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 pain, 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