The appointment before she got her first intrauterine device, or IUD, Ana Ni’s doctor asked about her pain tolerance. Low, she said; medium, if she’s being generous. The clinic had just begun offering nitrous oxide, or laughing gas, to patients to help manage pain during IUD placements and, given the alternative — to undergo the procedure sans anesthetics — she gladly accepted.Before the insertion late last year, Ni, a 26-year-old health care consultant, took deep breaths of the nitrous oxide. She started to feel woozy. “Initially you just feel relaxed,” she says, “and then suddenly you get a bit of a head high, similar to when you would hit a vape. That kind of feeling, but intensify it more.” During the procedure, she continued to breathe the gas through cramping. Without the laughing gas, she suspects the pain would have been more acute.“I know it’s a short procedure,” Ni says, “but I honestly cannot imagine it without the laughing gas.”Ni’s experience is a far cry from some of the more graphic depictions of IUD placements on social media. Over the last few years, people have posted clips of themselves wincing and even crying on exam tables during IUD placements, shedding light on what was long-held to be a largely painless medical procedure. Research prior to 2016 found that patients described IUD placement as causing them “minimal discomfort” or “uncomfortable,” and rated it four on a pain scale of one to 10. The reality is more complicated. Many patients felt they were lied to by their doctors whose only option for pain management was over-the-counter painkillers. Studies analyzing social media posts about IUD insertion found that almost all of them mentioned pain and discussed how this pain was minimized. Part warning, part public service announcement, these viral videos not only helped bring to light the real suffering patients were experiencing, but also shaped professional guidance regarding what pain management doctors should offer them. Within the past year, the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists (ACOG) released updated recommendations for pain management during IUD placement. Both suggest clinicians offer local anesthetics like lidocaine spray, lidocaine-prilocaine cream, and paracervical block — an injection of anesthetic around the cervix. Other providers are going further, offering anti-anxiety medications or general anesthesia. The most effective way to address pain is perhaps the most straightforward, and the most novel: talking to patients and hearing their concerns.While the ACOG guidance found insufficient evidence to support nitrous oxide use, Ni remembers her doctor telling her how it helped other patients. She had a similarly positive review; she says she’ll request it again when she needs to replace her IUD. “Unless there’s some other medication then,” she says. “But I feel like the laughing gas will suffice.”Over 6 million people in the United States currently use IUDs as contraception, and the evolving pain management standards around them show the medical establishment has moved to address women’s pain — and how much more work is left to be done. Aside from having a slate of pain management options on offer, the most effective way to address pain is perhaps the most straightforward, and the most novel: talking to patients and hearing their concerns. The shifting standards around IUD procedures point to the ways doctors are only beginning to see patients as experts of their own bodies, and to take women’s concerns seriously.“This fits right into a movement that has really picked up steam, but I doubt is the norm across medical disciplines,” says Eve Espey, a professor and chair of the department of OB-GYN and family planning at the University of New Mexico. “But if you approach patient care in that way — in thinking about what a patient might experience with a painful outpatient procedure — [it] would dovetail very nicely into that much more patient-centered approach.”A history of pain in gynecologyIntrauterine devices are a form of long-acting birth control that have grown in popularity over the last 30 years, especially among those between the ages of 25 and 34. There are two categories of IUDs: copper and hormonal, both of which prevent sperm from fertilizing eggs. Part of the allure of IUDs is that, unlike the pill, which must be taken daily, an IUD is effective for anywhere from three to 10 years, depending on type. No upkeep, no prescription refills. Some users report less cramping and bleeding during periods and less endometrial pain; others stop getting their periods altogether.