IUD Diaries: Are the current methods of pain control for intrauterine device insertion effective for nulliparous women?

Nina Roberts is a senior nurse anesthesia student at Virginia Commonwealth University in Richmond, VA. Part of her doctoral project titled, “are the current methods of pain control for intrauterine device insertion effective for nulliparous women,” was to create a podcast highlighting the lack of a standardized approach to pain relief for IUD insertion for women. If you're unfamiliar with the term nulliparous, it refers to a woman who has never given birth.

Nina became passionate about this project almost five years ago because of her friend Lizzie's experience with her IUD insertion. Because of Lizzie's story, Nina
began to hear other women's stories about their IUD insertions, many of which mirrored Lizzie's experience.  In this episode, listeners will also hear from Lauren and Callie as they share their personal experiences with this procedure. Additionally, you will hear from doctor, Chailee Moss, a board certified OBGYN.

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IUD Diaries script
Evidence Synthesis and references

Thank you to Gianna Salvi for the cover art.

Transcript

[Nina]: Hello everyone my name is Nina Roberts and welcome to IUD Diaries. I'm a senior

nurse anesthesia student at Virginia Commonwealth University in Richmond, VA. Part of

my doctoral project titled,

“are the current methods of pain control for intrauterine device

insertion effective for nulliparous women,” was to create a podcast highlighting the lack of

a standardized approach to pain relief for IUD insertion for women. If you're unfamiliar with

the term nulliparous, it refers to a woman who has never given birth. I became passionate

about this project almost five years ago because of my friend Lizzie's experience with her

IUD insertion. It was honestly quite eye opening for me. And because of Lizzie's story, I

began to hear other women's stories about their IUD insertions, many of which mirrored

her experience. So today we'll also hear from Lauren and Callie as they share their

personal experiences with this procedure. Additionally, we'll also hear from doctor,

Chailee Moss who is a board certified OBGYN.

[Nina]: But before we dive in, I'd really appreciate if all my listeners could fill out a short

survey at the end of the podcast, the link is below. Your feedback will help shape future

discussions and all the links to the current research discussed today will be included

below for further reading. So, without further a due, I'd like you first to hear Lizzie's story

and kind of understand why I started this project in the first place.

CUE LIZZIES INTERVIEW:

[Lizzie]: I think it was five years ago I was super excited to get an IUD because I've been on

oral birth control since I was 16 and I just wasn't super consistent with it so I was really

looking forward to getting this IUD placed. I've been told it's a little bit painful I already had

pap smears done at that point so you're kind of prepared for that discomfort and that's

what I thought it was going to be like and then I think as a woman too I just have like a

higher pain tolerance so going into it I was just like that's going to be fine so yeah I went to

get my IUD I'm like all calm cool and collected she injected some lidocaine into the cervix

[Nina]: we think she got a paracervical block we weren't able to find the records but that's

what we're thinking

[Lizzie]: I do remember feeling discomfort when the IUD was placed and then a lot of

severe cramping after that and then I started getting really dizzy lightheaded I was sweating

I was nauseous and they you know put me in trendelenburg they did all the right things this

practice was great and I have a lot of respect for them I don't think they did anything wrong

but they were like I just remember like they're taking my manual blood pressure they

couldn't really get a blood pressure I have low blood pressure to begin with but you know I

think I vasovagal-ed and they were whispering in the corner they’re like should we take her

to the emergency room and I was like no like I'm fine and maybe I should have I think it was

fine I really think I just vasovagal-ed yeah it was very painful and I had to sit there for a little

bit and that's when I called you guys and needed a ride home because I couldn't drivemyself home but I just wasn't thinking that it would be a painful experience I thought I was

going to be like in and out and then obviously I responded

[Nina]: I guess my other question is do you feel like you were adequately prepared for it did

they kind of give you a back story of like what you may experience or even tell you to take

any pre meds

[Lizzie] I don't recall taking any pre meds I do remember taking either ibuprofen or Tylenol I

remember being informed to take that I really think she was like you're going to feel a little

pinch like I they really think she made it sound like it wasn't going to be that big of a deal

