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Contraception, Uncategorized

Is an IUD painful? If so, how can I reduce the pain?

I hear from many women that they want an IUD (intrauterine device), but are worried about the pain of insertion. They report horror stories from friends and the thought of the potential pain can even become a barrier to getting an IUD, which is a shame as IUDs are the highest rated for satisfaction when compared with every other method of reversible contraception. They are have the lowest failure rates.

First of all, how bad is it really?

I’ve inserted many IUDs over the years and I can tell you that most women have some minor cramping or img_learn-morepain, which may last for a day or two, although for some women (the minority) the pain is significant.

I’ve also had two IUDs inserted myself over the years and honestly, I didn’t feel too much. Just some minor cramping. The next day I had some low backache, like my period was about to start and then it was fine.

However, that’s all anecdotal and retrospective at that. In a well done prospective study 33% of women had pain scores or 5 or more (on a pain scale of 0-10) with their IUD insertion, which means that 67% of women reported pain scores of 4 or less. In this study 46% of women had pain scores of 2 or less, so almost half of the participants found the pain pretty insignificant. I think this reflects what I see in my own practice.

Can anything be done to reduce the pain?

Say you are worried about being in the 33% of women who have pain scores of 5 or higher during IUD insertion. Is there anything that can be done to reduce the pain of insertion?

  • Non steroidal anti-inflammatory drugs (NSAIDs), think ibuprofen and naproxen. These medications are effective at reducing menstrual cramps, however, prospective studies with ibuprofen don’t indicate that they are very helpful for reducing IUD insertion pain. One small study indicates that naproxen 550 mg was better than placebo. So naproxen might possibly help. Is there a downside to taking 550 mg of naproxen 40 minutes before? Not if you are otherwise healthy.
  • Misoprostol (Cytotec). This is a medication that is used to soften the cervix before a variety of procedures. It is very effective at reducing abortion related discomfort, because it makes dilating (opening) the cervix easier). So, many providers think if it helps with the discomfort of abortion it must help with an IUD. However, the studies are not encouraging. It doesn’t appear to reduce the pain and may actually increase cramping afterward and IUD insertion. The last 3 links are from 3 randomized trials comparing vaginal misoprostol with placebo prior to insertion and the results of all 3 are no benefit and potential harm. A Cochrane review also shows no benefit from vaginal misoprostol. Inserting an IUD requires much less dilation than an abortion and obviously it’s a completely different procedure.
  • Topical lidocaine gel to anesthetize the cervix. Several studies show little benefit.
  • Injections of lidocaine into the cervix (a cervical block). This very commonly offered, although there are almost no studies to look at. There is a small, but high-quality study, indicated no benefit to lidocaine injections over placebo. I was surprised to find that there so few studies considering this is routine practice for many providers. Several of my colleagues were shocked to find the lack of studies and swore they felt it made dilating the cervix easier for many women. There is just no evidence to say it does help, however, it’s hard to abandon something based on a small study. More studies are definitely needed.
  • Insertion during the period. The idea being the cervix is open a little and so it may make insertion easier. I have always thought this was the case, but a meta-analysis shows that when an IUD is inserted (the Copper IUD) doesn’t seem to affect shorter term outcomes like pain. Keep in mind that the Mirena IUS is optimally inserted during the menstrual cycle, but that is so a woman can be protected form pregnancy that first month.
  • Taking a pain pill. A small randomized double-blinded clinical trial (a good quality study) indicates that tramadol (a non opioid pain medication) helps reduce pain even better than naproxen.
  • Focus on the fact that 2/3 of women find the pain of IUD insertion to be very tolerable. Anxiety increases pain and studies tell us that women who expect insertion to be painful are more likely to have pain.

I was surprised that many of the interventions common offered just don’t seem to work. This might be because the mechanism of pain for those women who have painful insertions may not be well understood. I think part of the pain for some women may be having the speculum opened very wide and for a typically longer period of time than a Pap smear. If you are anxious about the pain, the pelvic floor muscles will be more likely to spasm making the speculum pain worse. Non of the interventions described above, with the exception of trying to reduce anxiety and tramadol, would be likely to help with speculum related pain.

Keep in mind, all of the above information is based on studies looking at the general population of women who present for an IUD. If you have a history of scarring to the cervix or a previous difficult or painful IUD insertion then these studies may not apply at all to you and your situation.

