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Getting an IUD Doesn’t Have to Hurt Like Hell
I contemplated getting an intrauterine device (IUD) for over seven years. Every time I asked a friend who had one about her experience, she would say the same two things: It hurts like hell to get one inserted, and I should definitely do it.
Once an IUD is placed properly in the uterus, the tiny, T-shaped device is over 99% effective at preventing pregnancy for anywhere from three to 10 years, depending on the type. The Paragard brand is totally hormone free, but even hormonal IUDs, like the Mirena, keep the hormones localized in the uterus so they cause fewer side effects. Since 2012, the American College of Obstetrics and Gynecologists (ACOG) has recommended long-acting reversible contraception, or LARCs, as “first-line recommendations for all women and adolescents.” OB-GYNs even choose this form of birth control for themselves at rates much higher than the general population.
Still, the anecdotes I heard in person and online always gave me pause. In a Slate article troublingly titled “Pain on a Cosmic Level,” one woman says her insertion was “probably the worst pain I’ve ever been in.” My friend told me the experience was “easily one of the top three worst pains of my life… worse than when I dislocated my knee and had to go to the ER.”
For some people, of course, it’s not so bad. The Planned Parenthood website says people usually feel some cramping or pain when they’re getting their IUD placed. “The pain can be worse for some, but luckily it only lasts for a minute or two.”
It’s no surprise, then, that many people chafe against the language around IUD-related pain.
Even so, the “cosmic levels of pain” stories stuck with me. And I’m not alone: A study by the Kinsey Institute found 76% of women surveyed cited “fear of needles and pain” as a deterrent from trying the IUD.
There isn’t much research on what it feels like to get an IUD placed, but the available evidence shows the process can go far beyond mild discomfort. One study of 109 never-before-pregnant women revealed 78% of them found the pain of placement to be “moderate” to “severe.” Another study found medical providers underestimate the pain of the procedure by approximately 100%. It’s no surprise, then, that many people chafe against the language around IUD-related pain.
Three years ago, I was diagnosed with a condition called “hormonally mediated vestibulodynia,” which meant I had a raw and tender vaginal opening due to a hormonal imbalance — likely caused by birth control pill use. On top of that, I was diagnosed with hypertonic pelvic floor dysfunction, which means my pelvic floor muscles are unable to fully relax. In addition to painful sex and frequent urination, my specialist said this condition could make getting an IUD put in even more painful. But there was no data or studies to definitively say whether it would be painful for me or not. That was unfortunate, because my only other options were barrier methods like condoms — which can irritate an already angry “vestibule” — and the calendar-tracking or “natural” method, which would never be enough to put my neurotic mind at ease.
Could getting an IUD really be as bad as I feared? In July 2017, I officially embarked on my quest for a painless insertion — one that turned out to be frustratingly, though perhaps not surprisingly, byzantine.
An IUD placement is typically performed in an OB-GYN’s office, and the entire process takes around five minutes. There are three possible sources of pain during the procedure: the clamp that holds your cervix open, the sound the doctor uses to measure the depth of your uterus, and the insertion of the IUD itself. There is no standardized method for controlling the pain associated with the procedure, but commonly used methods include local numbing injections, ibuprofen, and misoprostol, which is used to soften the cervix. More generous doctors might take pity on you and prescribe a single benzo to help with anxiety and/or a single tramadol to help with pain during and after, but not every doctor will do this.
“Nobody warned me it would hurt so much or offered any pain relief,” said a friend of mine, who compared the insertion to dislocating her knee. She’s had an IUD placed twice, she explained, and “both places acted like I was a burden for having such a strong reaction to intense pain.”
“Nobody warned me it would hurt so much or offered any pain relief.”
Few of the interventions routinely offered by clinicians have been shown to reduce patient pain scores versus placebo. A survey of PubMed literature published in English between 1980 and November 2012 found none of the three most common interventions for IUD placement — ibuprofen, a cervical block (administered by injection), and the cervix-ripening agent misoprostol — were effective at reducing the pain of the procedure itself, although it did find that non-steroidal anti-inflammatory agents (NSAIDs) like Advil can help with cramps afterward.
Based on these findings, the authors concluded that “no prophylactic pharmacological intervention has been adequately evaluated to support routine use for pain reduction during or after IUD insertion.” Their recommendation for what to use instead? The “verbal anesthesia” of pre-procedure counseling. So, talking it out.
There is one intervention the authors of studies like these leave out: IV or “twilight” sedation, which contains a helpful blend of painkillers and anxiety meds. It’s used for numerous other procedures, including oral surgery, colonoscopies, and — sometimes, if it’s available and the patient opts for it — abortions. Couldn’t it hypothetically be used for this, too?
