When it comes to contraception, intrauterine devices (IUDs) have so much going for them. They have some of the highest efficacy rates compared to other forms of birth control, they can last up to 10 years depending on what kind you get, and you don’t have to remember to take a daily pill or mess around with shots or patches. But as I (and plenty of other people) have experienced firsthand, committing to an IUD comes with a frustrating downside: It can be really painful to get one inserted.
Thanks, in part, to social media—with some people live-streaming their IUD insertions—the pain associated with getting one of these just-over-an-inch-long devices placed in your uterus has warranted national attention (and plenty of headlines). To address this pain, the CDC released new guidelines on August 8, recommending the use of certain medications during IUD insertion. Specifically, the CDC stated that lidocaine (a commonly used anesthetic) in two different forms “might be useful for reducing patient pain.” The guidelines also urge practitioners to counsel their patients considering an IUD about the risk of pain and to help them come up with a personalized plan for the procedure.
In the world of contraception, this is a huge deal. Although IUD insertion may cause what’s described by the American College of Obstetricians and Gynecologists (ACOG) as “temporary discomfort,” that mild language doesn’t accurately capture the pain that a lot of people feel during the procedure. In my experience, it felt like a really long, horrible pinch in a place you never thought could (or should) be pinched. A friend of mine also compared the pain she felt during her IUD insertion to “bleeding out of her eardrums.”
This isn’t hyperbole, either. A 2016 study published in BMJ Sexual and Reproductive Health surveyed 109 women who hadn’t given birth a few times in the first year after they got an IUD and found that while most people were very satisfied with their IUD, 78% rated insertion pain as “moderate to severe.” Even worse, research also shows that providers often underestimate their patients’ pain during IUD insertion.
Kate White, MD, MPH, FACOG, chief of Obstetrics and Gynecology at Boston Medical Center and author of Your Sexual Health, who served on an advisory committee for the new CDC recommendations, feels this level of guidance is long overdue. “Part of me is so sad that something that should just be table stakes is getting so much attention,” she tells SELF. “Like, really, just saying you have to talk to people and offer them pain medication is this revolutionary recommendation? That’s where the bar is?”
Frustratingly, pain management has long existed as an option for IUD insertion. “Nothing presented [in the CDC recommendations] is novel to any ob-gyn,” Tierney Wolgemuth, MD, an ob-gyn who just completed her residency at Northwestern University Feinberg School of Medicine and who has researched and lectured on this topic, tells SELF. What’s different now, she says, is the emphasis on doctors having a conversation about these options every time a patient is interested in an IUD.
But what exactly are those options, and how well do they work? We asked top ob-gyns to break it all down.
First, let’s talk about why IUD insertion can be so painful.
IUDs protect you from pregnancy by sitting inside the uterus and either releasing hormones locally or preventing sperm from reaching and fertilizing an egg. But in order for a physician to place it in your uterus, they have to get past your cervix—a small canal that connects your uterus to your vagina. As such, there are a few points in the insertion procedure that can cause pain and discomfort:
Speculum placement: The device, also used for Pap smears, opens your vagina and allows your doctor access to your cervix, which can be uncomfortable or painful for some people. Stabilizing the cervix: Doctors use a tenaculum—kind of like a small pair of forceps—to hold the cervix in place during insertion. “There can be a ton of pressure that can lead to uterine cramping with the placement of those instruments onto the cervix,” Dr. Wolgemuth says. Measuring the uterus: Next, your ob-gyn will insert a small rod called a sound to measure the length of the uterus. Rachel Blake, MD, a board-certified ob-gyn, tells her patients this is “the first of two large cramps,” which can range from mild to very severe, but goes away once the sound is removed. Dilating the cervix: In some cases, a person’s cervix needs to be dilated before placing an IUD. This is more common with people who haven’t had a baby or who have low estrogen, Dr. Blake tells SELF. And it involves entering the cervix multiple times with increasingly larger dilators, which takes more time and can make the procedure more painful, she says. Placing the device: Your doctor will take a tiny tube holding the IUD and pass it through your cervix into the top of your uterus; the IUD then opens up like an umbrella. Insertion tends to come with more intense cramping, Dr. Wolgemuth says.