[Nina]: what's interesting is like if you did get the paracervical block kind of interested that

maybe it didn't work as well for you because I've definitely seen a lot in the literature that

paracervical blocks are really helpful some OB's make it a standard of care for IUD

insertion

[Nina]: so I decided to ask Lizzie if sedation was an option for her would she choose to go

through with it

[Lizzie]: if sedation was an option at the time I would probably have said no so but if it was

offered to me now I would have to think about it because even knowing that I had had that

experience I still have that ego where I think no I'm going to be fine but in reality I'm going to

be getting my IUD replaced and I am going to ask for some sedation yeah something

because of my experience that shouldn't be normalized yeah

[Nina]: what would you say to a healthcare provider listening to this podcast and kind of

how would they change their practice

[Lizzie]: I think by maybe warning the patient everyone does respond differently make sure

that you don't drive yourself maybe have someone drive you this is an actual medical

procedure you know make sure that the patient understands that you are going to have

pain don’t think that you can like run the world right after some people don't just need

ibuprofen or Tylenol you need to rest and take the day off maybe the next day and we don't

just need to brush it off because we have pain

[Nina]: what about to other women like what advice would you give

[Lizzie]: that you can have an experience like mine I do think at the end of the day it was

beneficial for me because having an IUD just gives me more reliability and consistency

[Nina]: It’s definitely more convenient

[Lizzie]: it is very convenient to have it but just knowing that the procedure itself is

uncomfortable it's not just an uncomfortable pap smear there is more pain that goes into itit is more invasive just be more prepared for that and see if you can have a healthcare

provider that you can trust that understands that you're going to be uncomfortable and

they can offer you something like a sedative sedation when it comes to these medical

procedures

INTRO – BACKGROUND:

[Nina]: As part of my project, I had to look at the current research and see what it looked

like for pain management options for IUD insertion and I wanted to share some of that

current evidence with you. What I have gathered on pain control methods during IUD

insertion is unfortunately quite inconclusive and there really is no clear consensus on the

best approach to minimize pain especially in nulliparous women. These women often

report higher pain levels due to anatomical differences, like a tighter cervix and for many

the pain is not sufficiently managed with our current practices. So I'm going to dive a little

deeper into what the research says. The research talked a lot about local anesthetics;

something that I found kind of interesting was multiple articles reference lidocaine

prilocaine cream and showed how it significantly reduced pain at key points, like at

tenaculum placement and IUD insertion itself. That being said, the literature also stated

that lidocaine gel alone was found to be less effective with minimal pain reduction

benefits. This kind of highlights the complexity of choosing the right form and application of

lidocaine to achieve optimal pain relief. Another thing that it pointed out was lidocaine

paracervical blocks. They have been shown to significantly decrease pain levels during

insertion, during uterine sounding, and even for up to 5 minutes after the procedure. I'd say

that these findings do suggest that local anesthetic blocks could play a critical role in

managing pain during IUD insertion, which is something that we are going to talk about

further with doctor Chailee Moss. On the other hand, NSAIDs like naproxen, ibuprofen, and

ketorolac, also known as Toradol, are often recommended for pain management but

they're effectiveness remains pretty inconsistent. However, Toradol has also been shown

to be superior to all of the other NSAIDs in reducing pain especially at the time of insertion

and for cramping post procedure. Something else that I kind of wanted to look into was

more of a holistic approach and the gap that exists in the research on non pharmacological

methods. For example, strategies like providing pre insertion counseling, ensuring a

supportive clinical environment, and focusing on anxiety reduction have shown a lot of

promise. But we still lack those high-quality studies that clearly define their effectiveness.

Anxiety honestly plays a significant role in how pain is perceived. Some studies suggest

that women who are anxious about the procedure, tend to actually report higher pain

levels regardless of the actual pain they experience. Additionally, something else that

came up in the literature and you also heard Lizzie talk about is vasovagal responses.

These are fainting or near fainting reactions caused by pain or anxiety and these are also

another important concern. These reactions are more likely to occur in nulliparous women

which makes it essential to manage both the physical and emotional aspects of pain

during the procedure. Effective pain control such as with local anesthetic blocks have

been shown to reduce these responses which makes the procedure safer and more

comfortable overall. And something that I keep repeating and you'll hear me keeprepeating, is what we're lacking is a standardized protocol for managing pain during IUD

insertion. There is significant variation in practice, and it leaves many women without

adequate pain relief. While paracervical blocks can be done by an OBGYN, I personally

think and something that I'd love to hear more people talk about is how anesthesia

providers could play a crucial role in assisting with the discomfort, not only associated

with the procedure but also with paracervical block placement. This type of anesthesia

would be monitored anesthesia care, so it's a type of sedation. I think by incorporating

MAC sedation, anesthesia providers can help ensure that women are more comfortable

and experience less pain throughout the entire process. I think a tailored approach to pain

management would allow for a more patient centered experience. And we can, and we

should, do more to ensure that all women receive the care they need for what can be a very

uncomfortable procedure.

