Getting An IUD Can Be Painful, So Why Is Anesthesia Used So Rarely?

At a recent party, I told a friend, “It was the worst pain I’ve ever experienced, but you should totally do it.” And for once, I wasn’t talking about my interest in kink and BDSM, I was talking about my IUD [intrauterine device]. You may have heard something similar from your friends, too. Or maybe you or your friends have been the lucky ones, for whom IUD insertion is NBD. Despite the potential difficulties surrounding IUD insertions, they remain one of the most reliable forms of birth control. They’re also one of the most popular — according to the United Nations, nearly 160 million people worldwide rely on an IUD (beating out the birth control pill by around 8 million users.)

If IUDs are so common, how is it possible there’s so much variation between insertion procedures and so much pushback from providers when it comes to pain relief? The answer, it turns out, is complicated.

According to a 2013 study published in the Journal of Family Planning and Reproductive Health Care, there’s a lack of studies exploring:

• if (and how much) IUD insertions hurt.
• the best ways to manage pain that may occur.
• whether there are “clinical benefits” to managing that pain.

Wouldn’t it be nice if patients simply saying “ouch!” was enough?

Getting funding for studies is tough, and that goes double for anything to do with sex, especially when it comes to issues that affect women, LGBTQ+ folks, and people of color. That means healthcare providers are often left to do their jobs with incomplete or outdated information.

It’d be nice if there was more agreement about how to make the IUD insertion process more comfortable for everyone, but in the meantime, here’s what doctors do know.

Does Getting An IUD Hurt?

The short answer? “It depends,” says Dr. Gene de Haan, an OB-GYN. To get a better sense of what each patient can expect, Dr. de Haan asks about their history with pelvic exams and then gets into the specifics of the IUD procedure. “I generally counsel that for some people, it feels a little uncomfortable; for some people, it’s incredibly painful and can be traumatizing.”

“There's sort of three uncomfortable steps with the IUD, assuming that the speculum placement itself is not uncomfortable,” Dr. de Haan says. (A speculum is a gynecological tool that looks like a duckbill and is used to open the vaginal canal for procedures. For many people, even the insertion of the speculum can be uncomfortable.)

After the exam, the first step that might be painful is the placement of a tenaculum, a type of forceps, used to hold the cervix. Dr. de Hann warns that the tenaculum can be uncomfortable, or cause an achy, crampy feeling.

The second step that can be painful is measuring the uterus. Everyone’s uterus is unique, and it’s important to make sure the selected IUD will be a good fit. The measurement is taken by inserting a uterine sound, which establishes not only the depth of the uterus but also the best placement for the IUD. This element of the procedure is more comfortable for people whose cervix is already open, determined largely by whether they’ve given birth.

Finally, the IUD is actually placed. It’s pushed through the cervix in its own applicator — like a narrow straw — and once inside, the IUD opens its arms and the applicator is removed. Dr. de Haan says that any of these moments can feel like a cramp and that the initial moments after the procedure are likely to be crampy as well. “[E]veryone's body is different. In some people, if you touch their cervix, they can feel nauseated, they can throw up, they can feel like they're gonna pass out, [and] they can be in horrific pain, whereas other people are like, ‘You're done? I didn't know that you'd done it yet.’ So that's part of the trouble. It's so unpredictable,” says Dr. de Haan.

Why Are Doctors Hesitant To Provide Pain Management For IUD Insertion?‌

Listening to some accounts of IUD insertions would have you believe that many providers are evil, sadistic, and want their patients to suffer. But the reality is far more complicated than that.

For starters, there’s the problem of insufficient research, which influences the training doctors are getting both in medical school and on the job. If no studies show that IUD insertion is painful, med students aren’t hearing it in class.

A lack of information leads to study conclusions such as this one, which deserves the understatement-of-the-year-award: “Providers underestimate pain during IUD insertion.” In the study, patients rated their pain from the procedure higher than their providers did a whopping 51% of the time.

Even more troubling, another study found that the disparity between a patient’s experience of pain and their physician’s estimate is “greatest among physicians with the greatest procedural experience.” These studies create more questions than they answer. If doctors are face to face with patients telling them it’s painful, why don’t they believe what they hear?

Aside from underestimating the amount of pain involved, another big problem is that some of the pain management options available require additional skills to implement. So when a provider says that something like a paracervical block causes more pain than it prevents, that might be true of the way they do it.

In addition to the skills issue, there’s the issue of risk. In 2019, Dr. Raegan McDonald-Mosley, chief medical officer at Planned Parenthood Federation of America told Jamie Peck, writing for Medium, “Sedation is not routinely offered for IUD insertions because research has shown that it is not routinely needed and because it increases some risks of the visit.” Peck goes on to describe issues with the American medical system, including health insurance reimbursements, as barriers to offering anesthesia or sedation.