In summary, misoprostol just isn’t supported (several studies) and may even worsen outcomes. There is probably no downside to taking a nonsteroidal anti-inflammatory, but the evidence to suggest that ibuprofen helps is underwhelming. Based on the current studies you may be better off with naproxen or a single tramadol. There is also probably no downside to lidocaine injections in the cervix, but whether it helps is up in the air. Also, don’t forget mind-body techniques to reduce pain, like diaphragmatic breathing, and focusing on positive affirmations such as the fact that you are more likely to be satisfied with your IUD than any other methods of contraception.

 

 

Remember, this post does not represent individual medical advice

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Discussion

15 thoughts on “Is an IUD painful? If so, how can I reduce the pain?

  1. My mirena insertion was quite painful in terms of cramping, and I cursed like a sailor until the nurse handed me a hot pack. I had taken Advil before the appointment, but the hot pack was far more effective. (The cursing helped, too.)

    Posted by Carolyn | June 22, 2013, 7:44 am
  2. My insertion was nothing. I had some mild cramping after and the actual insertion was nothing more than my normal period cramps. The RN who inserted it said she had never had someone who took the pain like I did. All of my friends that have had one say it was painful except one. I just took it out to conceive, and went to work right after. It is easier if you’re calm!

    Posted by Missy Q. | June 22, 2013, 10:00 am
  3. I’ve always wondered if those who are prone to menstrual cramps are more susceptible to pain during IUD insertion, also I believe in some cases pain may be down to poor training and experience from the practitioner. I don’t suffer menstrual cramps (in the 20 years I’ve been menstruating I can only recall a handful of times when I’ve experienced menstrual cramps, and they only occurred as a result of something pressing on my cervix), and I experienced absolutely no cramping what-so-ever with my IUD insertions.

    – IUD#1 no pain or discomfort at all – the nurses didn’t seem to believe me (but then nurses never believe me when I say I’m not uncomfortable with routine pap smears, STI screening, etc either), no one had told me that IUD insertion could be painful so I just assumed the nurses were warning me just to cover themselves. I was forced to lay down for 10 minutes, but after I went for a long walk and not once did I experience any cramping at all.

    – IUD#2 the doctor used the wrong tools – she used tongs with inch long sharp points that were jammed into my cervix and pulled…this was painful, and there was a lot of blood all over the table, for several days after I was tender, bled, and couldn’t think about my genitals without cringing. I had okayed her to go ahead with using this tool, we were both in the wrong and the doctor apologised for her mistake. I didn’t experience any cramps with that insertion either, and honestly believe if it wasn’t for the spikes stabbed into my cervix it would have been like IUD#1.

    Posted by Jay | June 22, 2013, 10:52 am
  4. http://iud-divas.livejournal.com/3404274.html
    Pain and IUD Insertions – Jounral of Contraception Study – IUD Diva Article on the Study

    http://ge.tt/5ZX0pbi/v/0?c
    The Study Itself ↑

    First Insertion – Horrible botched, one arm didn’t extend I was in horrible pain from the insertion to 3 months until I yanked it. Barely felt the plastic tenaculum. Paragard.

    Second Insertion – Went great, very tolerable pain wise. I over-medicated myself because of my terriblely painful experience with the first. Again I barely felt the plastic tenaculum. Paragard

    Third Insertion – Very crampy, practitioner wanted to find 6 cm and dug around in me for a while to find it, very crampy, achy, my uterus felt very battered and bruised for days afterwards. Also the tenaculum felt like something was biting my cervix, I had deep punctured wounds from this metal tenaculum that took weeks to heal. Flex T 300

    Every experience is different.

    By and by, do you have an opinion about unapproved IUDs? The only IUD that fits me is a Flex T 300, it’s a lot smaller than the Paragard and has been very comfortably retained unlike my previous two Paragard. I had to special order it from Canada because despite miscarriages, an abortion, a stillbirth and a vaginal delivery I am still about 5 cm deep and far too small for a Paragard. I will never try to fit one of those again, I suffered too long trying to make a Paragrd fit me, it was constantly sitting in my cervical os and gave me cervisitis too many times to count.

    Posted by Divine Oubliette | June 22, 2013, 1:24 pm
  5. Interesting! The team who did my insertion recommended NSAIDs and used the anaesthetic gel – I didn’t know they would do that until the day of – but they were also very good at telling me what to expect, and reminding me to breathe and relax specific muscles which I think helped a lot. I felt in control. They also took my BP before and after to check I was ok to leave the clinic and wasn’t going to faint somewhere!