INTRODUCING DR. CHAILEE MOSS:

[Nina]: Now we will hear from doctor Chailee Moss. Dr. Moss is an expert OBGYN and she

will explain what an IUD is, how the insertion process works, her personal

recommendation for paracervical blocks and how they're placed to manage pain during

the procedure. We're also going to discuss what the future may look like utilizing

anesthesia providers for IUD insertion.

CUE DR. MOSS’ INTERVIEW:

[Nina]: So just to get started if you wanna tell me a little bit about yourself and kind of what

got you into Women's Health to begin with

[Dr. Moss]: I was a patient at a clinic for vulvovaginal disorders so I think that's a way a lot

of people get into this work is through personal experience either with a loved one or

because of their own health issues and so I think that made me really interested in you

know just vulvovaginal disorders in general and when I was in medical school I worked with

the person who had helped me on a paper and then when I went to residency I focused on

pain but in a different way I looked at the way that we use opioids after benign gynecology

procedures so sort of in that same realm but pivoted a little bit towards how we handle

postoperative pain management which I think really plays into today's discussion and then

after residency I went to Hopkins where I did more research related to opioids and also

was the director of the colposcopy clinic at Johns Hopkins bayview doing a lot of outpatient

procedures I also did a lot of outpatient hysteroscopy for patients and placed a lot of iuds

as well so I was a general ObGyn for five years there and then sort of during my 6th year

ended up you know finding out about this job feeling like it was a really great fit for me in

terms of just like my interests my history my affinity for the patient population and took the

job at the centers for vulvovaginal disorder so i work there and so now I exclusively see

people who have pain with sex, dermatologic conditions of the vulva, so skin conditions of

the vulva.[Nina]: I'm sure we have a lot of listeners who don't really know what an IUD is. Do you

want to kind of talk about it and how it's placed and how the procedure takes?

[Dr. Moss]: Yeah so when IUD, IUD stands for intrauterine device and there have been

many versions of IUD's throughout the decades and they have been around for many

decades but the most recent sort of innovation in terms of IUD shape and function is

generally a T shaped IUD so the ID is shaped like a T but before it's placed it's in a tube so

that it's like the arms of the T if you can imagine the arms of the T being sort of squished

down against the sides of the device so that it's just in a small tube. The tube that it's in is

placed in the uterus and the way that we get into the uterus is usually to open the cervix

which is the tunnel between the uterus and the vagina and we can do that in the office so

the speculum exam the small tube goes into the tunnel of the cervix and into the uterus

and then the device deploys the IUD, the placement device deploys the actual intrauterine

device, and then the device is removed and the IUD stays in place. And the idea is it

provides contraception by being exactly in the spot where it needs to prevent pregnancy

and there are two main kinds of IUD's available in the United states one is copper which

works by sort of creating a mild inflammation in the lining of the uterus and then the other

one is levonorgestrel or progestin IUD so it works by sort of tricking the lining of the uterus

and the body into preventing pregnancy. Generally the levonorgestrel IUD works by making

cervical mucus so that it's so sticky that sperm can't really get to the egg. Both of them

work by being in the place that they need to prevent pregnancy and they can stay there for

five to 10 years or shorter if you want to have them removed sooner or longer if you would

like long term contraception.

[Nina]: and how long does it usually take to place one of these devices?

[Dr. Moss]: yeah so it can take about 5 minutes if it's an easy placement. The patients

positioned just as they would be for a Pap test so usually lying on their back with their feet

and in pedals or stirrups. The speculum is placed, the cervix is seen, it's cleaned off so that

no bacteria from the vagina go into the uterus and then the device is put into the cervix and

the device is deployed.

[Nina]: On the topic of kind of pain management, could you describe your approach to

managing pain during IUD insertion and if your approach has evolved over time as well?