Two years ago I began my pursuit of a sedated IUD insertion. I decided to forgo asking my usual OB-GYN provider, who had previously compared the discomfort of IUD pain to getting a pedicure. I figured she wouldn’t understand my desire for a pain-free procedure. I called up a local Planned Parenthood, which demurred, then flat-out refused, telling me they simply don’t do IV sedation for IUDs.
The insertion process was totally painless, as I intended it to be; as far as my recollection goes, I went to sleep, then woke up seconds later with a Paragard inside of me.
After some additional research, I managed to find one doctor in New York City who agreed to do it for me, but his practice set off numerous alarm bells: They only took cash and made me come in for numerous unnecessary tests, including an intensely scrapy pap smear. The last straw came when I asked if the copper IUD was safe for someone with a severe nickel allergy, and he shrugged his shoulders and told me to call the Paragard hotline. Eventually I relented and called my original OB-GYN practice and talked to a different doctor than the one I’d seen before. I explained my situation. “You can have sedation if you want it,” he said. “We’ll do it for you, no problem.” He transferred me to the practice’s surgical center, which booked me an appointment for one week later.
In the end, the insertion process was totally painless, as I intended it to be; as far as my recollection goes, I went to sleep, then woke up seconds later with a Paragard inside of me. Lying on the table beforehand, I felt a rush of emotions: relief that I was finally getting an IUD and could relax about the risk of unplanned pregnancy, anxiety about whether my insurance would cover the sedation (they told me it would, but you never know), and anger at how many people are not given this option. I was also angry on my own behalf, as I’d been using the pull-out method — which is an imperfect method for pregnancy prevention — for more than a year at this point. Why is IV sedation so common for commensurately invasive procedures — wisdom tooth extraction, for example — but basically unheard of for IUD insertions?
It’s not as though there isn’t a demand for it among people getting IUDs: Dr. Morris Wortman, who runs the Center for Menstrual Disorders and Reproductive Choice in Rochester, New York, and offers IV sedation as a routine option for IUD placement, says 80 to 85% of his IUD patients opt for it. (Although, he cautions, this is not a perfectly representative sample, as some patients are referred from other places specifically for this reason.)
Wortman has been advocating for office-based anesthesia for invasive procedures for decades now. In the 1970s and 1980s, he says, abortions were regularly performed without any analgesics, and he was one of the first physicians in the U.S. to offer IV sedation to his abortion patients. To this day, many abortions in the U.S. are performed with only a paracervical block. Sometimes an oral anxiety medication is also given. For so-called medication abortions, which can feel similar to an early miscarriage, Planned Parenthood recommends Tylenol or Advil.
Wortman sees the question of sedation for an IUD as similar, although not as egregious, as sedation during surgical abortions. He tells me he offers it because “it’s the right thing to do.”
This contradicts the stance of most OB-GYN practices. “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,” says Dr. Raegan McDonald-Mosley, chief medical officer at Planned Parenthood Federation of America. “In some circumstances, it may be possible to make arrangements for a patient who wants or needs sedation — in those cases, patients will have to speak with a clinician before moving forward with this option.”
For me, the risk of unplanned pregnancy was worse than the risk of a kind of sedation offered routinely for things like wisdom tooth surgery.
According to Wortman, IV sedation is difficult for doctors to provide due to onerous regulations and expenses, as well as poor reimbursement rates from insurance companies. While in-office sedation is technically legal, most doctors cannot afford to meet all the regulatory requirements, which means they must travel to a surgical center and team up with an anesthesiologist. This can make a five-minute-long procedure take more than an hour of the doctor’s time, and that means they lose money. It can also make it massively more expensive for patients— as I learned when I received a surprise bill for $3,000, which I eventually got covered by fighting my insurer.
As any doctor will tell you, there are risks involved any time you go under for a procedure. But it’s a person’s right to evaluate risks and decide between them. For me, the risk of unplanned pregnancy was worse than the risk of a kind of sedation offered routinely for things like wisdom tooth surgery. As someone who’s never been afraid of drugs, I felt safe in the hands of a board-certified anesthesiologist. Other people may decide differently.
Considering everything else Americans are up against right now with regard to reproductive rights and healthcare in general, I almost feel guilty for writing this story. Pain management can feel like a luxury when people are still fighting for the right to access abortion, birth control, and any baseline of socially-provided care whatsoever.
I count myself lucky that I was able to get an IUD at all; most health plans cover them, but they can cost up to $1,300 out of pocket — and 28 million Americans remain uninsured. I feel lucky that I’ve never had to suffer through a medical abortion with only Tylenol or Advil. I feel lucky that I grew up with the resources to plan when, and if, I want to become a parent. But when I hear horror stories, I’m reminded that the fight for decent healthcare should not be solely about defending the status quo. It should look to a future in which each patient’s needs are valued and prioritized, doctors have the time and energy to listen, and we can choose between the plethora of options modern medicine has to offer us.