Dr. Chelsea Daniels knows firsthand that the insertion of intrauterine devices, or IUDs, can be more than just a pinch.
"I had two IUDs placed in my life," Daniels said, "I currently have an IUD, and I wasn't offered anything for either of them."
Daniel works as a staff physician for Planned Parenthood of South, East and North Florida.
"They're not comfortable," she said about the procedure, "so I think it's hugely important that we're able to level that with patients."
According to a 2015 study from the National Institutes of Health, providers tend to significantly underestimate the pain experienced by patients during IUD insertions.
"We in medicine have done a poor job of taking women's pain seriously, historically and systematically," Daniels said.
The American College of Obstetricians and Gynecologists addressed this in May, when it recommended doctors counsel patients and provide pain management options for IUD placements and other in-office gynecological procedures.
The college's Clinical Consensus Committee on Gynecology recommends doctors use shared decision-making when discussing pain management with patients. It also listed the best pain management options for different procedures.
For IUD placements, it recommends a cream, spray or injectable version of lidocaine, a local anesthetic. It said nitrous oxide and over-the-counter drugs, such as ibuprofen, are not effective forms of pain management during this procedure.
Prior to these guidelines, doctors have been using these pain management options. But each practice is different, and some don't use any.
"There is an urgent need for health care professionals to have a better understanding of pain management options," the committee wrote, "and to not underestimate the pain experienced by patients."
What is an IUD?
The IUD is a long-term and reversible form of contraception. It can last anywhere from three to 10 years and is over 99% effective at preventing pregnancy. It does not protect against sexually transmitted diseases.
It is so effective because there is no risk of the user making a mistake, according to Planned Parenthood. A birth control pill, however, is less reliable and lowered to 93% effectiveness because people forget to take it.
The IUD is a small T-shaped device that is inserted into the uterus.
The insertion takes about three minutes, according to Dr. Karen Harris, attending physician and residency program director at the Women's Group of North Florida in Gainesville.
During this process, the cervix is stabilized, the depth of the uterus is measured, then the IUD is inserted.
The placement can cause cramping and post-procedure pain, which Harris describes as an "annoyed uterus."
But the IUD isn't always used as contraception. It can also help manage gynecological conditions relating to regulating heavy and painful menstrual bleeding.
Harris said she's had patients who have had their tubes tied, a form of sterilization that does not stop menstruation, but got the IUD to control their periods.
"The hormonal IUDs are great for women who have terrible, painful periods," Harris said, "Ninety percent less bleeding and 90% less cramping."
Nonhormonal IUDs can initially worsen menstrual bleeding and cramping.
Doctor-patient partnership
In its release,ACOG emphasized the importance of counseling patients so they can understand their pain management options.
It recommends shared decision making, which turns the doctor-patient relationship into a partnership. The goal is to find the best option for the patient.
Harris said that over the past 20 years she has seen a lot more emphasis on shared decision making.
She said it's very important to clearly discuss pain management options with patients because she cannot predict what they will experience.
"I don't know if someone's going to experience terrible pain," she said, "or if someone's not going to notice much more than a pap smear."
ACOG also said health care professionals cannot reliably predict the level of pain a patient will experience, so they should provide thorough counseling and pain management options.
The ACOG committee recommends the use of local anesthetics during IUD insertion. It does not include recommendations for IUD removal because there was not enough data.
"We have been here already doing the pain control mechanisms that are listed in this article," Harris said, "and I would say that the majority of physicians here at this hospital follow these guidelines. It's just nice to see them written down."
The Women's Group of North Florida, a residency practice for new doctors training to be OB-GYNs, offers injected local anesthesia and nitrous oxide.
Planned Parenthood offers injectable lidocaine. It also has oral and intravenous versions of sedation for anxiety.
At Planned Parenthood, Daniels will "walk patients through all of those options and let them choose what makes them most comfortable."
She said her previous workplace did not offer topical lidocaine or the injection. Instead, they would have a conversation with patients to set expectations.
"Dispelling myths" on social media
The New York Times reported that one reason the college revised its guidelines was to address concerns raised on social media.
In its release, the college did not mention social media, but it did discuss negative preconceptions about the procedure and the importance of counseling patients.
Data from the National Institutes of Health shows videos tagged #IUD on TikTok from 2024 tended to discuss negative experiences with pain and informed consent.
The study said these videos are a low-quality source of information about treatment options.
In some videos, content creators and people in the comments describe intolerable pain, some saying they passed out.
Patients will film themselves while getting the IUD to show their live reaction.
These videos are not necessarily inaccurate, but the amount of pain a patient will experience is unpredictable, which is why the college recommends thorough counseling.
"Unfortunately," Daniels said, "a lot of my job has become dispelling myths that TikTok propagates."
She described social media as a "double-edged sword."
But she does think there is value in talking about women's health on social media.
"There are so many things about women's health that are so stigmatized and so taboo," Daniels said. "We're all so afraid to talk about it, and then we don't, and it's actually this really communal experience."
Meryl Alappattu is a licensed physical therapist who specializes in pelvic pain.
"Social media, I think, provides a community for people to sort of come together and have their experiences validated," Alappattu said, "which I think is a really powerful thing."
She also mentioned how social media can impact health care professionals.
"I also think it provides an opportunity for providers," she said, "to take a closer look at ourselves and our practice and what our profession is doing."
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