Their IUD procedures were painful. Now they’re scared to have it removed.
Ami Claxton’s birth control method - an intrauterine device - expired 14 years ago. But she has been too scared to have it removed because of the excruciating pain she experienced the last time she had it replaced.
This summer, the 55-year-old asked her gynecologist for options to help manage the pain during removal, but was told there weren’t any. “So I said, ‘Forget it. I’m not going to get it out,’ ” said Claxton, of Chandler, Ariz.
While it has been well documented that many patients experience severe pain when getting an IUD, less is known about how those painful experiences affect reproductive health care. Some women say that their worries about pain have deterred them from getting IUDs removed or replaced when needed, and they have become reluctant to return to the gynecologist, even for different procedures.
Last week, federal health officials weighed in on the matter. The Centers for Disease Control and Prevention called for physicians to be more responsive to patient concerns about pain during IUD procedures, and to give women more information and options to deal with it.
Most patients fare better when their health-care providers are transparent about the procedures, the possibility of pain and any available pain control options, said Nichole Tyson, a clinical professor and division chief of pediatric and adolescent gynecology at Stanford University.
“Everybody wants to know what’s happening with their body,” Tyson said. “No matter how you look at this, you’re in stirrups, you don’t have your underpants on. It’s a very vulnerable time. I think that’s a legitimate thing we all have to think about and be compassionate about.”
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Avoiding the doctor because of IUD anxiety
An estimated one in five sexually experienced women ages 15 to 44 have used an IUD, data shows. In the past, IUDs were primarily used by women who had given birth, but the device in recent years has become popular with younger women.
But as the demographics of IUD use have changed, so have the challenges of pain management. Pain often is more common in women who haven’t given birth, because they may have a more narrow cervical canal and a smaller opening to the uterus. In one study, nearly eight out of 10 women who had never given birth reported moderate to severe pain with IUD insertion.
Some women who have delivered vaginally experience pain, too. One smaller study showed that women who had given birth reported a median pain score of five out of 10, vs. seven for those who had never given birth.
At 16, Andrea did not expect her IUD placement to hurt and her clinician didn’t warn her, she said. But during the procedure, she was crying and squeezing the hand of the medical assistant.
The experience has made her wary of other gynecological care, said Andrea, now 27, of Sacramento, whom The Washington Post is identifying only by first name for privacy. “I guess I have some mistrust there,” she said.
Christine Romano was so excited to get an IUD in 2012 that she didn’t think about possible pain. It was so severe that she screamed. “It exceeded any kind of pain that I’ve ever experienced,” said Romano, 41, of Queens. The experience left her traumatized and unwilling to consider getting it removed. “This is going to die with me,” she said.
Patients interviewed for this story said they do not want fears about pain to prevent people from using IUDs or getting them replaced, but they do believe IUD users should be more informed.
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What happens when an IUD is removed
During an IUD removal, the clinician inserts a speculum into the vagina and looks for the IUD strings, which are typically about two to three centimeters long. If the strings are visible, forceps are used to grasp the strings and remove the device.
Unlike an IUD placement, which usually takes several minutes, the removal takes only a few seconds. The removal can be uncomfortable, but it’s not usually as painful because it doesn’t require manipulation of the cervix, said Eve Espey, chair of American College of Obstetricians and Gynecologists’ Contraceptive Equity Expert Work Group.
But sometimes, the strings are not visible, or in rare cases, the device is embedded in the uterus. When this happens, the procedure requires additional steps, which can cause more pain for some people, Espey explained. Data on pain during removal are sparse. In studies, between five and 18 percent of IUD users had missing strings. Espey said embedded IUDs are even more uncommon.
Britten Rollo, 41, of Dumfries, Va. said her primary care physician couldn’t find the strings to her IUD. Removing it, in 2018, “was about a 15-minute process of her digging around in there, trying to find them,” she said.
By the end, both Rollo and her physician were in tears, she said.
Rollo said she is now debating whether to replace her IUD or pursue more permanent methods of birth control.
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Clinicians often don’t agree on pain management
When Rebecca Watkins, 44, of Raleigh, N.C., had her IUD replaced in 2019, she said it “felt like my insides were going to be pulled out.”
