IUD insertion: Women call for change on IUD pain, new guidelines say doctors must help manage it

CNN
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Gynecologic nurse Stephanie Edwards-Latchu has performed more than 450 IUD insertions. Some women barely notice when the device is in place, she said, but others report the worst pain they have ever felt.

The devices, which are placed in the uterus to prevent pregnancy, are the third most common form of birth control in the U.S. Still, some patients have come to her after being brushed off by other doctors — telling them to “calm down” or that their pain “isn’t that bad” or even “being dramatic.”

In new contraceptive guidelines released this week, the U.S. Centers for Disease Control and Prevention offered updated recommendations for doctors on how to help manage the pain some people may feel when the devices, known as intrauterine devices, are implanted. Lidocaine “may be useful in relieving pain in patients” 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 that physicians inform all patients about the potential pain and tailor the IUD insertion and pain management plan to each patient’s individual needs.

The individualized and patient-centered language in the guidelines is a big change from the 2016 guidelines, which were less detailed and specific, said Dr. Tessa Madden, professor of obstetrics, gynecology and reproductive sciences at Yale School of Medicine.

Madden’s research on lidocaine was cited in the updated guidelines. But, she noted, her research is nearly 12 years old — underscoring a long-standing challenge in improving pain management during surgery.

In a 2019 study of about 1,000 family planning providers, fewer than 5% reported using a lidocaine shot during IUD insertion. Instead, they were more likely to suggest ibuprofen, which studies have shown does not reduce insertion pain.

“Just saying you have to take ibuprofen is the bare minimum and it’s not enough,” said Edwards-Latchu, whose health clinic on the University of North Carolina Chapel Hill campus offers lidocaine gel and injections, heating pads, Valium and the option of bringing a support person. The clinic is also experimenting with umbilical cord vibrators that may reduce discomfort during the procedure.

The procedure to insert an IUD takes about 15 minutes or less. A healthcare provider performs a pelvic exam and then uses a speculum to open the vagina, through which the IUD is placed inside the uterus.

“Any of these steps can be uncomfortable for people—from the pelvic exam to the insertion of the IUD—although insertion is usually the most uncomfortable, when they feel the highest level of pain,” said Dr. Beverly Gray, assistant professor of obstetrics and gynecology at Duke University and an obstetrician and gynecologist at Duke Health.

Cramping and other uncomfortable or painful sensations may occur during and after insertion because the procedure involves using pointed forceps called forceps to stabilize the cervix and inserting the IUD through the narrow cervical canal.

“Patients were very vocal about their traumatic or painful experiences,” Gray added. “These guidelines emphasize the importance of discussing pain management and being honest about the range of experiences people may have.”

Pain in women has long been underestimated and undertreated.

“Women have been saying for decades, ‘My pain is not being taken seriously,’” Edwards-Latchu said. “It’s like shouting into the void.”

A 2021 study found that pain in female patients is consistently underestimated due to gender stereotypes, and women benefit less from pain medications than men, despite being equally likely to seek care.

“Medicine has historically not taken women’s pain seriously,” Madden added.

Edwards-Latchu described a patient whose appendix ruptured after her abdominal pain was dismissed as menstrual cramps, pointing to a broader problem of undertreatment of pain in women. Research supports this, showing that women in emergency rooms with similar abdominal pain scores as men waited longer and were less likely to receive painkillers.

This problem also applies to IUD insertion, where studies have shown that patients report significantly higher levels of pain than doctors realize.

There’s no surefire way to predict how a person will react to an IUD, according to Madden. She added that some of her patients experience severe pain, while others experience “very little” pain.

However, a patient who has not given birth naturally, has a history of painful periods, or has suffered an injury may be more likely to experience more pain during the procedure.

Some studies also indicate that anxiety is associated with greater pain during various medical procedures.

“People have different experiences. Sometimes it’s hard to predict who will have an easy experience with implantation and who will have a more difficult experience,” Gray added. “It’s important to understand that.”

A 2014 study of 109 women who had an IUD inserted found that 78% reported moderate to severe pain after insertion. That range is evident on TikTok, where many women have shared live streams from the treatment table while getting their IUDs inserted.

“Getting an IUD inserted is the worst pain imaginable,” one user wrote, showing her doubled over in pain.

“It was the worst pain I have ever experienced,” another person shared.

In both recordings, medical personnel inserting the IUD can be heard telling patients to expect pressure or a “pinching” sensation.

“It’s heartbreaking,” Edwards-Latchu said of the videos on her social media channel. “The first thing that comes to my mind is, ‘I doubt they’re getting anything for their pain,’ and that’s depressing to me.”

These films make us aware of potential pain, she said, adding that it’s important to “know the negative experiences in order to make a difference.”

However, Madden says, these videos can also discourage viewers from considering contraception, which could be a viable option for them.

“Patients come into the office and talk about videos they’ve seen on TikTok or Instagram, which is often where they get their information,” she said. “Seeing a video like that can be a significant deterrent.”

IUDs have a checkered history. Notably, in the 1970s, the Dalkon Shield caused cases of serious infections and other complications, casting a long shadow over the safety of IUDs. But modern IUDs have proven safe and effective and are used by more than 10% of women ages 15 to 49, according to CDC data from 2017 to 2019.

According to a 2012 study, their effectiveness can last up to 10 years or longer and they are 20 times more effective at preventing unplanned pregnancies than birth control pills and other short-term contraceptive methods.

“(The IUD) is a highly effective method that many patients are very happy with,” Madden added. “Some patients are reluctant to use it because they are afraid of the pain of insertion.

“If patients feel like we address their pain concerns and take them seriously, it may increase their willingness to use this method.”

The updated guidelines come as demand for contraceptives increases following the overturning 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 were uncertain about future access to reproductive care.

“They’re looking at long-acting, reversible contraception methods like an IUD, or if they already have one, they want a newer one so they have longer protection,” she said. “It’s something that you can hide and that no one can take away from you, especially if you’re going to a state where birth control could be a target.”

This context, she added, makes comprehensive and individualized conversations about managing implant-related pain more important than ever before.

Gray, Madden and Edwards-Latchu say the increased attention paid to insertion pain, long-term contraceptives and new guidelines are creating an opportunity for doctors to listen to their patients and create a better experience for them.

They say patients should actively ask questions during consultation visits to help make this easier, especially when it comes to pain management options and support for managing anxiety.

Edwards-Latchu advises asking about lidocaine locks, gels, sprays, and other pain relief methods described in the new CDC guidelines.

“If a patient feels like their doctor isn’t taking their concerns seriously or isn’t willing to offer some of the potential interventions, they may not want to have an IUD inserted with that doctor,” Madden added.

“We need to take this pain seriously.”

CNN’s Jacqueline Howard contributed to this report.