“There’s also some literature that says if you tell people that something’s going to hurt, that it hurts more, which is true.”Although the insertion itself only takes a few minutes, there are multiple points of pain throughout the procedure. First, the medical professional inserts the speculum, an instrument that opens the vaginal walls, which can be painful for some patients. Then, using a device called the tenaculum, the provider will grasp the cervix to straighten and hold it in place. The depth of the uterus is then measured, which can cause cramping, and finally, the IUD itself is inserted. Espey has placed countless IUDs during her 37-year career as an OB-GYN. For a while, she’d outline the risks and benefits and answer any patient questions. But she wouldn’t necessarily emphasize the potential for pain in order to avoid scaring patients. “We just assumed that if somebody came in for an IUD, that they wanted it,” Espey says. “It’s not that we wouldn’t describe the fact that it was painful — I did — but it’s also a little tough, because there’s also some literature out there that says if you tell people that something’s going to hurt, that it hurts more, which is true.”The people IUDs were originally intended for also shaped discussions of pain. When the first modern IUD was marketed in the 1970s, it was initially popular, with over 2 million users in the United States. But health complications, like increased risk of pelvic inflammatory disease sepsis, infertility, and even death, led the manufacturer to cease sales in the US just three years after its debut. These early health risks cast a shadow over the safety and efficacy of future IUDs. By the late 1980s, even with new safe, effective devices available, uptake remained low. The next wave of IUDs were recommended only for people who had given birth. Among birth control users ages 15 to 44 who had never given birth, only 0.5 percent had an IUD in 2002, compared to nearly 5 percent in 2013. A 2012 study found that 60 percent of providers rarely offered IUDs to patients who had never given birth. “Back in the day, we really reserved IUDs for women who had had kids,” Espey says.The concern was IUDs would be too difficult and painful to place for anyone else. “On average,” Epsey says, “women who have had vaginal births, particularly recent vaginal births, have far less pain with IUD placement than women who have not or who have only had C-sections.” Birth control pills were the go-to contraceptive method for decades, Espey says. But as more evidence emerged about the safety and efficacy of IUDs for people of all ages with uteruses, guidance about who should get an IUD began to change in the 2010s. But even as more people — particularly those who had never given birth — began to get them, the perception that the procedure was only mildly uncomfortable persisted. Indeed, medical providers often rated their patients’ pain during IUD placement as significantly lower than what the patients experienced. Women and gender-nonconforming people’s experiences in medical settings have long been dismissed. In a 2018 review of scientific literature about gender biases in health care, men were seen as “stoic” when it came to pain, while women were perceived as being more sensitive to pain and “hysterical.” Hysteria was a popular medical diagnosis for centuries, almost exclusively used to refer to women. The diagnosis was used to classify women as having a mental disorder associated with sexual and social repression and weak character.Women and gender nonconforming people’s experiences in medical settings have long been dismissed. The field of gynecology has similarly nefarious origins. The “father of modern gynecology,” James Marion Sims, developed gynecological practices by experimenting on enslaved women without anesthesia based on the false stereotype that Black people have higher pain thresholds. Amid the eugenics movement of the 1900s, those with low incomes, people of color, and people with disabilities underwent forced sterilizations. Even as late as the 1990s, contraceptive implants were marketed toward low-income Black communities as a means of controlling reproduction of those deemed unfit or unworthy of parenthood. “I’m an OB-GYN,” says Ashley Jeanlus, a board-certified OB-GYN in Washington, DC, “but I’m also not very naive that historically and to modern times, how we take care of patients isn’t always patient-centered.”The recent CDC and ACOG pain management guidelines are a welcome change, Jeanlus says. “We’re showing that there is improvement, that we’re taking important steps to making sure that we are standardizing care, ensuring that patients are receiving these procedures with compassion and dignity, and we’re not telling them to just tough it out anymore,” she says.Better evidenceACOG’s pain recommendations, released in May, were almost two years in the making. Between the uproar on social media and a greater availability of research showing the efficacy of local anesthetic during IUD placement and other in-office procedures, clinicians felt it appropriate to make a statement, says Kristin Riley, an OB-GYN and minimally invasive gynecologic surgeon at Penn State Health and one of the co-authors of the ACOG committee opinion on pain management. “There’s a lot more studies about this overall topic,” she says, “and we wanted to pull it all together in one place where clinicians and potentially patients could see it all together and really give people options.”Both the ACOG and CDC guidelines are just that: recommendations