Again, not everyone feels pain (or extreme amounts of it) during this process. But Dr. Wolgemuth says certain factors can up your risk of feeling pain while getting an IUD placed, like never giving birth, a history of pelvic pain or painful periods, and a history of sexual trauma, among others.
What are my IUD pain management options?
Dr. White says she tends to describe the options to patients as three levels: oral pain medication, lidocaine (available as a spray, gel, or injection), and sedation.
1. Oral NSAIDs
Taking Advil, Aleve, or another nonsteroidal anti-inflammatory drug (NSAID) about an hour or two before IUD insertion is a standard recommendation because it’s pretty low-risk, Dr. Blake says. You can find these for a relatively low price at any drugstore, and they don’t affect your ability to drive or otherwise get yourself home from the doctor’s office.
The downside: NSAIDs like ibuprofen don’t do much to address the pain of the procedure itself, but rather the cramping that can happen afterward, which lasts up to one or two days after the IUD is placed, Dr. White says—something she feels isn’t always explained to patients.
2. Topical lidocaine (as a spray or gel)
Next we have lidocaine, a topical anesthetic that can be put directly on your cervix via a spray or a gel 5 to 15 minutes before insertion. These are pretty easy for doctors to apply (or can be self-applied), Dr. White says, and are effective at reducing pain with tenaculum placement. “Not so much the IUD part, though,” she adds.
3. Paracervical block of lidocaine
“Paracervical block” is medical speak for getting an injection of lidocaine in the area around the cervix—kind of like how you get a Novocaine shot at the dentist before they drill into a cavity, Dr. White says. The injection itself isn’t painless, but she says that it tends to be far less painful than the cramping associated with IUD insertion. This method has largely been shown to help reduce pain during most of the procedure, including tenaculum placement, measuring the uterus with the sound, and actually putting the IUD in place.
However, there are potential side effects to be aware of, including dizziness; nausea; numbness in your lips, tongue, or face; ringing in your ears; and in very rare cases, a chance of seizures. Some people might also have bleeding from the injection site itself. Dr. Blake adds that the paracervical block typically makes the procedure a few minutes longer (since you have to administer it and then wait about five minutes for it to kick in), meaning more time up in the stirrups with the speculum in.
4. Sedation
Dr. White calls this the “ultimate level” of pain management for IUD insertion. Typically you get a lighter form of anesthesia than you’d get for say, gallbladder surgery, and it makes you sleepy, she says. Although sedation was not one of the explicit CDC recommendations, “there are patients who this is a really good option for,” Dr. Wolgemuth explains. Namely, people who have gone through medical or sexual trauma or who otherwise have had a bad experience with IUD insertion. Because of the anxiety that these past experiences can cause, being awake for the procedure might be retraumatizing (which can, understandably, make the whole thing that much more difficult).
Of course, there are downsides to keep in mind. The procedure will be longer, and you need to have someone on standby to take you home afterward (as there are generally some side effects, including headache, nausea, and drowsiness). Plus sedation may not be covered by insurance or might have a higher out-of-pocket cost, depending on your plan. And not all gynecologists can offer it, either, since it requires having anesthesia capabilities in-office.
“I don’t believe most people need sedation for this procedure, but I think that should always be available and discussed as a part of the range of options,” Dr. Wolgemuth says. Even if your ob-gyn isn’t equipped to do sedation, you should be referred to a practitioner who can if you and your doctor decide that’s what you need.
5. Supplemental options
“There are lots of ways to reduce pain and anxiety that are not actually by prescription,” Dr. White says, citing good doctor-patient counseling, aromatherapy, listening to music, and having a support person in the room with you as examples. But she feels those are best in addition to prescription options (if you need them), not as the first line of defense.
Dr. White adds that people who have anxiety disorders or high levels of anxiety surrounding IUD insertion might do well with Valium (an anxiety medication that calms your brain) or another similar medication. While anxiety meds can’t (and shouldn’t) fully replace the pain management options above, “there is absolutely a link between pain and anxiety” that should be considered, she says.
So where do we go from here?
