In the past few years, women have been voicing their concerns about the pain in IUD procedures in various media and social media outlets.

The vast majority of them demand better pain relief and gentle care when they go to their doctor for an IUD insertion.

For the end-user, the biggest unknown is: What triggers the pain during this procedure and how to minimize it?

Pros and Cons of Intrauterine device

A small T-shaped medical implant is a 99% effective contraceptive. It prevents the sperm from fertilizing the egg cell depending on whether a hormonal or copper coil IUD is used.

  • Hormonal IUDs release progesterone to thicken the mucus in the cervix to make it hard for the sperm to enter the uterus and thin the uterus wall to prevent ovulation.
  • Copper IUDs use a copper coil to directly kill the sperm that enters the uterus.

The benefits of having an IUD goes beyond just pregnancy – it has also shown to reduce the risk of ovarian cancer by 30 percent and it also helps in preventing endometriosis.

Pain in IUD procedures

The IUD is inserted into the uterus to prevent pregnancy. Image:Shutterstock.com

Although the IUD is a highly effective contraception method and is fairly quick to implement, many women are turned off because of their fear of pain.

While certain discomfort during this procedure is to be expected, some women report experiencing so much pain, which makes many women avoid the IUD. (1 2 3 4)

What triggers pain in IUD insertion?

Physical causes

There are two possible triggers for pain in the IUD procedure. The first trigger is physical pain caused by some instruments, such as the tenaculum and the uterine sound.

Most women complain of pain during:

  • The tenaculum placement,
  • Uterine sounding,
  • IUD insertion through the cervical os,
  • Contact with the uterine fundus.

The tenaculum is a scissor-like device that has a hooked edge used in pinching the cervical wall to stabilize it. This device was originally designed to extract bullets but has since then been used in gynecology after a few design changes.

 

Tenaculum was invented in the end of 19th century. Since then, it has hardly changed. Image: Shutterstock.com

Pinching the cervix with the tenaculum will cause discomfort and pain to most women. The uterine sound, a long tube with calibrations used to measure the length and position of the uterus, also causes pain in some women. (5)

Psychogenic triggers

A patient’s anxiety level before the procedure would profoundly affect whether they feel less or more pain in IUD insertion. This is the result of a 2020 study that looked into the possible causes of IUD insertion pain.

According to the research, anxiety that a woman experiences before the IUD insertion procedure contributes to higher pain perception, which causes them to feel more pain than they should.

Many factors could contribute to a woman’s anxiety before the IUD insertion procedure, such as social media posts about other women’s bad experiences.

Previous bad experiences with doctors, and seeing some of the instruments used for the procedure, specially the tenaculum which looks intimidating to say the least. (6 7)

The Nulliparity factor 

                 

Another factor that may contribute to the pain in IUD insertion is nulliparity – nulliparous women are those who have not given birth yet, while parous women are those who have given birth at least once.

Some studies show that nulliparous women are 17 percent more likely to experience pain in IUD insertion than women who have given birth at least once.

The cervix of nulliparous women is smaller in diameter than parous women, which may be why they are more likely to feel more pain in IUD insertions. (8 9 10)

According to a study, the pain in most nulliparous women ranges from moderate to severe. (11)

Although nulliparous women may feel more pain, IUD is still a recommended birth control method, because of its safety and effectiveness. (12)

The Case of Lucy Cohen

One of the most vocal advocates to speak out against pain in IUD insertion is Lucy Cohen. She went to the doctor expecting a relatively simple procedure – eventually, she went through excruciating pain related to the stabilization of her cervix with the tenaculum and measurement of her uterus with the uterine sound.(13)

Lucy shared her experience on social media and found out she was not alone. Having a strong feeling that something must be changed, Lucy made a petition demanding:

  1. Better expectation management of what the insertion and removal of an IUD entail.
  2. More pain relief options as standard including gas and air, sedation and muscle relaxants.
  3. Not everyone will choose to have additional pain relief, but for those who want it, it should be administered – and that real consent can only be given once all risks, including that of extreme pain, have been explained.