    The cramps at insertion were wicked but there were only about four of them and then it was like moderate period pain for the next 36 hours or so. And so far I love it! And I’m sure it hurts less than either an abortion or birth, so… :)

    Posted by QoB | June 22, 2013, 2:44 pm
  6. I’m an outlier (cervical scarring), and my Mirana insertion was terrible (even with Vicoden and Ultram). But it was worth it! For me it was a last-ditch try before hysterectomy for endometriosis, and it did the job quite well. One bad week in 5 years vs. surgery or heavy, bad cramping periods that last 10 days?

    No question.

    Posted by LoreleiHI | June 22, 2013, 9:33 pm
  7. I’ve had three insertions – all painful during insertion and with about 12-24 hours of cramping afterwards, but all to slightly different degrees. In my experience the insertion pain ispretty intense, but only for 10-20 seconds or so. It was worse the second time – I think because the Doctor had to remove the previous one immediately prior to inserting the new one (previous one had spent a few days working itself halfway out of my cervix!).

    It’s so worth it though. 20 seconds of intense pain followed by half a day of cramping for years of risk-free sex with my partner. It’s a no-brainer for me.

    Posted by JP | June 23, 2013, 9:07 am
  8. Mine was horrifically painful, I actually felt like I was being stabbed with a needle. And I had taken a Vicodin an hour or two beforehand.

    But then my whole Mirena experience was pretty disastrous, so I’m definitely an outlier.

    Posted by Wendy Lyon | June 23, 2013, 1:27 pm
  9. My last IUD was inserted by an intern who was doing it for the first time. IT HURT, but I focused on not making her feel more nervous than she already was. No sudden moves.

    After inserting it she said that it might be the last birth control I ever need. She was right. Am having it removed in a few weeks.

    Both of my IUDs served me well— so trustworthy, so always there. I recommend it for any woman who is forgetful and/or enjoys non-stop protection.

    Menopause works, too.

    Posted by wileywitch | June 24, 2013, 8:59 pm
  10. Sorry I’m late; I only just found your blog. I found it interesting that you mention Tramadol – I have endometriosis, and Tramadol is the only pain medication I’ve found that reduces the pain while still leaving me able to function. I spent some months trying out different types of pain medications at a pain clinic; most did not help significantly, some helped but also impacted my ability to function – and then Tramadol which leaves me clear-headed and with a manageable amount of pain. So I can very well see how it would work for other pain in and around the uterus – but then, it’s different for each person as regards how their ability to function is impaired…

    Posted by Apoidea Theorem (Bisatser) | July 14, 2013, 10:36 am
  11. I had Mirena inserted on Tuesday (day 6 of my cycle) and it was definitely the worst pain I have ever felt. I am 22 and nulliparous. My doctor prescribed 800mg ibuprofen and 400mcg vaginal misoprostol the night before, and 800mg ibuprofen an hour or so before. The misoprostol caused some cramping before the procedure, so I’m not sure if it helped or hurt. I had no local anesthetic; my gyno never mentioned that.

    My 23-year-old nulliparous friend had Mirena inserted a few months ago with ibuprofen and Xanax taken beforehand; she said it hurt a lot, but not as bad as it did for me. I have a fairly low pain threshold and anxiety issues so those definitely contributed to the pain. I tried deep breathing and was fairly calm throughout the procedure, but was very lightheaded and nauseous with low blood pressure afterward. Since the insertion I’ve had intermittent, average/mild cramps and some spotting.

    I should also mention that my gyno really, really tried to steer me away from the IUD by repeating how awful the insertion would be. I tried not to let that get to me, but I’m sure that played a role in my pain level too. She pressured me to stay on the mini pill (norethindrone), which I liked for the most part, but I wanted something more effective and long-term.

    I don’t know if I’d want to go through the insertion again in 5 years. I am optimistic about Mirena, and if it works well for me, then maybe I’d consider a repeat, but only with different pain control techniques, like Dr. Gunter mentioned. I am disappointed that I experienced as much pain as I did. I’m hoping that it’ll be worth it!

    Posted by Ashley C | July 19, 2013, 6:46 am
    • Note: I am not trying to scare anyone away from the IUD. After months of research and deliberation, I decided that Mirena was what best fit my contraceptive needs. The insertion sucked, but as long as it doesn’t expel and I don’t get pregnant, then I will consider it worth the pain. And this article gives me ideas for the future, if I decide to get another IUD someday.

      I also wanted to add that I really didn’t appreciate that my gyno tried to pressure me into sticking with a birth control that I didn’t entirely trust. I am young and nulliparous, but I’m also an adult and know what I need to fit my health and lifestyle. Don’t let doctors talk you out of what you feel is right.

      Posted by Ashley C | July 19, 2013, 6:51 am

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