Maeve McDermott loves her IUD. Actually, she says, she’s “obsessed” with it. “I always had issues with the various birth control pills I tried,” says McDermott, a 23-year-old Washington journalist. “Different ones would make my period crazy, my emotions were out of whack, and my resting weight was about 15 pounds heavier. I’m still getting used to the IUD, but I’m back to feeling 100 percent like myself. Plus, I appreciate that it takes human error out of the birth control equation.”
But McDermott’s first encounter with her IUD was not so dreamy. At her initial consultation, she asked her gynecologist about managing pain during the insertion process. Her doctor recommended she take a few Advil before the procedure, nothing special. Because of a scheduling conflict, a different doctor ended up inserting the device. “The new gyno tells me—while I’m on the table—that he would’ve gladly prescribed me some Xanax or Vicodin beforehand,” she says. “My Pap smears have been just momentarily uncomfortable, but the IUD insertion was on another level: an intense pain and really uncomfortable pressure for about 30 seconds. I was seeing stars by the end of it.” McDermott calls the insertion “probably the worst pain I’ve ever been in.”
Intrauterine devices—small, T-shaped apparatuses that sit in the uterus and use hormones or copper to prevent pregnancy for three to 10 years—have been making a comeback. Between 2006 and 2010, just 6 percent of women using birth control chose long-acting reversible contraception (LARC)—that is, IUDs or an implant. That proportion nearly doubled between 2011 and 2013, when 11.6 percent used LARC methods. (In 2012, nearly eight times as many women used an IUD as used an implant, so it’s safe to say that IUD use has accounted for a good chunk of this spike.) IUDs are “becoming the new standard of care for young, reproductive-age women in terms of first-line birth control options,” says Jennifer Lesko, an assistant professor of obstetrics and gynecology at George Washington University. “We know that there’s sort of a network effect—once one person kind of thinks something is cool, they talk to their friends about it, and more and more people come in.”
But many of those women arrive for their appointment feeling trepidation about the discomfort or, possibly, the agony that awaits them. Many women I spoke to said they’d scoured first-person online accounts of IUD insertions before their appointments to get a sense of what to expect. Sometimes, online anecdotes are like Yelp reviews: The people who feel compelled to write them are the ones who’ve had negative experiences. Jennifer Conti, a Palo Alto, California–based OB-GYN physician and Slate contributor, says most of her patients get through the IUD procedure with only mild to moderate discomfort. “Pain is an important issue with IUD insertion—it’s one of the main reasons that women are apprehensive about getting an IUD in the first place,” she says. “And it can be uncomfortable, but it’s extremely short-lived.”
The insertion process starts like most gynecological procedures: with a speculum. With the speculum holding the patient’s vagina open, the doctor swabs the patient’s vagina and cervix with antiseptic solution and inserts an instrument called a tenaculum, a clamp that’s used to hold the cervix in place. Then, the physician usually inserts a uterine sound, an instrument that goes through a patient’s cervix to measure her uterine depth. When the uterine sound is out, the doctor pushes a tube through the patient’s cervix, pulls the tube back to release the arms of the IUD, and pushes it up to the top of the uterus. Finally, the doctor pulls the tube out and makes sure the IUD’s strings are hanging through the patient’s cervix into her vagina, so she can check them monthly to make sure her IUD is still in place.
Although the insertion process is relatively standardized, women’s reactions to it can vary widely. (Conti usually tells her patients they’ll feel three quick cramps: one from the tenaculum, one from the uterine sound, and one from the insertion tube.) For some women, the most painful part is the tenaculum. “I couldn't breathe for a moment or two and I immediately broke out in sweat,” wrote one woman of her encounter with the clamp. “ ‘Fuck, doc, that really hurts,’ is all that I could push out between my clenched teeth.” For others, the uterine sound or the actual entry of the IUD insertion tube hurts the most. Pain tolerance threshold, body response, facility with language—there are too many factors that shape a personal pain narrative to make any single account authoritative.
Slate senior podcast producer Andrea Silenzi, 30, has one of those horror stories that could dissuade anyone from getting an IUD. She says her doctor told her to take some aspirin before her Mirena insertion two years ago. “She said, ‘You’ll feel a little uncomfortable,’ and I started laughing at her,” Silenzi says. “I’d read all the stories, and I knew it would be pain on a cosmic level.” When a medical resident began the procedure under the doctor’s guidance, the torment was too much for Silenzi to bear. “I felt like I was going to faint. At the moment I felt like I couldn’t take any more, I said, ‘How much longer?’ [The resident] said, ‘We’re just getting ready to insert it.’ ” Silenzi doesn’t remember which pre-insertion implement caused her such terrible pain, but no matter—she had to call off the procedure halfway through.
Afterward, the resident came out and apologized. (Silenzi points out that if you’ve ever watched Grey’s Anatomy, that might seem like a no-no; many doctors think apologies could be used against them in malpractice suits.) “Then the supervising doctor came over and told me that if I’d had children it would have been a cinch, that IUDs are typically for women who’ve had children,” she says. Mirena—which, along with Paragard, is one of the two best-known IUDs—is technically only FDA-approved for women who’ve had children, because the tests used to apply for certification were all done on women who’d given birth. Lesko says she suspects that’s because testers were playing it safe with a demographic of women who had already demonstrated a certain degree of reproductive health and whose cervixes were already accustomed to opening wider than usual.
Since Mirena’s FDA approval, several studies have shown it to be safe and effective for women who haven’t given birth, but Mirena prescriptions for these patients are still technically off-label. “It’s now become the first line of contraception that we recommend for women who are even as young as adolescents who are sexually active, because we think it’s effective birth control that is safe,” Lesko says.