As a result of the petition, the guidance policy about pain relief of The FSRH (Faculty of Sexual & Reproductive Healthcare, the Royal College of Obstetricians and Gynecologists, London) was updated.

The NHS also changed its description of pain in IUD insertion in their website. (14 15)

How to ease the pain and what to do after the procedure?

There are many cases where providers underestimate the experience of pain in IUD insertions to patients, resulting in patient complaints being ignored. Pain in IUD insertion is real and any complaints by patients should be taken seriously.

While currently, no standardized pain management guidelines to mitigate pain in IUD insertion exists, there is a bit of good news from an abortion-related study published recently.

According to this study, self-administered lidocaine gel treatment over a prolonged time may help reduce or eliminate pain in IUD insertions. (16)

In a study published in March 2019, researchers try to find the best way to reduce pain in the IUD procedure. They tested nonsteroidal anti-inflammatory drugs (NSAIDs), anesthetic agents  and cervical priming with misoprostol.

The study shows that lidocaine plus prilocaine (genital mucosal application) helps significantly reduce tenaculum placement pain and IUD insertion pain and post-procedure pain. (17)

 What can women do to help reduce IUD insertion pain?

  • Schedule the procedure during the period because these days, women’s cervix is more open (18)
  • Take an over-the-counter pain reliever an hour before the procedure. Women can also ask the gynecologist who will do the procedure for more options like anesthetics
  • Relaxing is also a good way to reduce pain perception

Stress management and relaxation techniques can ease the anxiety related to the procedure. Image: Pexels.com

Since anxiety increases pain perception before IUD insertion, it would significantly help have a relaxed state of mind while women are in the clinic waiting for the procedure to start. Here are some suggestions on how to feel more comfortable:

    •  Mentally prepare for the procedure by researching the procedure and reading about the safety of the procedure
    •  Distract the mind from fear by reading a book, listening to music, or even chatting with friends before the procedure begins
    •  Have a moral support team
    •  Talk with the gynecologist when having concerns
    •  Deep breathing helps ease anxiety (19)

The new device shows promising results

As the tenaculum is one of the major culprits when it comes to pain in IUD insertions, replacing it from the medical procedure may ease a lot of the complaints.

That is why researchers are looking for ways to stabilize the cervix without using a tenaculum.

Aspivix is developing a device that might reduce the pain and bleeding, thus eliminating the trauma related to the IUD insertion.

The device is designed with women’s experience in mind and based on suction technology.

Author: Team Aspivix

Sources:

1.      Magazine, S. (2017, June 15). From Medical Pariah to Feminist Icon: The Story of the IUD. Smithsonian Magazine. https://www.smithsonianmag.com/science-nature/medical-pariah-feminist-icon-story-iud-180963699/

 2.      Lanzola, E. L. (2021, July 31). Intrauterine device. StatPearls [Internet]. Retrieved March 23, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK557403/#:~:text=Introduction-,Intrauterine%20devices%20(IUDs)%20are%20one%20of%20the%20most%20effective%20forms,levonorgestrel%2Dcontaining%20IUD%2C%20have%20similar

3.      Johnson, B. A. (2005, January 1). Insertion and Removal of Intrauterine Devices. American Family Physician. https://www.aafp.org/afp/2005/0101/p95.htmlhttps://www.ajog.org/article/S0002-9378(18)32107-0/pdf

 4.      Lopez LM;Bernholc A;Zeng Y;Allen RH;Bartz D;O’Brien PA;Hubacher D; (n.d.). Interventions for pain with intrauterine device insertion. The Cochrane database of systematic reviews. Retrieved March 23, 2022, from https://pubmed.ncbi.nlm.nih.gov/26222246/

 5.      Leon, R. (2019, June 10). Part 2: Minimizing the pain of the IUD insertion: all effort required. This Changed My Practice. https://thischangedmypractice.com/iud-part2/

 6.      Bahamondes L;Mansour D;Fiala C;Kaunitz AM;Gemzell-Danielsson K; (n.d.). Practical advice for avoidance of pain associated with insertion of intrauterine contraceptives. The journal of family planning and reproductive health care. Retrieved March 23, 2022, from https://pubmed.ncbi.nlm.nih.gov/24076534/