[Dr. Moss]: Definitely so I would say first of all that that informed consent piece is so

critical for determining how pain is managed during IUD placement because there are lots

of people especially in my practice where people have had a lot of trauma related to

medical care with pain with speculum insertion. I often will say this is not a procedure that

you have to have awake and the venue is a really important consideration right like yes we

can do this in the office but it doesn't mean that we should and if you've had a lot of trauma

if it's really stressful to you to contemplate an awake procedure that involves pain in your

genitals which is just the reality of the placement in the office then going to the operating is

super reasonable. And I talked to lots of patients about that. So that's the first thing is likeis it even appropriate to do this in the office and then if I think the patient is a good

candidate in the office then I always do a paracervical block and that is where you put a

little bit of numbing medicine before you even attach any instruments at all because the

cervix needs to be held while the IUD is being placed and so generally and so and that

instrument that holds the cervix is called the tenaculum and it looks pretty barbaric if you

look up a picture of it. It's got little hooks on it that'll hold on to the cervix and so I always

put a little bit of numbing medicine before the tenaculum is even placed and then once the

tenaculum is placed I do something called a paracervical block which is where you put two

injections of numbing medicine one on either side – it’s at the border of the cervix and the

vagina. That's been shown to do a really good job of making the cervix itself numb it's not

as good at numbing the inside of the uterus which is sort of higher up and more difficult to

numb but I always do a paracervical block.

[Nina]: Exactly and what I found in my research is that honestly not all providers use

paracervical blocks in fact many still recommend over the counter pain relief like ibuprofen

or Tylenol and studies show it isn't effective for reducing insertion pain I think the use of

local anesthesia like paracervical blocks and especially in the literature has been shown to

make a significant difference there's research that shows that while paracervical blocks

reduce cervical pain they don't always numb the inside of the uterus where the IUD is

placed to reiterate what Dr. Moss said. This is where i think that we could do more like

incorporating sedation or other anesthesia techniques

[Dr. Moss]: I was not trained that you should always do a paracervical block and in fact you

know for 10 years I would say I have evolved from rarely doing them when I was in training

and being trained that it wasn't necessary, to always doing them so it was sort of a gradual

shift overtime.

[Nina]: Have you seen that shift in other providers as well over time that?

[Dr. Moss]: And I do think that we have evolved somewhat but the word still needs to be

spread I think it's just we're in a different time now where we haven't when we're

recognizing how harmful it is to do these procedures without sufficient anesthesia.

[Nina]: Absolutely and as you said the word needs to be spread and there's still so much

more we can do the literature shows that while there have been some improvements we

still lack a standardized protocol for pain management during IUD insertions I found

multiple studies with mixed results on various methods and it just highlights the need for

more comprehensive guidelines especially for nulliparous women who are often left to

manage this pain with little more than verbal reassurance

[Dr. Moss]: I think that we sometimes are with women's procedures where we were with

dental care 100 years ago right like people would have a tooth extracted without

anesthesia and there are a lot of people who can tolerate it but there are also a lot of

people who will be traumatized by that and we would never do that now because eventhough some people can tolerate it doesn't mean we should do it. And I think that's where

we were with IUD placement where people were just not talking about it not regarding the

fact that it was really painful and the people who were making decisions about it frankly

were not people with uteruses often or people who had ever experienced the procedure. I

will say I'm on my third IUD I had a paracervical block the first time and it was really helpful

to me and so certainly I would say I always advocated for a paracervical block and people

who hadn't had babies before because if you haven't had a pregnancy it can be you know

the cervix hasn't been dilated it can be I think much more uncomfortable. But I also now

just feel like why would anyone whether you've had a baby or not need to tolerate

discomfort right it's just not necessary paracervical blocks are pretty low risk they take a

minute to do and they don't meaningfully extend the procedure and they very meaningfully

reduce pain.

[Nina]: yeah I've definitely told some of my friends who are you know looking to get IUD's

replaced or are thinking about getting an IUD now, I'm like you know you can ask for a

paracervical block and

[Dr. Moss]: And you can decline the procedure without one and I you know again no better

do better I was a provider who wouldn't have automatically offered it five years ago but now

I do and you can certainly provoke thought in the clinician who's seeing you by asking for

one and not being willing to undergo the procedure without one and finding a different

clinician if that is not you know if that's not something that the clinician you're seeing is

willing to provide.

[Nina]: And then my other question for you too is, so something that I really have found

helpful giving in various Women's Health procedures is Toradol would you think of that I

mean I the way that I described toradol to patients is like ibuprofen on steroids

[Dr. Moss]: and I think in terms of how it works it's a prostaglandin inhibitor, you know it’s a

nonsteroidal anti-inflammatory, so it works on the prostaglandin axis. It makes sense to

me that that would help with cramping I'm not sure it would help with the visceral pain of

tenaculum placement or the IUD placement itself again it makes sense to me for

afterwards but I think during it we really needs like lidocaine sort of sodium channel based

anesthetics to be really aggressive with the anesthetic there.

