IUD: In or Out?

This article originally appeared on pages 52-53 of the Spring 2023 issue of Coulture Magazine.

The appeal of IUDs is crystal clear: long-term and reversible — you can forget about taking those pesky pills every night. According to Planned Parenthood, IUDs, small pieces of flexible plastic shaped like a T, are more than 99.9 percent effective at preventing pregnancy. Depending on which kind you get, you are constantly protected from pregnancy for 3 to 12 years. Planned Parenthood reports that since 2009, their health centers have seen a 57 percent national increase in the use of IUDs. But what does getting an IUD feel like, exactly? The Mayo Clinic compares the pain of insertion to “mild cramping,” but depending on who you ask, it can reach levels of blinding agony.

“A lot of the worry concerning IUD insertion is about the unknown and anticipation of what it might be like. Having a good understanding of the process can be really helpful,” Dr. Jes Morse, associate professor at UNC-CH’s Department of Obstetrics and Gynecology specializing in complex family planning, said. “I often tell my patients that we’ll spend more time talking about it than with the actual insertion.”

The first step of the IUD insertion process is similar to a pelvic exam or a pap smear, according to Morse. To put the IUD in, the provider will insert and spread open a speculum —  a medical tool for investigating body orifices — in the vagina to see the cervix, the entry point to the uterus. The provider will then use a slender, long-handled instrument called a tenaculum to stabilize the cervix. Next, what Morse describes as a “really thin straw” will be used to measure the length and direction of the cervical canal and uterus. Finally, a tube containing the IUD is inserted. The IUD is pushed into place, and once it is in the proper position in the uterus, the arms spread open into a T-shape. A string attached to the IUD will hang a couple of inches out of the cervix, felt by inserting a finger into the vagina. This is how an IUD user knows their device is in the right place.

For Cam, a 20-year-old UNC-CH student who’d like to remain anonymous, the worst part of the process was the measuring of their uterus. 

“It had me almost off the table in pain,” she said. “After the IUD was inserted, the instrument that was holding open my cervix got a little stuck, and they had to essentially wiggle it around to get it out. That experience was extremely uncomfortable.” 

So if inserting IUDs can be so painful, why is there no standard protocol for controlling the pain?

According to Morse, it is because there is minimal data to support one single method for reducing discomfort. Although the entire IUD insertion takes less than five minutes, according to Planned Parenthood, Cam’s experience is not unusual. 

Although there is no standardized method for pain management during IUD insertion, many OB-GYNs suggest taking over-the-counter medication before an appointment to ease cramping. Some doctors will prescribe Valium or Ativan for anxiety, offer ibuprofen or acetaminophen for pain or misoprostol to soften and open the cervix before the procedure. Under more severe circumstances, doctors might inject local anesthetic to numb the cervix, administer nitrous oxide for conscious sedation or general anesthesia for full sedation.

“We’re able to use lidocaine gel that the patient inserts themself. The provider can also place numbing medicine around the cervix,” Morse said. “Both of those things are shown in studies to help with pain. We also talk about using relaxing medication, like Ativan. Pain is all about perception, so if you’re loopy or dopey, your sense of pain is a little different.”

When former UNC-CH student Liz, who’d like to remain anonymous, got her IUD inserted three months ago, she was running late and forgot to take any pain medication that morning. During the procedure, Liz’s doctor smeared lidocaine gel — one type of local anesthetic doctors might administer for IUD insertion — on the inside of her cervix. Similarly, Cam was given a suppository of lidocaine to insert herself.

“My heart was racing. I was definitely kicking myself for not taking any pain meds before coming,” Liz said. “Up to this point, nothing had been very painful — just uncomfortable — but the pain came during the insertion for me. The opening of the IUD inside me was comparable to being thrust into the worst day of your period.”

There are a lot of non-pharmacological ways to manage pain too, like music or meditation. Many patients find that simply talking about the procedure is enough to ease some discomfort. For others, the language surrounding IUD-related pain is enough to deter them from the process altogether.

“It seemed like for every one good insertion story, there were 30 talking about how it was the worst pain of their life,” Liz said. “I talked myself out of an IUD for months by convincing myself that a little bit of nausea, weight gain and a higher chance of accidental pregnancy would all be better than an IUD insertion.”

But with the 2022 Supreme Court decision in Dobbs v. Jackson Women’s Health Organization, which overturned the constitutional right to abortion, many feel their future access to contraceptives and birth control hangs in the balance, and are turning to IUDs for long-term protection from pregnancy despite the horror stories.

After the Dobbs decision, Justice Clarence Thomas wrote in a concurring opinion that the justices should reconsider “all of this Court’s substantive due process precedents.” This includes the case of Griswold v. Connecticut, which ruled a ban on contraceptives unconstitutional. As of September 2022, 12 states already allow some healthcare providers to refuse contraception-related services, according to the Guttmacher Institute.

It is still too early to see any data concerned with future access to contraceptives and abortion care, according to Morse, but in her clinical experience, the rise in IUD insertion post-Dobbs is notable. More importantly, it does not have to be a painful experience.

“It is pressure and uncomfortable, especially to a cervix that has never opened or relaxed to allow a baby through, but the muscles and tissue of the pelvic floor can stretch a lot,” Morse said. “To put in an instrument that is pretty thin and small is nowhere near maximizing the potential of the vagina.”

