Too many women ‘grin and bear it’ when getting an IUD. I helped write new pain management guidelines to change that.

Millions of American women have had an IUD (a tiny T-shaped contraceptive device) inserted into their uterus. Many of them likely walked into their doctor’s office with a bit of anxiety, not knowing what exactly the procedure would feel like: Would it be just a pinch or would it be incredibly painful? (There is no shortage of viral horror stories.) Also, would your doctor take your pain seriously? Up until recently, there wasn’t a standard of care for IUD pain management. Women are often told to pop over-the-counter pain relievers before coming in for the procedure, even though they don’t always control the pain. Any pain relief beyond that has been up to the woman’s doctor or hospital, and depended on what options they had available.

That’s changing thanks to new guidelines on pain management for IUD placement issued by the American College of Obstetricians and Gynecologists last month, which follows the Centers for Disease Control and Prevention’s updated guidelines in 2024. ACOG called out the “urgent need” for doctors to acknowledge and treat patient pain and added that patients should “have more autonomy over pain control options for their health care.”

Genevieve Hofmann is a nurse practitioner who coauthored the new ACOG guidelines. In this interview with Yahoo Life’s Rachel Grumman Bender, Hofmann explains why IUDs can be painful for some, why any fears shouldn’t scare people off from getting this highly effective contraceptive and how these pain management guidelines are an important step in the right direction.

IUDs are really one of the most effective birth control methods out there. We call them LARCs, or long-acting reversible contraceptives. Hormonal IUDs are over 99% effective at preventing pregnancy, and nonhormonal IUDs are equally effective. What’s nice about hormonal IUDs is that we also use them to manage a lot of gynecologic conditions, such as heavy menstrual bleeding and painful periods.

However, patients are coming to us and saying, “I do not want to have this horrible experience with getting an IUD. How can we manage this?” I’ve been in practice for a little over 20 years, and [when I started out] we would tell people to take some ibuprofen beforehand and try to do some distraction techniques while we’re putting it in. There’s a lot of grin and bear it in gynecology and in women’s health.

It’s really challenging for us as providers to give people an accurate assessment of what they’re going to experience with IUD placement. I’ve seen people who have had IUDs placed, where it was like, That was not terrible, and then all the way to That was the worst pain that I’ve ever had in my entire life and I had a natural childbirth. There’s a very large range of how people experience pain as well as anxiety.

So I think as a provider, the guidelines really put the onus on us to help people anticipate the pain and have that conversation about what they can expect. Sometimes they won’t know until they’re in the throes of it, and so it’s about being prepared with some pain options in anticipation that it could be a really painful and uncomfortable procedure for them.

Why IUD insertion can be painful

IUD insertion requires the placement of a speculum, which sort of holds open the vagina in a way that’s not normal. So having a speculum in the vagina is not really comfortable.

Then there’s the procedure itself. A lot of times, we have to manipulate the position of the uterus, and we do that sometimes by putting a clamp on the cervix. It’s this sort of sharp instrument that takes a little “bite” out of the cervix to hold it in place. So that tenaculum placement can be very painful.

IUDs are placed in the uterus, which is a muscular organ. To do that, you have to go through the cervix, which is the opening to the uterus. The cervix can be very tight, especially if someone has not had a vaginal birth. And so getting through that cervical opening can be really painful for some.

The uterine body itself has some nerves, so something going into the uterus is just crampy and painful — it’s a very deep, visceral pain that is hard to explain to people if they’ve never had any kind of instrumentation in the uterus before. We also have a really large nerve called the vagus nerve that goes through the cervix; so people can also have this kind of vasovagal-type response when we manipulate the cervix, which makes people feel really terrible too.

It makes you feel like you’re going to pass out, and you get hot, and you feel like you’re going to throw up. And sometimes people feel like they have to poop, and that is a really uncomfortable feeling as well. So there are many different aspects that cause pain.

But not everyone’s going to feel that way. As a provider, I don’t want to scare people out of getting this really effective birth control method or way to manage heavy menstrual bleeding. So [it’s about] finding that balance between giving people the information they need so they can feel, OK, I’m going into this with my eyes open, but also not terrifying and scaring people away that they say, Yeah, I’m never ever gonna do that.

I always say it’s like going to a restaurant. You’re going to tell 25 people when you have a terrible restaurant experience. But if you have a great restaurant experience or a mediocre restaurant experience, you don’t really tell anybody. So, I think there are a lot of people who do great with their IUD insertion and really manage it well, but they’re not as vocal about it as somebody who’s had a really awful experience.

Why the new pain management guidelines are important

What the evidence for the guidelines really demonstrated was that using some sort of topical lidocaine, which is a numbing agent, on the cervix was beneficial compared to a placebo or compared to other distracting techniques or ibuprofen and other pain medications.

Many of us have been offering better pain management options in the last several years compared to maybe what was happening 10 or 25 years ago. We know from the evidence that anxiety tends to worsen pain. I think providers will give anxiolytics [medications to treat anxiety], so telling patients to take a little bit of Xanax or some Ativan to help with the anxiety. And I do think people are using localized lidocaine, whether that’s in a gel or a spray or putting in an injectable lidocaine through a paracervical (nerve) block. I think that is becoming much more typical. There’s also IV sedation.

The other big thing that comes out of these guidelines is that we as providers owe it to our patients to have a discussion about some options that are available to them. So, it’s really having the conversation, guiding patients to make the best decisions for themselves and then hopefully being able to find some interventions that you can do in your clinic safely and effectively to give people some options.

I hope that these guidelines get the conversation started in a way that we’re meeting people where their needs are … that they feel heard and can access things like IUDs that are really highly effective … and that we believe patients when they say, “This was really painful.” Or, “I had a really terrible experience last time I did this.” [We should] trust them to know their bodies and say, “OK, here are the things we’re going to do to hopefully try to improve that experience this time.” So I hope that’s what comes out of it.

Patients need to feel like they’re in a space where they can advocate for themselves and be heard.

This interview has been edited for length and clarity.