As if that weren’t enough, the opioid epidemic creates yet another roadblock to pain management under our current system. “Often, specifically asking for opiates will trigger a knee-jerk reaction from a physician to avoid prescribing [it]. For example, my institution tracks how many opiate prescriptions the providers write and will intervene if there are high outliers,”‌ says Dr. Dallas Holladay, an emergency medicine specialist.

It’s important to note that while many patients are dismissed when reporting pain, both of the doctors I spoke to highlighted the disproportionate effect this has on patients of color.

“Western medicine has a horrific track record, particularly [with] ignoring pain in Black patients. I mean, we have so much data that basically says that Black patients do not have their pain treated adequately,” says Dr. de Haan. A meta-analysis of 20 years worth of research found that “Black patients were 22% less likely than white patients to receive any pain medication.”

How Can You Find The Right Doctor For Your IUD Insertion?

The doctors I spoke with emphasized the importance of being choosy when it comes to selecting a provider. “There are lots of [nurse practitioners, physician assistants] and physicians out there, [so] if [your] provider isn't listening to you, find someone else,” says Holladay.

Dr. de Haan suggests, “Look for providers who are trauma-informed. Because we are always looking for ways to keep people as comfortable as possible, in all sorts of ways.” Trauma-informed providers generally have additional training in consent practices, ways to help patients feel in control, and know to clearly explain the whys and hows of each step of the procedure.

Of course, the medical system isn’t always easy to navigate and not everyone can pick and choose their providers. Planned Parenthood offers free or low-cost IUD insertion. When I got my first IUD there, the only pain management they offered was a topical spray, which was next to useless for me. According to Planned Parenthood, their available pain management options varied by health center location. “Most of our patients do well with over-the-counter pain medicine like acetaminophen or ibuprofen. A heat pack on the uterus is great for cramping! In rare instances, we can provide oral sedation or sedation through an IV for patients who may need it,” says Dr. Meera Shah, Chief Medical Officer of Planned Parenthood Hudson Peconic.

Dr. de Haan identifies some specific requests you can make, including oral anxiety meds and numbing the tenaculum site. They also suggest simply starting the conversation with, “I’m scared that this is really going to hurt. Can you talk to me about the things that you have available, that you feel comfortable doing, to help make this less painful for me?”

Dr. Holladay adds, “If you've had a painful insertion before, say so. Explain that the IUD is your preferred method of birth control but that your previous insertion was very painful and ask if there are options in addition to Tylenol and ibuprofen.”

What about full anesthesia? That needs to take place in a hospital setting and would be booked and managed just like any other surgery — and most OB-GYNs do have operating room access. Some providers also have access to moderate sedation clinics. Although these options are rarely offered up front, you can absolutely ask for sedation or anesthesia. Heck, even dentists offer a wide range of pain and anxiety management tools these days, so why not gynecologists?

If you’re open to alternative medicine options, there are even more forms of relief available. After two painful IUD procedures, I got a lot pickier the third time around and found a provider who offered acupuncture. They placed a handful of needles in my ear before the insertion and I experienced significantly less cramping than I did the first two times. Your mileage may vary, but if you generally respond well to acupuncture, it could be worth looking into.

Some People Say The Benefits Of Their IUD Outweigh The Pain

Yes, having an IUD inserted might hurt like heck, but there are a variety of pain mitigation options available if you ask for them. And even among people who’ve had painful procedures (including me), many report it’s well worth the five to 10 years of reliable birth control you get in return.

Experts:

Dr. Gene de Haan, MD, OBGYN

Dr. Dallas Holladay, DO, Emergency Medicine

Dr. Meera Shah, Chief Medical Officer of Planned Parenthood Hudson Peconic

Sources:

Bahamondes L, Mansour D, Fiala C, et al Practical advice for avoidance of pain associated with insertion of intrauterine contraceptives Journal of Family Planning and Reproductive Health Care 2014;40:54-60.

Maguire K, Morrell K, Westhoff C, Davis A. Accuracy of providers' assessment of pain during intrauterine device insertion. Contraception. 2014 Jan;89(1):22-4. doi: 10.1016/j.contraception.2013.09.008. Epub 2013 Sep 21. PMID: 24134898.

Mody, Sheila K et al. “Paracervical Block for Intrauterine Device Placement Among Nulliparous Women: A Randomized Controlled Trial.” Obstetrics and gynecology vol. 132,3 (2018): 575-582. doi:10.1097/AOG.0000000000002790

Meghani SH, Byun E, Gallagher RM. Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med. 2012 Feb;13(2):150-74. doi: 10.1111/j.1526-4637.2011.01310.x. Epub 2012 Jan 13. PMID: 22239747.

Talya Miron-Shatz, Maayan Ormianer, Jonina Rabinowitz, Yaniv Hanoch, Avi Tsafrir, Physician experience is associated with greater underestimation of patient pain, Patient Education and Counseling, Volume 103, Issue 2, 2020, doi.org/10.1016/j.pec.2019.08.040.