Addressing IUD fears and ensuring patient comfort

Opinion

Hey there, time traveller!
This article was published 31/05/2024 (488 days ago), so information in it may no longer be current.

I am alarmed that many women electing to have an IUD inserted believe they have to face the fear of “Fifteen minutes of pure agony” — Free Press, May 27, 2024.

Thank you, Eva Wasney, for highlighting the basic right these women have to be valued, not dismissed, and properly prepared for this procedure.

IUDs are not only one of the most effective methods of contraception but the progestin-containing Intra Uterine System is also very effective in managing abnormal uterine bleeding, pelvic pain caused by adenomyosis or endometriosis and can also be used as part of a hormone therapy regimen.

These medical uses for an IUD help to decrease the need for further surgical interventions such as endometrial ablation (destruction of the lining of the uterus) and hysterectomy. These devices, depending on the indication for insertion, can be left in place for eight to 10 years — or longer.

Unfortunately, many more women could benefit from the contraceptive efficacy and medical benefits of IUD therapy, if the negative culture associated with its insertion and continued use can be addressed and changed. As more streamlined and smaller IUD inserters and devices are developed, well-trained practitioners have the knowledge and ability to insert them more efficiently, and there are more options available for pain control.

Insertion of an IUD in both the patient and some physician’s eyes is not considered to be a surgical procedure. This is a fallacy. It should be dealt with the same way as all invasive surgical procedures requiring training, skill, good communication, and plans for adequate pain control. Documented informed consent is essential.

All invasive surgical procedures have complications or adverse events. IUD insertion can rarely be associated with significant bleeding and post-op infection and, in some cases, a vasovagal reaction can occur with manipulation or stretching of the cervix. This can lead to faintness, nausea, sweating and a slow pulse rate. These complications can be dealt with quite effectively and can be prevented in most cases.

There are a select group of women who are very anxious, have cultural biases or have had psychosocial or sexual trauma. In addition, there are also women who have significant pelvic pain with a tender uterus on examination. They will probably not do well having an IUD inserted in the office. It is my experience and best practice to insert the device in a procedure room or operating room under intravenous conscious sedation with local anesthesia, as well as performing a diagnostic hysteroscopy (looking into the uterine cavity).

All other women will probably do quite well if the procedure is done in an office setting. Pelvic pain and uterine cramps are the most common adverse events. It is very difficult to determine which patients will suffer more than others.

It is my opinion after years of experience that it is best to assume that most will feel significant discomfort, and I discuss options for prophylactic pain management with them.

It is also best to have a nurse or other health care professional in the office during the procedure for patient support and additional help if necessary.

Acute pain can occur while the internal OS of the cervix (opening into the uterus ) is entered or stretched. Once the device is properly placed in the uterine cavity, it is very common for women to experience menstrual-like pain.

The acute pain related to stretching the internal OS, as well as a vasovagal reaction, can be controlled or even prevented in most cases by performing a uterosacral nerve block. An adequate amount of fast-acting local anesthesia is injected into both uterosacral ligaments at the base of the cervix.

Local anesthetic spray or gel on the outer cervix is usually not as effective and the traditional paracervical injections of small amounts of local anesthesia at several points around the cervix is less effective than a uterosacral nerve block. Cervical softening with prostaglandin tablets prior to insertion is also not as effective and can produce cramping.

The menstrual-like cramps that occur once the device is in the uterine cavity can usually be controlled with pre-medication of nonsteroidal anti-inflammatory drugs such as Advil or naproxen and post procedure.

I concur with Dr. Renee El-Gabalawy’s comments in the article regarding trauma-informed care. Communication is essential.

If we can prepare our patients by having them know what to expect, know that we care and assure them that adequate pain control will be provided we can expect positive outcomes and minimal mental health sequelae.

Richard Boroditsky MD is a professor of obstetrics, gynaecology and reproductive sciences at the University of Manitoba.