An intrauterine device, or IUD, insertion can be very, very painful. Not for all women, but for many. In recent TikTok videos documenting the experience, women grimace, cry and clutch the exam table. Often a provider can be heard in the background reminding a woman to breathe, or chirping, “Almost done, OK?”
Seemingly in response to growing concerns over doctors dismissing women’s pain, the Centers for Disease Control and Prevention recently recommended, for the first time, that providers counsel patients on the “potential pain” from IUD insertion. They also suggest that doctors can offer options for pain management, including using the local anesthetic lidocaine.
I’m glad the agency is joining the conversation. But as a physician who performs hundreds of gynecologic procedures every year, including IUD placements, I can say with certainty that lidocaine will not solve the problem. And although counseling about pain is important, the fact that the C.D.C. has to remind doctors about this basic component of informed consent shows how deep the problem runs.
The impetus behind the C.D.C.’s timidly worded guidance isn’t a preponderance of new or convincing data. The agency acknowledges that the evidence for lidocaine is unsettled. Some studies have found that patients report lower pain scores when using lidocaine. Others find that it makes no meaningful difference. What we do know is that providers tend to underestimate patients’ pain during IUD placement. This might be explained by the longstanding, paternalistic tradition of physicians trying not to scare patients away (“This won’t hurt a bit …”). But there are other, more practical considerations at work. In the grueling pace of modern medicine, it’s tempting for providers to downplay a potentially painful procedure to patients (and to ourselves), because admitting otherwise could require much more time. It’s much faster to rush through the procedure, assuring the patient that her “discomfort” is “totally normal” and then dash out the door to the next waiting patient.
We do so at a very real cost to women.
Imagine: You are alone, half-naked behind a closed door with a person in a position of power. This person assures you that this isn’t going to hurt, then places a gloved hand and cold instruments inside you. The instruments do hurt. You cry out, or you fight back tears. But the pain continues. Afterward, you’re told it wasn’t that bad.
For many women, this is deeply unpleasant. For those who have experienced sexual violence (more than half of women), IUD insertion can be downright traumatic. This is not to say that most women getting IUDs feel assaulted by their doctors. But for too many the experience is of violation, a deep betrayal of the sacred bedrock of the doctor-patient relationship: trust.
When a woman’s doctor leads her to believe that IUD insertion won’t hurt, then downplays the pain she feels, that woman is less likely to trust her doctor with other aspects of her reproductive health, including pregnancy and childbirth. The consequences are particularly damaging for patients who may already have reason to distrust the health care system. American medicine bears a long history of reproductive coercion and forced sterilization of Black, Indigenous and incarcerated women — a history of which our patients are often well aware. When practitioners and policymakers wring our hands over the maternal mortality crisis in this country (our unacceptably high rate is about three times as high for Black women compared to white women), we must acknowledge that this is in part a crisis of trust, and that we are responsible for it.
Lidocaine is, to be sure, a valuable pain management tool for IUD insertion and other gynecologic procedures. I use it all the time. But the pain isn’t the only problem; sometimes it isn’t even the main problem. Women are capable and often quite willing to tolerate pain as an expected part of a medical procedure, when it’s acknowledged and taken seriously. It’s the betrayal that is egregious and permanent — and unlike pain, this betrayal is entirely preventable. It requires only that we slow down, listen to patients and tell them the truth.
The truth is: Some people will feel almost nothing with IUD insertion, and some will feel excruciating pain. It is hard to know who will have what experience, and whether lidocaine — or even stronger medications — will help. (Like many areas of women’s health, more research might go a long way toward answering some of these questions.) In the meantime, as the C.D.C. reminded us, the bare minimum of informed consent requires that every woman hears transparent counseling and has a chance to ask questions. But this takes time — a lot more than the 30 seconds required to inject lidocaine around the cervix.
Attending to a woman’s pain during the procedure also takes time. Doctors don’t rush through IUD insertions because we’re heartless automatons. Many of us have IUDs ourselves and know how painful insertion can be. (When I had my first IUD inserted, I almost kicked the provider in the face, so startling and severe was the pain.) But I also know the very real pressure to keep moving through a busy clinic. In one clinic where I work, an IUD insertion appointment is 15 minutes long, including check-in and documentation. Providers need more time with patients, particularly for gynecologic procedures. This change will have to come from practice owners and administrators who set clinic schedules, and from the insurance companies that determine procedure reimbursement rates.
In the meantime, I have some tools at my immediate disposal: I can use the word “pain” instead of euphemisms like “discomfort” or “cramping.” I can say very clearly: “If you tell me to stop at any point, I will listen to you. I will stop.” Often simply handing someone this sense of control is enough to assuage her fears and earn her trust: She gets to choose what amount of pain is tolerable, not me. Then I must be true to my word. When this takes more than 15 minutes, I can — and must — attend to the person in pain on the exam table, and let the next patient wait.
By and large, I don’t hear my patients asking for pain-free IUD insertions. I hear them asking for their voices to be heard and believed. And it’s not only doctors who need to listen, but also the insurers, administrators and policymakers controlling the flow of health care dollars in this country. How nice it would be if this were a problem that could be solved by a bit of lidocaine. But it’s not that simple.
The post I’m a Doctor. The Conversations About IUD Insertions Are Long Overdue. appeared first on New York Times.
