IUD Insertion Pain: What to Know and How to Find Relief

Women are increasingly turning to the intrauterine device, or IUD, as a form of contraception, according to data from the Centers for Disease Control and Prevention published today. Yet it’s widely known that having an IUD inserted can be excruciatingly painful, and few doctors offer effective relief. The anticipation of the pain is “a potential barrier” to expanding access, said Dr. Lauren Zapata, an epidemiologist with the division of reproductive health at the C.D.C.

Roughly 20 percent of women relied on an IUD between 2015 and 2019, up drastically from the 8 percent who used one between 2006 and 2010. But social media platforms are awash with women commiserating over their painful IUD insertions, and sometimes removals. A study published this year that scanned TikTok for the top 100 videos with the hashtag #IUD found that of the videos presenting a patient’s experience, almost all — 97 percent — highlighted the pain of the procedure and other negative side effects.

“I generally always recommend an IUD,” said Dr. Jenny Wu, an author of the TikTok study and a third-year obstetrics and gynecology resident at Duke. “But then I also noticed that a lot of my younger patients, the Gen Z, just don’t want an IUD.” A separate report by the C.D.C., also published today, found that only 6 percent of teenagers have used an IUD, making it among the least prevalent methods for that age group.

There are a handful of effective pain management options for IUD insertion. Yet doctors have rarely discussed or used them, said Dr. Eve Espey, chair of the obstetrics and gynecology department at the University of New Mexico. A survey published this year found that only 4 percent of trained physicians in the United States offered an injection of a local anesthetic, which has been found to be effective for pain relief. And almost 80 percent of trained doctors, the survey showed, offered over-the-counter painkillers, like ibuprofen, which have been shown to be less effective.

That may be because, historically, there was little data to support the usage of some pain management methods, like a local anesthetic, Dr. Espey said. And 10 to 15 years ago, a majority of IUD users were women who had given birth — and there is evidence to suggest that they experience less pain during insertion, she added.

It also comes down to minimizing women’s pain, said Dr. Andrew Goldstein, a gynecologist and pelvic pain specialist. “I do believe that gaslighting is a common thing,” he said. “Women’s pain should be believed and relieved.”

As new research affirms the effectiveness of some methods, and as informed patients advocate for themselves, some doctors are beginning to offer multiple pain relief options for IUD insertion and even removal — a shift in practice that started to pick up “in the last three years or so,” Dr. Wu said.

The C.D.C., whose current guidance is vaguely supportive of using a local anesthetic, is in the process of reviewing recently published data on pain management for IUD insertions with plans to update recommendations next year.

Getting the T-shaped device into the uterus means that it first has to make its way through the cervix. “Any manipulation of the cervix can be quite uncomfortable,” Dr. Goldstein said, because it has several different nerves that signal pain. The internal canal of the cervix is also “physiologically closed,” Dr. Espey said, and “you have to push pretty hard” or even use a dilator for the IUD to get in. Women who have given birth are more likely to have a slightly more open cervix, she said, which is why insertion might hurt less for them.

The procedure lasts three to four minutes.

Doctors can provide either targeted pain management options that focus on the cervix or more generalized pain relief. However, “pain perception is very idiosyncratic,” Dr. Goldstein said, and what works at reducing pain for one woman might not be adequate for another.

With this option, lidocaine is injected at two different spots near the cervix to numb the area. In 2016, the C.D.C. found only limited evidence that this method might reduce IUD pain. But more recent research, including studies published in 2017 and 2019, suggests it is effective during and after the procedure, and more physicians are now beginning to use it more routinely, Dr. Goldstein said. The paracervical block is also typically covered by insurance.

But not every clinic is set up to offer the method, and it can also double the time of the insertion procedure, Dr. Espey said. Also, when you describe what it takes to get a paracervical block, “people don’t love the idea,” she added, “because it’s another needle.”

Doctors might also offer a topical lidocaine gel or spray, but the evidence on its effectiveness is mixed, Dr. Goldstein said. Some studies suggest that it might reduce the pain of grasping the cervix during the procedure, but it’s “nowhere near the amount of pain relief that the paracervical block provides,” he said.

A wide variety of drugs, including not only Tylenol and ibuprofen but also strong opioids, like Oxycodone, fall into this category. Though a majority of doctors suggest an over-the-counter medicine, “we’ve got enough studies now to know that it doesn’t work,” Dr. Espey said. There is limited evidence on opioids, though they generally seem to be more effective than over-the-counter drugs at reducing pain, she added.

But bear in mind that any of these options can take up to an hour to kick in, so if you walk into a clinic wanting to receive an IUD the same day, the medicine will add time to the procedure.

It was long thought that the drug used in medical abortions, misoprostol, might relieve the pain of IUD insertions because it softens the cervix, Dr. Espey said. But research doesn’t support that theory, and though the C.D.C. recommends against its use in most cases, roughly 15 percent of trained physicians still use it for women who have never given birth before. If a doctor suggests it, you should push for more options, Dr. Goldstein said.

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