Are Doctors Underestimating the Pain of IUD Insertion?

This felt more like a punch than a pinch.



My IUD insertion experience was a debacle of the highest order. It happened in the fall of 2015 in New York City where ob/gyns taking new appointments are hard to come by. And after waiting months for an appointment, the copper IUD wasn’t inserted properly.

I had heard that the insertion process, which, according to Mayo Clinic, involves the placement of a small, T-shaped device through the cervix and into the uterus, was painful—something that Christina Cauterucci’s 2016 Slate article described as “pain on a cosmic level.”

I went in expecting the worst, but confident in my ability to tough it out since my pain tolerance has always seemed high. I ended up passing out on the exam table during the procedure. I’m not sure if it was my tendency to pass out when getting anything from a shot to an ear piercing, or a reaction to this procedure specifically, but apparently this type of vasovagal reaction isn't an uncommon experience during IUD insertion.

After persisting through my fainting spell and extended probing via transvaginal ultrasound, I laid curled in the fetal position in the waiting room before I could summon the strength to get downstairs and into a cab.

Research shows that some doctors underestimate the amount of pain patients experience when getting an IUD.

After determining in a follow up appointment that my IUD actually wasn’t in the right spot, I was referred to Anne Davis, M.D., an ob/gyn at Columbia University Medical Center, a few weeks later. The procedure with her, which included local anesthetic, was practically painless in comparison to the first insertion, and she talked me through the whole thing.

When I mentioned the disparity between my two experiences, Dr. Davis told me that there's research to suggest some doctors may be underestimating just how painful this procedure can be. She directed me to a 2014 study published in the journal Contraception that she completed with Karla Maguire, M.D., an ob/gyn at the University of Miami and the study’s lead author.

Using what’s called a 100 millimeter visual analogue scale—a sliding scale comprised of the numbers one to 100, each spaced one millimeter apart—patients were asked to put an X on the number that corresponded to the level of pain they experienced at four different points of the IUD insertion procedure, the highest of which was considered their maximum pain score. They also asked providers to rate the pain they perceived patients experienced during each point. As their study notes, “to our knowledge, this is the first study to compare IUD insertion patient and provider pain scores,” since previous studies on IUD pain completely omitted patient-reported scores.

They found that patients and providers were rating pain at very different levels. One thing patients and providers could agree on was the most painful part of the procedure: a process called uterine sounding, which consists of measuring the depth of the uterus pre-insertion. But, on average, the study found that patients rated their maximum pain as 64.8 out of 100, while providers perceived this pain to be 35.3 out of 100—a gaping difference to say the least. The study authors concluded that, “providers significantly underestimate pain during IUD insertion."

So why don't patients and providers agree on the pain associated with IUD insertion?

Dr. Maguire tacks it on to a general and larger misunderstanding of patient's pain that doctors of all varieties wrestle with. She explains that similar pain discrepancies are “found in [other] procedures and emergency room practices,” adding that trying to understand patient pain is addressed in schooling, “but it's important to remember it.” Of course, truly understanding another person's pain is probably an impossible task, but if patients are reporting pain that's nearly twice as bad as doctor's think it is, providers have more work to do.

Interestingly, IUDs are actually a popular birth control method among doctors, so it's possible that at least some providers have first-hand experience with the pain. According to a 2015 studypublished in the journal Contraception, family planning providers are more likely to use IUDs than the general population is.

The pain associated with IUD insertion varies widely from person to person.

And that might be one reason for the discrepancy between pain assessments from patients and providers. Most doctors will inevitably base their pain assessment on what they see in their own office. So if they have some patients reporting a lot of pain while others don't (or don't speak up about it) they might assume it's not that bad.

Rachel Dzombak, a 27-year-old Berkeley resident, tells SELF that she was nervous to get an IUD “because my cousin told me that the pain level gave her a glimpse into childbirth, and my best friend passed out after her insertion.” But, in the end, her own experience was nothing to write home about. “I had hyped it up so much in my mind, but it was fine and quick. My doctor did a great job talking me through all the steps,” she says.

Ali O’Reilly, a 27-year-old living in Minneapolis, didn't know what to expect, so she started Googling. “There was a spectrum of reactions to the pain of implanting an IUD, ranging from exclamation-laden YouTube videos to others equating the pain to a bee sting,” she tells SELF. When it came to her experience, O’Reilly puts it this way: “It fucking hurt. It felt like getting pinned in my cervix four times with a staple gun. I remember thinking that my body was responding to pain in a way that was out of control.”

The contrast in pain levels that women like O’Reilly, Dzombak, and the 17 women in this SELF article report can depend on a variety of factors like personal pain tolerance and whether or not a women has had a child before. Sheila Mody, M.D., an ob/gyn at UC San Diego Health who specializes in contraceptive counseling, tells SELF that during insertion, IUDs have to “go through the cervix and into the uterus. For women who have [previously] had vaginal deliveries, their cervix has been opened before so they can have less discomfort.”

Yet, Dr. Mody is careful not to perpetuate a common stereotype that IUDs aren’t an option for women who haven’t had a child. While the insertion process may be a bit more uncomfortable for someone who hasn't had their cervix dilated before, it's certainly still a safe and highly effective method of birth control for them. And if you're in the market for a hormonal IUD, there are a few smaller methods out there these days.

Communication and realistic expectations may be the key to a better IUD experience.

Dr. Mody attributes some level of pain variance to the amount of time providers spend counseling their patients on what to expect. "There's probably not going to be zero pain—there will be some discomfort," she says. So preparing yourself ahead of time, coming with a friend or partner, and having big plans to relax and do nothing after the appointment are all great ideas.

They're also ideas I learned the hard way. After getting my IUD, I assumed I’d be able to hop on the subway and head right into work. When it was done, I would have given my firstborn child (that the procedure was designed to prevent) to have a friend there to lean on throughout and to guide me home after. I had to call in sick to work because I couldn’t manage doing anything else that day besides lay in bed, and I didn’t plan for that.

“I think I counsel [prospective patients] better now, especially those who haven't had children before," says Dr. Maguire, when asked how her research on this pain discrepancy has affected her practice. "I counsel them to expect more pain—if they have less, great, but I want them to be prepared."

Arming yourself with some over-the-counter pain medication can also help. Dr. Davis tells SELF, “So far, the search for an oral pill to help with placement pain hasn't turned up anything effective. But anti-inflammatories do work for the cramping afterwards, so [they’re] worth taking.”

But despite that 64.8-level pain during the insertion, many women—like me—still swear by the IUD.

"Most women, even if they tell me that they had discomfort…come back for another IUD [later on]. It’s still worth it for most women,” Dr. Mody says. After all, it's just one part of a birth control method that lasts for years. Even after O'Reilly's painful experience, she tells SELF she'd highly recommend the method, and she mentioned that her “doctors at Planned Parenthood were amazing as always.”

And while doctors may never truly know what a procedure will feel like to an unsuspecting patient, just being aware of that fact should help them be more empathetic and more open about what to expect.

“We have to be aware that we are underestimating our patients' pain," Dr. Maguire says. And it can't hurt to suggest a full day of Netflix and sweatpants afterward, too.

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