for practitioners. They urge doctors to better understand what pain management options are available and supported by research, and to inform their patients of these options, risks, and benefits. CDC guidelines simply mention topical lidocaine “might be useful for reducing patient pain.” ACOG goes a step further, saying pain management options “should be discussed with and offered to all patients seeking in-office gynecologic procedures.” But whether doctors follow the guidelines is completely voluntary. Getting an IUD? Here’s how to advocate for yourself.Learn about the different options for pain management. What might be best for you?Discuss your concerns, fears, and preferences with your doctor ahead of time. Don’t wait until the day of your appointment to ask about anesthetics or anti-anxiety medication. Ask as many questions as you want until you feel comfortable. Make sure your doctor explains all of your options, which may include referring you to another clinic with more resources. Develop a plan. What medications will you take pre-appointment? What form of anesthetic will your provider use during the procedure? If your doctor isn’t taking your concerns seriously or doesn’t offer pain management that you want, find a new one. Ask if your doctor has a referral list. Or you could reach out to a hospital affiliated with a university. There might be a higher chance of finding a provider that offers additional pain management there, Jeanlus notes. You can also try searching for a provider who is fellowship trained in complex family planning, which means they have received additional training in abortion and contraceptive care.Pain is complex and subjective, which makes studying it difficult. Patients who have a history of sexual abuse and trauma or prior negative gynecological experiences can also experience greater pain during IUD placement. The number of different pain medicines — injected lidocaine, sprays and gel-based lidocaine anesthetics, over-the-counter painkillers — and the various combinations in which researchers use them in studies make it difficult to reach conclusive results, Riley says. Danielle Tsevat, an OB-GYN at the University of North Carolina at Chapel Hill who studies gynecological pain, says the most conclusive evidence for pain relief during IUD insertion points to a lidocaine paracervical block, especially among patients who have never given birth. During her medical residency a few years ago, Tsevat had a mentor who utilized the anesthetic during IUD placements. She’d seen it used for other procedures, like abortion or miscarriage evacuations, but the shot wasn’t commonly used for IUD placements. Other studies have found topical lidocaine gel or creams to be effective at minimizing pain from the tenaculum (the device that holds the cervix in place during the procedure), Tsevat says. Other methods aren’t as definitive. Ibuprofen hasn’t been shown to help during the insertion, but can ease cramping afterward. Some clinicians will offer anti-anxiety medications since anxiety can put a patient at higher risk for pain, Tsevat says. “They report improved outcomes after that too,” she says. “That one also doesn’t really have much evidence behind it yet…but it’s something that we’ve seen offered.” Nitrous oxide, what Ana Ni used during her procedure, has also shown promise in studies, Espey says. Meanwhile, misoprostol, one of the pills used in medical abortions, was found by ACOG to cause more abdominal pain during IUD placement. No one option provides a panacea because there is no one source of pain during IUD placement, and the pain itself is relatively short-lived, lasting all but a few seconds. Additionally, a shot itself can be uncomfortable. Perhaps the paracervical block — administered after the speculum is inserted — would be more effective if clinicians waited a few minutes after giving the shot. “But that also prolongs the procedure too,” Tsevat says. “A lot of patients just say, ‘I want to get this over with and done,’ and not be in the speculum for that long.”During her medical training, Fran Haydanek, a board-certified OB-GYN in Rochester, New York, says she was never taught about pain management during IUD placement. After hearing from her patients, and others’ horror stories on social media, she began counseling patients on pain management options and offering paracervical blocks in 2021. She estimates 80 percent of her patients opt for the injection, and her practice eats the cost because insurance won’t reimburse for the medication, she says. “There’s clear guidelines from medical organizations that are saying this [medication] should be offered,” Haydanek says. “Doctors should be reimbursed for that.” However, across the board, few providers seem to be offering these medications. In a small recent study, only 28 percent of clinics offered lidocaine, including paracervical blocks, for pain management; 85 percent recommended ibuprofen. Another study that looked at pain medications for IUD placement within the Veterans Affairs Health Care System found that