Gynecology nurse practitioner Stephanie Edwards-Latchu has performed over 450 intrauterine device insertions. Some women will barely notice when the device is placed, she said, but others report the worst pain they will ever feel.
The devices, which are placed within the uterus to prevent pregnancy, are the third most common form of birth control in the US. Still, some patients have come to her after being dismissed by other providers — told to “calm down” or that their pain is “not that bad” or even “you’re being dramatic.”
In new contraceptive guidance published this week, the US Centers for Disease Control and Prevention gave updated recommendations for clinicians on how to help manage the pain some people may have when the devices, known as IUDs, are inserted. Lidocaine “might be useful for reducing patient pain” when injected as a local anesthetic or applied topically as a numbing gel, cream or spray, the CDC said in the update, the first since 2016.
The CDC also recommends doctors inform all patients about potential pain and personalize IUD placement and pain management plans for each individual.
The individualized and patient-centered language is a large shift from the 2016 guidelines, which were less specific and less detailed, according to Dr. Tessa Madden, professor of obstetrics, gynecology and reproductive sciences at the Yale School of Medicine.
Madden’s research on the use of lidocaine was referenced in the updated guidelines. However, she noted, her research is nearly 12 years old — highlighting the longstanding challenge in improving pain management during the procedure.
In a 2019 survey of about 1,000 family planning providers, less than 5% reported using a lidocaine injection during IUD insertion. Instead, they more frequently suggested ibuprofen, which research has shown does not reduce insertion pain.
“Saying to take ibuprofen is the bare minimum, and it’s not enough,” said Edwards-Latchu, whose campus health clinic at University of North Carolina Chapel Hill offers lidocaine gel and injections, heating pads, Valium and the option to bring a supporting person. The clinic is also experimenting with umbilical vibration devices that might reduce discomfort during the procedure.
The procedure to insert an IUD takes about 15 minutes or less. A health-care provider performs a pelvic exam and then uses a speculum to widen the vagina, through which they place the device within the uterus.
“Any one of those steps can be uncomfortable for people—from the pelvic examination to the IUD insertion—although it’s typically the insertion that’s the most uncomfortable, when they experience the highest level of pain,” said Dr. Beverly Gray, an associate professor of obstetrics and gynecology at Duke University and an obstetrician and gynecologist at Duke Health.
Cramping and other uncomfortable or painful sensations can occur during and after insertion, as the procedure involves using pointed forceps called a tenaculum to stabilize the cervix and passing the intrauterine device through the narrow cervical canal.
“Patients have clearly spoken out about their traumatic or painful experiences,” Gray added. “These guidelines highlight the importance of discussing pain management and being frank about the spectrum of experiences that people might have.”
‘My pain is not being taken seriously’
Female pain has long been underrecognized and undertreated.
“Women have been saying for decades, ‘my pain is not being taken seriously,” Edwards-Latchu said. “It feels like screaming into the void.”
A 2021 study found that pain in female patients is consistently underestimated due to gender stereotypes, and women are judged to benefit less from pain medicine than men, despite equal likelihood of seeking care.
“In medicine we historically have not done a very good job of taking women’s pain, in particular, seriously,” added Madden.
Edwards-Latchu described a female patient whose appendix ruptured after her abdominal pain was dismissed as menstrual cramps, pointing to a broader issue of women’s pain being mismanaged. Research echoes this, showing women in emergency rooms with similar abdominal pain scores to men waited longer and were less likely to receive pain relief.
This issue also extends to IUD insertion, where studies have shown patients report significantly higher pain levels than providers perceive.
There is no guaranteed way to predict an individual’s response to an IUD insertion, according to Madden, who said that some of her patients have high levels of pain while others experience “very little.”
However, increased pain during the procedure is more likely if the patient hasn’t had a vaginal birth, has a history of painful periods or has experienced trauma.
Some research also suggests that anxiety is associated with worse pain across various medical procedures.
“There is a variety of experiences that people have. It’s sometimes hard to predict who will have an easy experience with insertion and who will have a more challenging experience,” Gray added. “Understanding that is important.”
A 2014 study of 109 IUD recipients found that 78% reported pain ranging from moderate to severe upon insertion. That range is clear on TikTok, where numerous women have shared live videos from the exam table as their IUDs were inserted.
“IUD insertion is the worst pain imaginable,” wrote one user who showed herself writhing in pain.
“This was the most excruciating pain I’ve ever experienced,” another shared.
In both videos, the health-care providers inserting the IUDs could be heard telling their patients to expect pressure or a “pinch.”
Social media shows part of the picture
“It’s heartbreaking,” Edwards-Latchu said of the videos on her social media feed. “The first thing that I think is, ‘I doubt they were given anything for their pain,’ and to me, that is upsetting.”
The videos bring awareness to the potential pain, she said, adding that it’s important “to know about the negative experiences so that something changes.”
However, according to Madden, the videos can also dissuade viewers from considering a contraceptive option that could be a viable option for them.
“Patients come into the office talking about videos that they’ve seen on TikTok or Instagram, which is where a lot of times patients are getting their information from,” she said. “Seeing a video like that could be a significant deterrent.”
Intrauterine devices have had a tumultuous history. Notably, the Dalkon Shield in the 1970s caused cases of severe infection and other complications, casting a long shadow over the safety of IUDs. However, modern IUDs have been proven to be safe and effective, and are used by over 10% of women aged 15 to 49, according to CDC data from 2017-2019.
They can last for up to 10 years or more and are 20 times better at preventing unintended pregnancies than birth control pills and other short-term contraceptive methods, according to a 2012 study.
“[An IUD] is a highly effective method that many patients are very satisfied with,” Madden added. “For some patients, the concern about pain with insertion is the reason that they’re not using [it].
“If patients feel like we’re addressing their concerns about the pain, and taking the concerns seriously, then that might increase people’s willingness to use the method.”
What to ask your doctor
The updated guidelines come as there’s a rise in demand for contraception after the reversal of Roe v. Wade in 2022.
Edwards-Latchu explained that each year around graduation, her campus health clinic sees a surge of students seeking IUDs. Many of these students were preparing to move to areas with restrictive reproductive health laws and are unsure about future access to reproductive care.
“They are looking at long-acting, reversible contraceptive methods like the IUD, and if they have one already, they want a newer one so they have longer protection,” she said. “It is something that you can hide and that somebody can’t take away from you, especially if you’re going to a state where contraception could be a target.”
This context makes comprehensive and individualized conversations on insertion pain management more important than ever, she added.
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Gray, Madden and Edwards-Latchu say the increasing attention to insertion pain, long-term contraceptives and the new guidelines present an opportunity for providers to listen to their patients to create better personal experiences for them.
Patients should actively ask questions during their consultation appointments to facilitate this, particularly about pain management options and anxiety support, they said.
Edwards-Latchu suggests asking about lidocaine blocks, gels, sprays and other pain control methods as described in new CDC guidelines.
“If a patient feels like the the clinician is not taking their concern seriously or not willing to offer them some of these potential interventions.. then maybe that individual doesn’t want to get IUD with that clinician,” Madden added.
“We need to be taking this pain seriously.”