About Those CDC Guidelines Around IUD Pain Management

I have some bad news, but there is a solution

IUD placement pain has been in the news recently because the CDC released new recommendations for pain management, but I have some bad news.

Before we get to the bad part, I want to make it clear that many people have a very manageable level of discomfort or even no discomfort. If you’ve given birth, chances are placement will be very unlikely to cause significant discomfort. If you haven’t… well, somewhere between 17-78% of you may experience “moderate to severe pain”—and yet even those who experience pain with placement report being pretty darn satisfied with the IUD as a birth control method. 90% would recommend IUD placement to a friend, even if placement was painful. No method is right for everyone, but IUDs are pretty well-liked.

Now the bad news.

Because my own IUD placement in 2011 was intensely painful—I literally screamed involuntarily, twice—when it came to having it removed and replaced, I went to the peer reviewed research to see what the evidence said was effective for pain management. In fact, I went to find research that supported what my provider had suggested. What I found was a paper whose title might as well have been, “What your provider recommended? Here’s evidence that it does nothing.”

With my first IUD placement, my key memory is slapping my own hand over my mouth to stifle my scream, so I wouldn’t scare other patients in the office.* So I kept digging into the research.

I found what the CDC found (here’s the CDC’s detailed review, for all my nerds), but, because it was my pain and my body, I came to a different conclusion. I ended up with a folder of two dozen peer (PDF) reviewed studies that all concluded, from my point of view, that there is no strong evidence that anything reliably helps to manage pain. There is “moderate” evidence at best. That, frankly, is not enough, given the intensity of the pain I experienced.

I want to point out the difference between my personal conclusion and the CDC’s, despite having the same evidence, because it underscores, as one paper concluded, “Patients' reported pain levels were significantly higher than those reported to have been observed by their providers.”

But I did absolutely all the things, trying to make replacing my IUD okay. I even took anti-anxiety meds, prescribed by my psychiatrist. I did everything I could. And then the removal alone was so painful that I changed my mind and walked out of the office with a prescription for the pill.

Is there any solution?

YES.

Long story short, I consulted with an ob/gyn, trying to understand my options. At the time I did not know I was autistic, so I didn’t know that I was missing a (to me) subtle social cue that what I should do is call Planned Parenthood and ask for twilight sedation with IUD removal and placement, and pay cash for it. I don’t know why the doctor didn’t just say it outright—is there some ethical problem with just straight up referring to me a provider who had the infrastructure I needed for this crucial aspect of my medical care?—but I only figured it out about a year later.

It is the best option, which is truly great from a pain management standpoint, but terrible from a financial and policy/procedure standpoint. Your insurance will almost certainly not cover it, and it will be expensive, and the provider might say no just because it’s not the way they usually do things.

And that’s bullshit. They can do twilight sedation for wisdom teeth removal and for colonoscopies, which, like IUD placement, is a once per 5-10 years procedure. Why can’t they offer it as standard procedure for IUD placement?

Of course not every patient would be okay with something medical happening to their vagina while they were unaware, and those patients obviously deserve to decline sedation, just as they can decline sedation with any procedure.

I believe that in 10-20 years, we’ll be better at predicting which patients might have significant pain with IUD placement, and we’ll be offered sedation as standard protocol, to make this very ordinary medical procedure painless. In fact, Connecticut seems to be leading the way!

Somebody better at activism than I am, could you please get us organized around this? A couple years ago I started corralling a group of clinicians and researchers who are interested in this topic... but then I had a podcast to finish and a book to finish and also I got long COVID and I'm just not going to be the person who is in charge of getting us all together to talk about creating change for patients. But I hope somebody will. There’s a lot of us out there who believe that patients deserve better.

In the meantime, I’m still on the pill.

PS And obviously all of this is null and void if birth control becomes illegal because not enough folks voted for a world where birth control is legal. Sorry to harp, but… it’s kind of a big deal? Please vote if you can! If you can’t, like if you’re not American, I bet you have a voting-eligible friend you can talk to!

* My second most intense memory? Lying in the recovery position, hands shaking around a juice box, and the doctor saying to me—and this is true, I couldn’t make this up—“I hope he buys you something nice.”

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