‘Fifteen minutes of pure agony’ Increasing calls for better pain-management planning before IUD insertions Silenced Symptoms
By: Eva Wasney Posted: 3:00 AM CDT Monday, May. 27, 2024 Last Modified: 6:49 AM CDT Monday, May. 27, 2024 Updates

Hey there, time traveller!
This article was published 27/05/2024 (857 days ago), so information in it may no longer be current.

When Cara McCaskill filled her birth control prescription, she didn’t expect to end up on an exam table, sweating and fighting to stay conscious.

“I was told that it could be a little uncomfortable and that I might experience some cramping,” McCaskill, 26, says of the prognosis for her IUD insertion. “It was 15 minutes of pure agony.”

In recent decades, IUDs, or intrauterine devices, have become an increasingly popular contraceptive option, owing to their effectiveness and convenience.

The small, T-shaped pieces of plastic contain either copper or a low dose of the hormone progestin. Both varieties are more than 99 per cent effective in preventing pregnancy — a failure rate on par with sterilization — and can be left in place for five to 10 years, depending on the brand.

It’s a long-acting, reversible form of birth control deemed suitable for a wide range of people, from teens to those experiencing perimenopause.

The set-it-and-forget-it nature of the device appealed to McCaskill, as did the potential to forgo her lifelong painful periods with an hormonal IUD. Her family doctor made a referral and she was advised to take an ibuprofen before the appointment.

Typically, IUD insertions take just a few minutes without complications. During McCaskill’s procedure, however, the doctor struggled to set the device in the correct position. The pain was extreme and surprising. There was blood. A nurse stood by, dabbing her forehead with cold towels to keep her from fainting.

McCaskill’s experience isn’t an anomaly.

While some patients feel only mild discomfort during the procedure, others are left writhing in pain. Research and popular culture are beginning to shine a light on the wide range of experiences.

Harrowing videos of women recording their live reactions to IUD insertions have gone viral on social media and spurred petitions calling for better pain-management options.

Duke University researchers found the most popular TikTok videos showed overwhelmingly negative encounters and encouraged distrust in doctors, with some containing health misinformation.

At the same time, it’s impossible to ignore the comment sections of these posts, which are filled with users finding validation for their own painful experiences.

Many studies suggest the procedure is tolerable for most patients without pain relief. Yet, a 2023 survey out of Brazil saw 49 per cent of respondents describe the pain as intense (the top level of the scale), with women who had never been pregnant reporting the highest pain scores. Those who had given birth vaginally generally experienced less pain. The sensation can be heightened for those with a history of painful periods or endometriosis.

Several studies have also found that doctors tend to underestimate patient pain levels during IUD procedures.

McCaskill wishes pain had been part of the conversation at all.

“I wish I knew that it’s not super uncommon for some people to have extreme pain and I wish I knew that pain management was something I could ask for,” she says. “It just highlighted for me how much further there is to go in women’s health care because having such an invasive procedure and not being offered pain management as the default would just not happen in any other type of medical procedure.”

At the 15-minute mark of her first IUD insertion, McCaskill’s doctor stopped, apologized profusely and referred her to a gynecologist. Despite fears of another painful procedure she decided to try again — at the time, the purported benefits of an IUD outweighed her anxiety.

She was prescribed misoprostol — a medication used to soften and dilate the cervix — and received localized anesthetic at the clinic. The second procedure was again “extremely painful” and McCaskill experienced severe cramping for a week before the device fell out of place.

Twice was enough.

“I just couldn’t mentally make myself do it again,” McCaskill says. “I ended up having to find a different method of birth control.”

Dr. Jenna Yuen is a family physician and interim medical director at the Women’s Health Clinic. Over the last 12 years, she’s conducted her own informal pain study while administering hundreds of IUDs at the Graham Avenue health centre.

“I’ve taken to always asking people, ‘On a scale of one to 10, how bad did it hurt for you at its worst?’” she says. “The average, I’d say, is six to eight.”

During consultations, Yuen tries to be straightforward about pain without stoking fear. Lately, she’s noticed more clients coming in with questions and expectations gleaned from social media — something she views as a positive development.

“Everything in medicine is a conversation about pros and cons,” she says. “And that informed decision-making is really important.”

Yuen likens the insertion to a piercing: an experience where a degree of pain is expected, but short-lived. Her pain management decisions are often based on a person’s level of anxiety prior to the procedure. Mitigating discomfort is far from an exact science.

“There’s no way to anticipate how painful it might be for a person ahead of time,” she says. “Some people are able to do it without any medical intervention and other people have all of the pain control mechanisms and still have a traumatic time.”

The insertion process has several potential pain points.

At the Women’s Health Clinic, the procedure starts with a general and manual pelvic exam — which can include pap testing and sexually transmitted infection screening — to check the size, shape and position of the uterus. A speculum is inserted into the vagina and the canal is prepped with iodine.

Patients are encouraged to take over-the-counter pain meds before their appointment and a topical lidocaine spray is applied to the cervix to “take the edge off” the next step: holding the uterus in position with a tenaculum.

“Don’t Google it,” Yuen says jokingly of the sharp, hooked metal forceps. (Not-so-fun fact: the tenaculum was developed more than 100 years ago with a design inspired by bullet extractors commonly used on battlefields.)

The uterus behaves much like a balloon; it’s tethered in place but can shift around within the pelvis. Gripping the cervix with a tenaculum holds the organ steady.

Next, a measuring tool is inserted through the opening of the cervix to determine the correct placement depth. The IUD is then pushed into position at the top of the uterus through an insertion tube and the removal strings are trimmed to length.