After the procedure, her gynecologist suggested that she request a sedative the next time. But when that time came, her new doctor told her it wasn’t an option. Watkins said that second replacement was also painful, and afterward, the doctor conceded that she should have used the sedative after all. “It was infuriating to me,” Watkins said.
For routine IUD removals, most clinicians do not offer pain management. But for complicated removals or when patients request pain control, the options are the same as for IUD insertions. Aside from over-the-counter anti-inflammatory medications, numbing agents such as a lidocaine spray or gel, or a lidocaine injection in the cervix called a paracervical block are the most commonly used. Some physicians said anti-anxiety medications before the procedure such as Xanax or Valium can help.
Sedation and general anesthesia are rarely considered because of the risks, as well as the need for special equipment and supervision by an anesthesiologist.
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Why some people feel more pain during IUD removal
It can be difficult for clinicians to predict who will experience pain with IUD removal. While complications such as lost IUD strings or an embedded IUD can cause pain, other factors also can play a role. These include patients with greater pain sensitivity, chronic pain syndromes, past traumas or previous gynecological procedures that have caused cervical scarring, which can make the removal process more painful.
Espey, chair of the OB/GYN department at the University of New Mexico, said the discomfort of IUD removal typically is quick and manageable. She said clinicians should be trained to talk to patients about their preferences and concerns before the procedure. If complications arise or the patient asks to stop, clinicians should pause and be willing to abandon it or use pain control, she said.
Patients who are anxious or who have had negative experiences with IUD procedures should discuss pain management options before the next procedure, said Aileen Gariepy, director of complex family planning at Weill Cornell Medicine. “People don’t have to have the procedure without any medication, but it does need a conversation.”
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Delaying care because of pain fears
Holly Lee, 55, of Plymouth, Ill. said the nurse midwife for her first IUD removal told her it would be “a little pinch,” but it felt like “a branding iron or something hot and on fire had been stuck up there.”
The next time, the removal pain was worse. “I was literally sobbing,” Lee recalled, saying she cried out for the nurse midwife to stop, instinctively dug her heels into the stirrups and pushed herself backward on the table to escape the pain, which she described as “something tearing out of you.”
“I’m terrified to have it taken out,” she said. “It’ll stay in as long as I can leave it in, honestly.”
Research shows that while hormonal IUDs lose effectiveness after their duration of intended use, some physicians said there is limited risk associated with leaving them in long term assuming fertility is not a consideration. There are rare case reports of pelvic infection associated with IUDs, but many people keep in the devices without issue, physicians said. Depending on the brand, hormonal IUDs are approved for use for up to eight years, and copper IUDs up to 12 years.
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Some people remove their own IUDs
Bianca Allison, a pediatrician and assistant professor at the University of North Carolina School of Medicine, recently co-wrote a commentary on barriers to removal of IUDs. Allison and her colleagues reported that limited access to the health-care system, potential breaches in confidentiality and provider bias may lead adolescents and young adults to remove their own devices.
“If people are doing it on their own, it’s possibly because they’ve experienced barriers,” she said.
For a month after having her IUD placed in 2016, Kirby Lowenstein, 33, of Philadelphia, had unrelenting pain and cramping. She went to an urgent care three times and to a gynecologist who dismissed her pain, telling her she should wait it out. She said the experience left her “feeling completely disempowered.”
In a moment of desperation at home, Lowenstein grabbed the strings and pulled out her IUD, immediately passing out. “The pain got to a point where I couldn’t take it anymore, and I felt like I had no other choice in that moment,” she said.
While some health-care providers said IUD self-removal may be safe in uncomplicated cases in which the IUD strings are easily accessible, others discouraged it.
“I think it encourages them to leave us out of their health-care team,” said Megan Wasson, chair of the department of medical and surgical gynecology at Mayo Clinic in Arizona.
Wasson emphasized that providers should encourage patients to exercise their autonomy, particularly during gynecological procedures - telling their clinician to stop when a procedure is too painful.
“We need to build that relationship between providers and patients,” she said. “Not making them go through hoops to get the care they need, but making sure that they look to us as a resource and as a partner in their health, not an adversary.”
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