Federal officials affirmed this month that the pain people might feel when getting an IUD can be more than doctors' promises of "just a pinch."
The local anesthetic lidocaine "might be useful for reducing patient pain" when inserting intrauterine devices, according to new guidance from the U.S. Centers for Disease Control and Prevention, which also encourages doctors to have a conversation with patients about pain management.
Women have used social media to advocate for more pain-management options, even recording and posting videos to document their grimaces, screams and tears as IUDs are put in. But complaints of pain are not limited to the small, long-lasting birth control device.
Many relatively quick outpatient procedures can cause pain, including biopsies and examinations of the uterus and cervix. Gynecologists and patients say there need to be more conversations about options for local anesthetics — as well as other pain-relief options for these procedures.
Pain relief options
Lidocaine spray or gel used as a local anesthetic and other pain treatments — think ibuprofen or an injection of an anesthetic — are safe for most patients and can be effective, gynecologists say.
The CDC's new guidance is just that — not a hard rule. And the American College of Obstetricians and Gynecologists spokesperson Rachel Kingery said in an emailed statement that there's no timeline for the group to provide clearer guidance on pain management for in-office procedures.
All of Dr. Cheruba Prabakar's patients who get an IUD also get a local anesthetic spray at minimum. The owner of Lamorinda Gynecology and Surgery in Lafayette, California, near Oakland, also books patients for 45-minute appointments in which she can thoroughly answer their questions and talk through concerns.
Some practices offer even stronger choices. After requests from their patients, Planned Parenthood League of Massachusetts added in March sedation options for IUD insertions and certain procedures in which doctors cut out possible cancers. Patients are not fully asleep, but drowsy.
Dr. Luu Ireland, an OB-GYN at Planned Parenthood League of Massachusetts and UMass Memorial Hospital, said there are lighter pain-management offerings, including anxiety pills and local anesthetic.
"I can't tell you how many patients I've seen choose less effective methods of birth control or forgo birth control (entirely) because they're afraid to undergo the procedure," she said of IUDs.
Prabakar believes that the biggest barrier to more patients having their pain taken seriously isn't cost or equipment. It's time and trust.
"There are a lot of patients with a history of trauma, history of shame," said Prabakar, who serves as an advisor to the Alliance for Women's Health and Prevention. "They barely can tolerate a speculum, let alone some of these other procedures."
Gynecology students should be taught on "Day One" about how trauma affects patients, said Dr. Deborah Bartz, an OB-GYN at Brigham and Women's Hospital who also teaches at Harvard Medical School.
That can include how anxiety levels and trauma can affect the level of pain a patient feels at the gynecologist, and how people who have never given birth may be at higher risk for pain during these sorts of visits, she said.
Research shows providers regularly underestimate the pain of IUD insertions. Women of color are less likely to have their pain taken seriously by providers; ample research shows Black people are undertreated for pain relative to white patients.
"If women have had their pain dismissed forever, since they were little kids having their periods, they're probably going to be more primed to experience trauma in the health care system," said Kate Nicholson, executive director of the National Pain Advocacy Center, a nonprofit focused on policy changes.
Advocating for medication
When the guidelines — or gynecologists — fall short, the onus may fall on the patient to speak up.
"(In obstetrics and gynecology,) there is that culture of: 'Women are strong. We can do this without pain medicine.' But why? Why is that?" said Sarah Friedberg, a Massachusetts mother of three who first experienced pain at the gynecologist since she got an IUD insertion 20 years ago — despite taking an over-the-counter pain reliever.
Friedberg's periods had always been exceptionally heavy, and after having three children, her doctors recommended removing her uterus. In August 2022, she went in to have blood drawn and other tests run in preparation for a hysterectomy. A doctor said they'd need to take some tissue samples from inside her uterus.
This was the first she'd heard of needing a biopsy, and she hadn't taken anything for pain ahead of time. Friedberg said no, and that she needed to reschedule the appointment.
"I'm a person who, if I don't like the nail polish they're putting on, I would never say, 'let's not do that,' or 'this is wrong,' or 'I want something different,'" Friedberg said. "I like not to make a splash in general."
She read up on what the biopsy would generally entail. The internet told her she had an option — lidocaine spray — and she asked her doctor for it. It took a search, but her doctor found some.
Her advocacy paid off. She didn't have extreme pain.
Friedberg hopes the updated CDC guidelines means women—including her daughter, when it's time — will have a different experience at the gynecologist.
"But it's very, very late," she said. "It's 2024. Come on, guys."
What questions should I ask at the gynecologist?
- What are my options for pain management? They're likely to tell you one of three levels: oral (ibuprofen), local anesthetic (lidocaine spray or gel) and injection (paracervical blocker). Sedation may be an option, but you'll likely need to book that ahead of time and line up a ride home.
- How will I know how much pain I might feel? Every person's pain threshold is different, and your levels of anxiety and stress can play a role, too. Talk to your doctor about your past experiences and concerns, even if you're just nervous.
- What if my doctor doesn't listen to me or provide the medication I request? Continue to advocate for yourself and come armed with knowledge. Experts agree that patients often don't know their options, and the new CDC guidance encourages gynecologists to talk with patients first. You can always seek a second opinion if needed and if time allows.
It's not "rocket science," said Cheryl Hamlin, an OB-GYN in Cambridge, Massachusetts and the reproductive care lead for the American Medical Women's Association. Doctors just need to tell patients their options, answer their questions and let them decide.
