Insertion into the uterus, or IUD, can be very, very painful. Not for all women, but for many. In recent TikTok videos documenting the experience, women cry, sob and clutch the exam table. A service provider can often be heard in the background reminding a woman to breathe, or chirping, “Almost done, okay?”
Ostensibly in response to growing concern that doctors dismiss women’s pain, the Centers for Disease Control and Prevention recently recommended, for the first time, that providers counsel patients about the “potential pain” of IUD insertion. They also suggest that doctors can offer pain management, including using the local anesthetic lidocaine.
I’m glad the agency is joining the conversation. But as a doctor who performs hundreds of gynecological procedures every year, including IUD placements, I can say with certainty that lidocaine does not solve the problem. And while counseling about pain is important, the fact that the CDC needs to remind doctors about this basic aspect of informed consent shows how deep the problem runs.
The motivation behind the CDC’s modest guidelines is not the preponderance of new or compelling data. The agency acknowledges that the evidence for lidocaine is inconclusive. Some studies have found that patients report lower pain levels when using lidocaine. Others feel that it doesn’t matter. What we do know is that providers tend to underestimate patients’ pain during IUD insertion. This may be explained by the long-standing paternalistic tradition of doctors trying not to scare patients away (“It won’t hurt…”). But there are other, more practical considerations at work. In the frenetic pace of modern medicine, it’s tempting for providers to downplay a potentially painful procedure for patients (and ourselves), because admitting otherwise may require much more time. It is much quicker to rush through the procedure, reassure the patient that her “discomfort” is “completely normal” and then rush 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 closed doors with a person in a position of power. This person assures you it won’t hurt, then inserts a gloved hand and a cold instrument inside you. The instruments do hurt You cry, or you fight back the tears. But the pain continues. Afterwards you are told it wasn’t so bad.
For many women, this is very uncomfortable. For those who have been sexually assaulted (more than half of women), IUD insertion can be downright traumatic. This is not to say that most women who get an IUD feel attacked by their doctors. But for too many, the experience is a breach, a profound betrayal of the sacred bedrock of the doctor-patient relationship: trust.
When a woman’s doctor makes her believe that an IUD won’t hurt, then downplays the pain she feels, that woman is less likely to trust her doctor about other aspects of her reproductive health, including pregnancy and childbirth. The consequences are particularly harmful for patients who may already have reason to distrust the health care system. American medicine has a long history of reproductive coercion and forced sterilization of Black, Native American, and incarcerated women—a history our patients often know well. As practitioners and policymakers grapple with the maternal mortality crisis in this country (our unacceptably high rates are about three times higher for black women compared to white women), we must recognize that this is in part a crisis of confidence and that we are responsible for it.
Lidocaine is indeed a valuable pain management tool for IUD insertion and other gynecological procedures. I use it all the time. But the pain is not the only problem; sometimes it’s not even the main problem. Women are capable and often quite willing to tolerate pain as an expected part of a medical procedure, when it is recognized and taken seriously. It is fraud it’s rough and permanent—and unlike pain, this betrayal is completely preventable. It just requires us to slow down, listen to patients and tell them the truth.
The truth is, some people will feel almost nothing when the IUD is inserted, and some people will experience excruciating pain. It’s hard to know who will have what experience and whether lidocaine — or even stronger drugs — will help. (As in many areas of women’s health, more research could go a long way toward answering some of these questions.) In the meantime, as the CDC reminded us, a minimum of informed consent requires that every woman hear transparent counseling and have the opportunity to ask questions. But this takes time – much more than the 30 seconds it takes to inject lidocaine around the cervix.
It also takes time to attend to a woman’s pain during the procedure. Doctors don’t rush through IUD insertions because we are heartless automatons. Many of us have an IUD ourselves and know how painful insertion can be. (When I had my first IUD inserted, I almost kicked the provider in the face, so excruciating and intense was the pain.) But I also know the very real pressure of continuing to go through a busy clinic. At one clinic where I work, the IUD insertion appointment is 15 minutes long, with registration and documentation. Providers need more time with patients, especially for gynecological procedures. This change must come from the owners and managers who set up the clinics, and from the insurance companies who set the reimbursement rates for procedures.
In the meantime, I have a few tools at my disposal: I can use the word “pain” instead of expressions like “discomfort” or “cramp.” I can say very clearly, “If you tell me to stop at any time, I will listen to you. I’ll stop.” Often simply giving someone that sense of control is enough to reduce their fear and gain trust: She gets to choose how much pain is tolerable, not me. Then I have to keep my word. When this takes more than 15 minutes, I can – and must – do the painful thing on the exam table and let the next patient wait.
By and large, I don’t hear my patients asking for a painless IUD insertion. I hear them praying for their voices to be heard and believed. And it’s not just doctors who need to listen, but also insurers, administrators and politicians who control the flow of health care dollars in this country. It would be nice if this was a problem that could be solved with a little lidocaine. But it is not that simple.
#Inspection #doctor #conversations #IUD #insertions #long #overdue