 7. https://www.sciencedirect.com/science/article/pii/S1701216319308485#:~:text=There%20is%20also%20evidence%20that,may%20influence%20perceptions%20of%20pain.&text=Worry%20and%20apprehension%20can%20be,their%20experience%20of%20the%20procedure

 8.      Can You Use an IUD If You Have Never Given Birth? (2020, September 2). Verywell Health. https://www.verywellhealth.com/iud-use-in-nulliparous-women-906759#citation-5

 9.      Bahamondes, L. (2014, January 1). Practical advice for avoidance of pain associated with insertion of intrauterine contraceptives. BMJ Sexual & Reproductive Health. https://srh.bmj.com/content/40/1/54

 10.   Hall, A. M., & Kutler, B. A. (2016, January). Intrauterine contraception in nulliparous women: A prospective survey. The journal of family planning and reproductive health care. Retrieved March 23, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4717389/

 11.   Hall, A. M., & Kutler, B. A. (2016, January). Intrauterine contraception in nulliparous women: A prospective survey. The journal of family planning and reproductive health care. Retrieved March 23, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4717389

 12.  Hillard, P. A. (n.d.). Practical Tips for Intrauterine Devices Use in Adolescents. Retrieved March 23, 2022, from https://www.jahonline.org/article/S1054-139X(12)00418-1/fulltext

 13.  PatientSafetyLearning Team. (2021, June 24). The pain of my IUD fitting was horrific. . .and I’m not alone. Patient Safety Learning – the Hub. https://www.pslhub.org/learn/patient-safety-in-health-and-care/womens-health/the-pain-of-my-iud-fitting-was-horrific%E2%80%A6and-i%E2%80%99m-not-alone-r4765/

 14.   Cohen, L. (n.d.). Sign the petition. Change.org. Retrieved March 23, 2022, from https://www.change.org/p/offer-better-pain-relief-for-iud-insertions-and-removals

 15.  Medical #metoo Drives Updates in IUD Guidelines. Aspivix | Reshaping Gynecology & Women’s Healthcare. https://www.aspivix.com/lucy-cohen-petition-drives-updates-in-iud-guidelines/https://clinicaltrials.gov/ct2/show/NCT02447029

 16.  Conti, J. (n.d.). Self-administered lidocaine gel for pain management with first trimester surgical abortion: A randomized controlled trial – full text view. Self-Administered Lidocaine Gel for Pain Management With First Trimester Surgical Abortion: A Randomized Controlled Trial – Full Text View – ClinicalTrials.gov. Retrieved March 23, 2022, from https://clinicaltrials.gov/ct2/show/NCT02447029

 17.   Samy, A., Abbas, A. M., Mahmoud, M., Taher, A., Awad, M. H., husseiny, T. E., Hussein, M., Ramadan, M., Shalaby, M. A., sharkawy, M. E., Hatem, D., Wali, A. A.-E.-din, Abd-el-fatah, S. M., Hussein, A. H., & Haggag, H. (2019, January 2). Evaluating different pain lowering medications during intrauterine device insertion: A systematic review and network meta-analysis. Fertility and Sterility. Retrieved March 23, 2022, from https://www.sciencedirect.com/science/article/abs/pii/S0015028218322076

 18.   F;, H. (n.d.). [which stage of the menstrual cycle in best suited for the insertion of IUD?]. Ceskoslovenska gynekologie. Retrieved March 23, 2022, from https://pubmed.ncbi.nlm.nih.gov/679301/

 19.  Irish, A. (2020, April 13). 5 Tips to Help Deal With the Anxiety of Getting an IUD Reinserted. Https://Www.Thebody.Com/Article/Iud-Anxiety-Tips. https://www.thebody.com/article/iud-anxiety-tips

 20.  Legardeur, H. (2021). Safety and Efficacy of an Atraumatic Uterine Cervical Traction Device: A Pilot Study. Frontiers. https://www.frontiersin.org/articles/10.3389/fmed.2021.742182/full   

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