all day long, every day.

• 55:04Holly Frey?

  They're funny. I have many great stories of the ones at the aquarium here, because I used to do animal husbandry and some of those stories are not suitable for this podcast.

• 55:12Tracy V. Wilson?

  Yeah.

• 55:16Tracy V. Wilson?

  Anytime I'm anywhere that I know that they live, I'm on the lookout for them. What if I get to see one?

• 55:21Holly Frey?

  Yeah, they're cute.

• 55:23Tracy V. Wilson?

  So thank you again, Hannah, for this email. If you would like to send us a note, we're at [email protected]. You can find our show notes with all our source lists on them at our website, which is missedinhistory.com. And you can subscribe to our show on the iHeartRadio app and anywhere else you like to get your podcasts.

• 55:46Tracy V. Wilson?

  Stuff You Missed in History Class is a production of iHeartRadio. For more podcasts from iHeartRadio, visit the iHeartRadio app, Apple Podcasts, or wherever you listen to your favorite shows.

• 56:00Holly Frey?

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