More Than 'Just a Pinch'? Patients Film Their Expressions Getting IUDs

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Young women are filming their faces during insertions of intrauterine devices (IUD) and posting the videos on TikTok, where they are racking up hundreds of thousands of views.

In some, patients wince and cry out during the procedure, and in others, healthcare workers audibly dismiss their pain. Many have commented that they are scared to get an IUD because of potential pain.

However, those with more neutral or positive experiences are joining the trend to show that IUD insertion isn't universally scary or painful. This window into the pain some patients experience also reflects how social media can influence patients' expectations.

A recent study in Obstetrics & Gynecology assessed the top 100 TikToks tagged #IUD and found that nearly 40% had a negative tone compared to just 20% with a positive tone. Nearly all negative and tonally ambiguous videos highlighted pain and side effects from IUD insertion.

Study author Jonas Swartz, MD, MPH, assistant professor of obstetrics and gynecology at the Duke University School of Medicine in Durham, North Carolina, told MedPage Today that the quality of health information in the videos varied and that conducting this research made him rethink his "conception of what is accurate health information."

"Before starting ... I might have thought of this as a dichotomy -- someone's either offering real health information or false health information," he explained, adding that "individual patient experiences that are not consistent with published evidence on side effects" can complicate that framework. Now, he has conversations with patients about whether they've watched TikToks about IUDs and what they thought about them, since that influences their expectations.

"If a doctor goes into the interaction dismissing the person's experiences, it's damaging to the patient-provider relationship," said Swartz.

Indeed, a 2014 study in Contraception found that doctors underestimated patient pain during IUD insertion. While mean patient maximum pain was 64.8 mm on a 100-mm visual analogue scale (VAS), doctor's assessment was much lower at 35.3 mm.

And while physicians use various strategies to manage pain and discomfort, there aren't universal guidelines.

"There's a lot of heterogeneity in the studies on pain management with IUDs," Swartz said. "We don't have enough information to make guidelines yet."

Indeed, a 2016 committee opinion from the American College of Obstetricians and Gynecologists (ACOG) that was reaffirmed this year notes that IUD insertion "is painful for many women, particularly nulliparous women" and that "studies have not demonstrated an effective strategy to mitigate this discomfort." Because there isn't universal guidance, many doctors give patients a menu of options and make a decision together.

Bianca A. Allison, MD, MPH, assistant professor of pediatrics at the University of North Carolina at Chapel Hill School of Medicine who researches adolescents and IUDs, told MedPage Today that there isn't a one-size-fits-all experience with IUD insertion.

"I think pain is incredibly personal and subjective and there's so many things that people bring into the experience of getting an IUD related to trauma, experiences of other painful procedures, trust in the healthcare system or their physicians around managing pain, and anxiety, depression, other mental health issues," Allison said, noting that there's not enough research on the experiences of young people, who require different information.

A 2023 study in Adolescent Health, Medicine and Therapeutics recommended certain strategies for talking with adolescents about long-acting reversible contraception like IUDs. It suggested acknowledging that it could be uncomfortable, but assuring them that doctors can offer medication or other comfort measures. Allison said this is crucial because many adolescents have not had sex before and most have not delivered a child, so these sensations may be novel.

Jill Rabin, MD, an ob/gyn with Northwell Health on Long Island, said that taking a good patient history -- including how patients have done with dental work -- is vital because it informs how that patient might experience pain and discomfort as well as what size IUD is most appropriate. Young and nonparous people, for instance, would likely need the smallest size.

Swartz added that he asks patients about their history with pelvic exams before the bimanual pelvic examination and prior to IUD insertion and gives patients an idea of what to expect. Doctors use a speculum to open the vagina, measure the uterus, and use a tool to place the IUD through the opening of the cervix into the uterus.

"I usually describe it as three cramps: one cramp when we place the tool that holds on to the cervix, one cramp when we measure the uterus, and then one cramp when we place that IUD," Swartz said. But the cramps can vary in severity and duration from person to person. "Some people have a cramp initially when you place that tool in the cervix, and then the cramp dissipates, other people continue to cramp after you place that tool until you take it off," he said.

Allison added that it's "important for doctors to be upfront that you can't predict someone's experience. It could be just a pinch, or it could be tremendously painful cramps worse than a period," she said. She also said bleeding or irritation might occur from the tools used to open the cervix.

Rabin noted that she often offers nonsteroidal anti-inflammatory drugs (NSAIDs), like naproxen, aspirin, ibuprofen, or a shot of ketorolac. NSAIDs reduce prostaglandin, which "makes the uterus contract" and cause "crampy pain." Paracervical blocks are another option, which involves using local anesthetic, like lidocaine, to numb the area and reduce pain. For injections, topical anesthesia like benzocaine can make it so patients don't feel the needle.

Allison noted that if patients come in nervous, an anti-anxiety medication or muscle relaxer can help. She also said talking a patient through what is happening reduces confusion and surprise.

"If we at least had ... a certain baseline that all clinicians were doing to manage pain, and then you could always add more on top of that, I think that would be a really nice, patient-centered way to think about this," Allison said.

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