There are two types of IUDs to choose from: hormonal and non-hormonal. The hormonal IUD works by releasing a tiny amount of progestin — a form of the hormone involved in pregnancy and the menstrual cycle — into the body over several years, which can stop the ovaries from releasing eggs and thickens cervical mucus to prevent sperm from reaching an egg. As for the non-hormonal IUD, a copper wire coiled around the frame disrupts the process of conception. 

“The biggest difference between the hormonal IUD and the copper IUD is changes to the menstrual cycle, which for many is quite welcome, but some people like the reassurance of getting a period every month,” Morse said. “It’s all patient-driven.”

The hormonal IUD can make periods lighter, and some people stop getting their period altogether. In contrast, copper IUDs can make periods heavier and increase cramping intensity, especially during the first three to six months.

Since getting the hormonal IUD, Liz has noticed that her period is practically nonexistent. She will only cramp the first two days her period would normally come. For Cam, who got the copper IUD inserted in late August, it is still too early to discern any side effects.

“I have not had any cramps yet, but I have irregular spotting and bleeding, which I was told is normal for the first 6 months,” Cam said.

But what if you need the IUD removed?

When it comes to discontinuing this method of birth control, the tiny device comes with its own set of complications. For example, if you are taking a birth control pill and start to experience troubling side effects, you can take a break from using it to figure out the cause of your symptoms. With an IUD, this is not the case. The only way to combat bad side effects is to get the entire thing removed. 

An IUD user might get their device removed for a plethora of reasons. According to Morse, a popular one is the continuation of irregular or heavy bleeding, although this is incredibly rare with the hormonal IUD.  

“Others feel like they’re getting frequent yeast infections or bacterial vaginosis, but there’s not great data to support that that’s caused by the IUD,” Morse adds. “Some people might come in with concerns about weight gain, although IUDs are not typically associated with that either.”

Despite the presence of certain side effects not being supported by clinical research, affected IUD users may hold to their belief that the device is causing their symptoms. 

“A lot of women feel ignored, diminished, or written off, or they are told ‘It’s in your head,’” Morse said. Throughout medicine’s long history of gender bias, women as medical patients have encountered dismissal and discrimination.

Personally, I (Younts)  had many complications with my Kyleena IUD, one of the hormonal options. Getting it inserted was the worst pain I had felt in my life. I had never felt my cervix before, but lying on parchment paper with an ice-cold speculum between my legs, I quickly became aware of it. It was a foreign, piercing discomfort, like the worst cramp I have ever had multiplied by ten.

Although my insertion was miserable, I did not have the typical cramping and spot bleeding that follows for most people. In fact, for the first couple of months, my IUD went largely unnoticed. My period disappeared, and the deplorable pill-caused headaches, mood swings and weight gain that had defined the three years prior were gone. 

Then came the pelvic floor muscle spasms. It felt like getting my IUD inserted all over again, only this time, I was not prepared. The spasms happened daily — sometimes multiple times a day — without any warning. It was a blinding but manageable pain for about a minute, and then it was gone.

What was not manageable was an imbalance in my pH. Although there is limited research to support the notion that IUDs can cause frequent yeast infections or bacterial vaginosis, IUDs can throw vaginal pH off kilter — or at least make it nearly impossible to rebalance it — according to the National Institutes of Health. 

I saw multiple doctors, tried five different medications and still felt like I was not being heard. The pain got to the point where I was taking three medications weekly and still was not comfortable. I knew that my IUD was causing these problems, but this idea was devalued by the people that I was going to for help.

In the back of my mind, I was thinking: what if the problems actually were not being caused by my IUD? If I went through the trouble of getting it removed, only to find out that the problems persisted, I would have to go through the pain of getting another one inserted. I tried everything I could, but eventually decided I had had enough. 

IUD removal is simple. The provider lightly pulls on the string, the arms fold up and the IUD slides out. For the first time in six years, I was birth control-free. I felt a wide range of emotions. I felt freedom from having my hormones artificially regulated, finally completely in control of my body. At the same time, I was scared of an accidental pregnancy, my period cramps and headaches returning in full force and what might happen to my body with such a sudden change. 

On birth control, the body’s natural reproductive processes are repressed. When birth control is taken away, the body may experience withdrawals from these exogenous synthetic hormones, or hormones that are not produced by your own endocrine glands. This can result in Post-Birth Control Syndrome (PBCS). 

“It’s not a medical condition that many doctors would be familiar with,” Morse said. 

Due to a lack of research in post-contraception, PBCS falls under the domain of naturopathic medicine, according to Healthline, and is subject to controversy surrounding its legitimacy as a “syndrome.” Regardless, there is anecdotal evidence to support a collection of symptoms that can arise and persist for months after discontinuing birth control. Symptoms can include complications to the menstrual cycle — like heavy, infrequent or absent periods — but are not constrained to just the reproductive system. Hormonal alterations can also lead to digestive issues, hair loss, migraines, acne and weight gain. 

For a long time I did not know why I was getting frequent headaches and breaking out, why all my hair was falling out and my period had never regulated with an IUD. No one told me these side effects could occur after such a large hormonal change. Then again, many people can relate to the frustration that comes with not being clinically heard or validated.

“Are there some women who experience this ‘syndrome’ after birth control? Absolutely,” Morse said. “Women’s health doesn’t get the attention it needs. Many are frustrated about the lack of clinical attention to and research of their experiences. Birth control grants women autonomy over their sex lives and actual lives. That’s a pretty powerful thing.”