Manipulation of the cervix is another common pain point.

“With the insertion, we’re stretching (the cervix) by four or five millimetres,” Yuen says, adding that even minor dilation can induce contraction-like cramping. “That’s where it’s similar to labour and delivery pain.”

At the moment, there isn’t a perfect pain management solution for IUD insertions.

Lidocaine, administered topically or injected, can blunt external sensations, but it’s difficult to block the nerve pathways within the cervix and uterus, Yuen says. Numbing is also not a standard practice at all clinics.

If anxiety is the main hurdle, Yuen may prescribe an anti-anxiety medication or suggest conscious sedation. Although, both routes have downsides, such as the side effects of an altered mental state and the need for a ride home.

“It turns a quick office visit into something you need a day of recovery from,” she says. “It’s overkill for the majority of people but, absolutely, some people need it.”

Sydney, 29, was sedated for her first IUD, which was inserted following a surgical abortion.

“It was a matter of convenience,” Sydney says. The Free Press has agreed to withhold her last name for the sake of medical privacy. “The pill was obviously not working out for me.”

But the hormonal IUD did. She no longer had to worry about taking a daily pill and enjoyed the long span between appointments. Avoiding her period was an added bonus.

Five years later, when it came time to remove the device, Sydney started to worry about how the procedure would feel if she was conscious. Friends and strangers on social media did not offer glowing reviews.

“I’d seen so many people say that it was the worst pain they’ve ever experienced,” she says. “I just didn’t want it to hurt, simple as that.”

She went into the appointment prepared to advocate for herself. After an attempt to remove the IUD proved painful, the doctor agreed to sedation. Still, she dreads the possibility of being denied anesthesia in the future.

While Sydney is quick to recommend the contraceptive to others, she always includes a caveat when the subject comes up.

“You probably don’t need to be put under,” she says. “But you can definitely ask for pain management — it probably shouldn’t hurt that much, you know?”

Andrea Nazeravich, 29, got an IUD in the hopes it would relieve the painful gynecological symptoms of an undiagnosed condition. In the weeks leading up to and during her period, Nazeravich deals with shooting pain and cramps that cause her to keel over.

Her gynecologist recommended an IUD to stop her period as a first line of treatment before committing to laparoscopic surgery to assess for endometriosis. Due to physical complications, the procedure was scheduled at the Health Sciences Centre, which Nazeravich describes as “one of the most traumatic experiences in my life.”

Upon arrival at the hospital, she was given medication to soften her cervix. She was on her period at the time — which can make insertion easier in some instances — and was left to wait in a shared room, wearing a gown without underwear or menstrual products, while the meds kicked in.

During the procedure, Nazeravich was put under light sedation and given internal anesthesia. The drugs proved ineffective.

“I was telling her, ‘I can feel everything, this is uncomfortable,’” she says. “I was having a panic attack at this point, tears were streaming.”

Her gynecologist proceeded with the insertion and she was sent to a recovery room in obvious distress. At a routine followup appointment she was informed by the same doctor that the brand of IUD she received had been discontinued.

“In my mind, I was like, ‘Shouldn’t you have called me about this?’” she says. “It felt like she didn’t really care.”

Nazeravich continued to experience painful periods and requested to undergo the diagnostic surgery for endometriosis. She was sedated and her IUD replaced at the same time.

While the first procedure was surprisingly painful, the dismissal she felt from her gynecologist has left a lasting mark.

“I’m at the point where it’s been five years and I need this taken out, but I’m terrified to go in,” Nazeravich says, adding that she won’t be getting another IUD. “I don’t want to see this doctor again.”

Dr. Renée El-Gabalawy is the director of the Health, Anxiety and Trauma Laboratory at the University of Manitoba. She studies medical trauma and its impact on mental and physical health.

Medical trauma is a highly subjective experience and can occur in response to an acute illness, difficult diagnosis, sudden life-threatening event or surgical complications. While many people struggle psychologically in the wake of these kinds of events, most recover within a month, El-Gabalawy says. A minority of patients, however, experience persistent post-traumatic stress symptoms.

“There are certain things that can occur that will increase the risk of being in that minority,” she says. “If someone perceives they have no control in the situation, that’s a risk factor; if they have perceived or actual mistreatment from a health-care provider or if there’s a significant amount of intolerable discomfort or pain.”

A traumatic experience in a medical setting can lead to worse health outcomes in the long run. Some patients may avoid further treatment, which can compromise their condition, or proactive health measures, such as vaccinations, because of the fear associated with a procedure, clinic or provider. Anyone with continuing symptoms should seek professional counselling.

El-Gabalawy regularly lectures med students on the importance of trauma-informed care — an increasingly popular approach within the medical field, which takes past trauma and lived experiences into account. In the case of IUD insertions, where a degree of pain is unavoidable in most cases, patient preparation is key.

“Communication is essential in these circumstances,” she says. “If we can prepare our patients just by having them know what to expect, that can be very helpful and reduce the risk of some of these poor mental health outcomes.”

It’s equally important for patients to relay their concerns prior to a procedure “so that the doctor has the opportunity to tailor their care accordingly,” El-Gabalawy adds.

While Yuen at the Women’s Health Clinic feels for patients who have been blindsided by the pain of an IUD insertion, she also feels for other physicians working in Manitoba’s overburdened health-care system.

“I don’t have to worry about seeing 20 patients in a day and I have the time to make sure that my patients are fully informed,” she says. “I think the pressures of the medical system make it so that it’s tough to please everyone.”

eva.wasney@winnipegfreepress.com

X: @evawasney