Silenzi interviewed several women about their IUD experiences for a podcast episode, and she discovered that aspirin wasn’t her only option. “My theory is that a lot of women self-medicate to make it through, and I’m not someone who has a pile of drugs lying around my apartment,” she says. “It is unnerving to hear from some friends that they were given a pill to numb things, an injection to numb things.”
Liz, a 27-year-old San Francisco audiologist, was told to take two ibuprofen before her IUD appointment, but ended up using marijuana to dull the post-insertion pain. “I was not told how severe the pain could be, nor was I advised to take the day off of work following my early morning appointment for insertion,” she says. “I took Aleve every few hours after to help with the cramping … and ate an edible that night to help me sleep. I was a cramping zombie for the next 16 hours.”
“Some people take a shot, and some people take Valium,” says Rachel Wolther, a 29-year-old filmmaker. “I took both.”
One 37-year-old woman whose doctor did tell her she might want to take the day off work after her insertion told me she got mixed messages from within the same gynecological practice. “I think I was told to take Tylenol prior to coming in. I wasn’t given much other instruction,” she said. “When I arrived, the nurse asked if I had used a cervical relaxer—I had not and was not told to. She seemed a little surprised, but then said it shouldn’t be a problem.”
The cervical relaxer the nurse mentioned was probably misoprostol, a common prescription for medical abortion that can also be used to soften and dilate the cervix. Doctors used to think the drug would make it easier for them to insert the IUD depositor into the patient’s uterus, causing the patient less pain. But studies in 2011 and 2012 showed that a pre-insertion dose of misoprostol does not make IUD insertion less painful for patients; they just experience more pre-insertion cramping and nausea.
Sometimes the best way to prevent IUD insertion pain is to have a baby. When a woman delivers vaginally, her cervix dilates to 10 centimeters, changing its anatomy and making it easier to get something past it a second time. Lesko has had an IUD inserted both before and after having children. She didn’t feel that much discomfort during her first go-round; she thought it was “just a weird experience. It felt a little bit like someone had grabbed my belly button, like someone had tugged on it from the inside.” The second time, after having had a baby, she says, “I honestly felt like I didn’t even know it was happening.”
In its literature on IUD insertion for adolescents, the American College of Obstetricians and Gynecologists advises that pain relief during the procedure “may include supportive care, nonsteroidal anti-inflammatory drugs (NSAIDs), narcotics, anxiolytics, or paracervical blocks.” (A paracervical block is an injection of a local anesthetic like lidocaine into the cervix.) ACOG media relations and communications director Kate Connors says the association recommends an “individualized approach” that depends on the patient’s needs and history, plus the doctor’s experiences.
But studies have shown that most NSAIDs don’t help mitigate pain during IUD insertion, and neither does a low-dose lidocaine gel. The NSAID naproxen, the active ingredient in Aleve, and the opioid tramadol do help some, as do certain lidocaine creams, sprays, and injections. ACOG’s IUD literature admits that “the most effective method of pain control has not yet been established.” But pain is notoriously hard to measure, for both doctors and patients. One study on the efficacy of a paracervical block during IUD insertion in 50 women found that women who got the injection rated their pain a median of 38 points lower on a 100-point scale than those who hadn’t gotten it. But because of the wide range of responses on both sides, the results couldn’t be termed statistically significant.
Even the insertion instructions on two different brands of IUDs differ when it comes to pain management. Mirena’s website advises a paracervical block “if needed” before inserting the uterine sound; Paragard’s doesn’t. Paracervical blocks represent “an additional procedure that can be painful to administer,” Lesko says. “The contraceptive community doesn’t really highly recommend that.” Still, OB-GYN Rachel Chan Seay of the Johns Hopkins Bayview Medical Center says it may be appropriate for patients who have elevated concerns about pain or who’ve had difficulty with previous pelvic exams. But she says some medical practices routinely proffer paracervical blocks to women who are getting an IUD but haven’t had children.
Amid all these vague and conflicting signals, some doctors seem to advise simply gritting your teeth and getting through it. “I see a lot of concern about insertion: ‘They’re going to put something in my body! I’m going to need anesthesia!’ ” doctor Nerys Benfield told Cosmopolitan earlier this year. “But it’s actually a very simple procedure—it takes 30 seconds and feels like a Pap smear, plus some cramping.” But as Lesko points out, “There are some women who have substantial anxiety or might have a history of sexual abuse,” factors that would make IUD insertion into “something that they would not able to tolerate as a routine office procedure.” Seay says she has placed IUDs in patients who were going under anesthesia for an unrelated procedure and asked her to insert the device while they were under.
A doctor’s technique can also make a big difference in the degree and variety of IUD insertion pain. Melissa Henry, 28, a San Francisco public health researcher, got her IUD from a doctor who provided a heating pad to use on her abdomen during the insertion. The doctor played music to relax Henry and talked her through some breathing exercises. Elise, a 27-year-old business administrator in New York, has gotten two IUDs; with her first, her doctor injected her cervix with novocaine and took every step deliberately—an experience Elise likened to slowly peeling off a Band Aid. The second time, with a different doctor, there was no injection. There was soft music playing, dim lighting, and even a few fake candles. This doctor was more aggressive; her “very extreme push-and-pull technique” was an improvement on the first experience, Elise says. “It was like she took a gun and shot it up my cervix.” That she relays that visceral image with admiration may perfectly crystallize the most frustrating thing for a would-be IUD owner to hear: For every patient, there’s no telling how it’ll feel.