lidocaine was used only 0.2 percent of the time, while nonsteroidal anti-inflammatory drugs were used during 8 percent of IUD placements.Whose pain matters?Perhaps the most effective pain management option is IV sedation or general anesthesia, which ACOG notes requires additional research to determine risks, benefits, cost, and accessibility. It’s an even more resource-intensive option. “I would bet a million dollars that if we studied IV sedation and IUD pain that we would find that it significantly reduces pain,” Espey says. But clinics would need a pharmacy, nursing staff, advanced monitoring equipment, a recovery room — all of which could drive up costs for patients. The many years that passed before women’s pain was taken seriously for IUD insertions, as well as the continued lack of research into the cost and accessibility of general anaesthesia, lead to a logical question: Whose pain does the medical establishment take seriously? Men have long been offered pain medication for below the belt treatments. Men have long been offered pain medication for below-the-belt treatments. Anesthesia was used in urological procedures as early as the late 19th century. A 1972 Esquire article describing a typical vasectomy noted that patients received local anesthetic, while some received a “tranquilizer shot” beforehand. Women, on the other hand, weren’t officially included in clinical research in the US until the 1990s. A recent study found that over half of patients seeking care for vulvovaginal pain considered stopping care because they felt dismissed by their doctors. That their pain during a specific medical procedure wasn’t addressed until recently isn’t entirely surprising. Aside from medications, innovations to the devices used during IUD placement could make the procedure more comfortable. The tenaculum, for instance, the tool that grasps the cervix and is a major source of pain, dates back to the 1800s. A Swiss company, Aspivix, has developed an alternative tool, called Carevix, that uses suction to secure the cervix. The device is FDA-cleared in the US and is used in 21 health care centers worldwide, including at the Indiana University School of Medicine and Columbia University, according to the company’s chief marketing officer, Ikram Guerd.Given the absence of a silver-bullet solution, the most consequential change when it comes to addressing pain is far more understated. “The most important thing that we’ve done, ironically, is stressed how important it is to talk to your patient,” Espey says. Trauma-informed care — in which doctors take a patient’s past into account — puts the patient at the center of treatment. When patients feel safe to discuss prior challenging IUD placements or past sexual assault, the provider can better individualize pain control. Giving survivors of sexual assault control over their medical appointments can help avoid retraumatizing them. But how much control, how much information, is appropriate to share with patients? Doctors walk the fine line between disclosing how much discomfort to expect from a procedure (and potentially causing increased anxiety) and downplaying their concerns. Research shows that the more people expect pain, the more painful the experience actually is. But to say IUD insertion is entirely pain-free might come across as gaslighting. “Do you minimize pain to reduce that anticipatory anxiety at the expense of potentially looking like you’re lying to your patient about something quite painful?” Espey says.For Espey, the sweet spot is offering patients plenty of options, from prescribing anti-anxiety medications prior to the procedure or rescheduling them at a clinic with more resources. “Just giving patients options really helps people feel like they can make a decision,” she says.In a current study, Tsevat, the UNC OB-GYN, is surveying patients post-IUD placement. The feedback has been interesting, she says. Some patients report low pain, while others have compared the experience to razor blades in their uterus. Some were offered pain management, others were not. One participant, who was getting her IUD replaced after eight years, was delighted when her doctor explained the pain management options available. “She said it was still painful,” Tsevat says, “but she was just happy that she had gotten something and [it] helped her experience a little bit.” Most notably, patients hardly ever discussed their experience with their doctors afterward; it wasn’t something they thought was appropriate to mention. When patients don’t feel seen or taken seriously, it can have lasting impacts and may result in their avoiding future health care. While one aspect of women’s pain in medicine is finally being discussed, others with painful periods or endometriosis may still feel dismissed. There’s still room for more conversations, more transparency.“Providers,” Jeanlus says, “we definitely need to do a better job of listening to our patients and trying to make sure that we aren’t gaslighting them or trying to normalize something that’s really affecting their daily life.”