Now that the CDC has released these recommendations, “I hope patients feel more empowered to walk into the office, and if the IUD is on the list of [contraceptive] methods they want to consider, that they actually have a long conversation about pain medication options,” Dr. White says. Ideally, she adds, [she hopes] all insurance companies start covering all the pain management techniques available too.
Unfortunately, the reality of implementing these recommendations (and addressing patient pain in general) is a bit more complex. For starters, providers will need to be trained on new practices and techniques for IUD insertion, and how to better navigate these conversations with their patients, Dr. Blake says. I just encountered this uncomfortable reality during my annual exam. I asked my ob-gyn about pain management for IUDs (because I want a new one), and she only mentioned ibuprofen. When I pressed her about specifics from the CDC recs, she said that in her 30 years of administering IUDs, she had never once used pain medication. She ultimately did talk to me about the different forms of lidocaine, but with what felt like skepticism and a clear reluctance to actually use any of these options. I left the appointment feeling frustrated and dismissed. And if I—a health journalist who has done tons of research on the topic—can get brushed off by my doctor like this, what does that mean for someone with less knowledge and privilege than me?
Even if you have an ob-gyn who is more “with it” than mine (and I hope you do), there are a lot of other barriers to consider. As mentioned earlier, not every ob-gyn’s office is equipped to offer every option, like paracervical blocks or sedation. Dr. Wolgemuth adds that a lot of clinic appointments are short and not currently designed for adequate counseling (although she believes that needs to change). All of this assumes you have reliable, affordable access to a doctor too. Data shows that 30% of US women between the ages of 19 and 44 are underinsured (meaning their insurance plans come with high deductibles or out-of-pocket costs), and 10% of women between the ages of 19 and 64 are uninsured —limiting access to any gynecological care, not just IUD placement and its pain management.
Even with access and great counseling from doctors, the options that exist for managing IUD insertion pain just aren’t that great. Experts say the research is very limited—both in terms of what exists and the findings—and what has been shown to work comes with limitations. “My concern is that patients may have false hope that this procedure will be pain-free,” when that’s not necessarily the reality, Dr. Blake says.
For that reason, all three experts say we need more research on IUD insertion to understand if there are more effective pain management options with fewer downsides, which is challenging in and of itself. “Pain studies in general are difficult because they’re very subjective,” Dr. Blake says. There are also a lot of variables in IUD insertion that are hard to control in a study, she adds, such as the skill and experience of the provider, and whether or not the patient has had children.
All that said, the CDC guidelines are certainly a step in the right direction, particularly in that they validate the pain that lots of us have felt for so long. “Historically and currently, there’s a problem with not taking women’s pain [seriously], particularly marginalized populations, including women of color, women on public health insurance, and women of lower socioeconomic status,” Dr. Blake says. “The advocacy that this could provide for patients is helpful.”
Advocating for yourself can be daunting, particularly when you’re wearing an ugly hospital gown with your bits exposed. Start by reading up on your options at home from reputable sources, Dr. White suggests, so that you’re armed with basic information before you step in the door. When you’re with your doctor, ask to hear about all of your contraceptive options, including the pros and cons of each. If an IUD feels like the right option for you, Dr. White suggests being up-front about your concerns around pain—whether that’s citing what you’ve read, what your friends have shared with you, or your own past experiences. Ask not only what your pain management options are, but what the doctor can offer themselves.
If your doc balks or pushes back, don’t hesitate to ask specific questions or point to your source material. This could look like, “The CDC mentioned X option and I’m curious about it,” or “I’ve read that ibuprofen only helps with the cramping afterward—what can you provide for the pain of the actual procedure?” It might feel awkward or taboo to question your doctor, but it’s their job to counsel you on stuff like this so you can make a fully informed decision. And if your doctor still isn’t helpful or supportive, it’s okay to not get the procedure that day, Dr. Wolgemuth says.
Ultimately, IUDs are a great form of contraception that lots of people love. And if you want one, there are ways to manage the potential pain from the insertion itself. Dr. Wolgemuth hopes this step from the CDC will make people more open to this form of birth control, and increase the trust between patient and doctor. “Going to the gynecologist is hard enough,” she says. “It shouldn’t be incredibly painful as well.”
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