[Nina]: it was impossible to be honest, to find anything about even sedation like MAC

sedation

[Dr. Moss]: yeah I know, no randomized trials or nothing right but I think you know we have

more to do in terms of research but I also think like again we would never randomize

people to getting a tooth pulled with and without anesthesia, so it's just like is that the

study we need to do or do we just need to listen to people and say like my experience is so

much better with this and yes there's a marginal increase in cost to do a paracervical block

but the significant reduction of pain is worth it to me and to the patient the other thing Ithink we don't account for when we're thinking about the simple economics of these

procedures right like OK what instruments are we going to use what do they cost, what

does the device cost, and what would this extra instrumentation and medication cost to

add the paracervical block or sedation. We're also not thinking about like down the line the

cost and IUD's can be really important in terms of people controlling their own sort of

reproductive destiny and also preventing things like heavy uterine bleeding and anemia

and so I think it's short sighted to only calculate the cost of the procedure right we need to

calculate what is the cost of this person being traumatized in this setting and not seeking

care later maybe they don't get their Pap test because they had a really bad experience

with IUD placement and they want to stay away from the gynecologist and then they get a

precancer or cancer like there are so many other downstream effects to evoltizing patients

that we need to do everything we can to limit pain during these procedures.

[Nina]: Yeah you know just with the current climate that we're in now with reproductive

health and abortions which I won't go in depth about but you know the lack thereof is

concerning because if you know women are scared to get an IUD and they don't want to go

on to hormonal pill birth control and the next option would be I mean you could have other

options but if you really wanted an IUD but you were afraid to get one it's like I wish women

knew what they could have offered to them because so many women that I've talked to

they were like these were my options. They said you can take Tylenol and ibuprofen and

you know they told them it might be like a pinch.

[Dr. Moss]: I know yeah

[Nina]: that's not a pinch

[Dr. Moss]: No and and I think we have a bias right and our bias is towards convenience as

clinicians. So it's easier to listen to the patient that says that wasn't that bad and say this

person that says this was really bad as an outlier but really it's a spectrum and if a large

portion of the spectrum reports substantial pain during the placement even though they

feel like they could tolerate it, doesn't mean they should

[Nina]: yeah honestly I think this system tends to prioritize efficiency and honestly that

often comes at the cost of patient comfort many women endure unnecessary pain

because more comprehensive options like sedation or monitored anesthesia care aren't

offered I think there's this idea that anesthesia should be reserved for more serious

procedures and I think that ideas outdated there's no reason why women should have to

tolerate pain when we have lots of tools to alleviate it

[Dr. Moss]: yeah and it's costly in ways of like preventing people from seeking care, trauma

to the patient. But there's also a whole network of people that are affected right because

women talk when they have painful procedures and it makes the next person less likely - I

have so many patients who have difficulty with certain kinds of contraception and would

benefit from an IUD but they're afraid to get the IUD because they've heard of all their youknow their friends and sisters and other you know loved ones experience with the pain and

so they don't want to get it because they've heard it's terrible and it doesn't have to be

terrible you know certainly there are some people who can't tolerate the device and you

know but it shouldn't be because of the pain of the placement in my opinion

[Nina]: I agree

[Nina]: and that’s such a key take away from the research so many women avoid getting

another IUD or even regular gynecologic care because of the trauma from their first

experience I mean studies have shown that inadequate pain management during IUD

insertion and during other gynecological procedures can lead to long term negative impact

on women's willingness to seek care

[Dr. Moss]: That we can fix yeah

[Nina]: In the past when you said during training you weren't using necessarily paracervical

blocks have you noticed a significant change in the feedback that you received like now

versus before and what your patients say after they've received the IUD?

[Dr. Moss]: I would say overwhelmingly people who got a paracervical block now there are

exceptions but most of the people who get a paracervical block say that it wasn't as bad as

they thought it was going to be and people who got a paracervical block that had a bad

experience before say that it's night and day. You know I can see that I think that in the

transition of my thinking from being selective paracervical block administer or to a

universal paracervical block administer there are people who I would you know OK place

the tenaculum without paracervical block they seem to have a lot of pain so I stopped and

did the paracervical block and that patient provides their own control you can see that they

feel so much better and are so much better able to tolerate the procedure once you've

administered the block and so then it just felt like well why am I doing this where I like

decided they need a block based on their response initially because that's probably

traumatizing in and of itself the attempt without the block so that's sort of what pushed me

to like you know I don't need to do this thing where we decide let's just do it for everybody it

just didn't know yeah and it's just it's just not a super time consuming thing like you have to

train your staff you have to make sure people know that they're going to get a local

anesthetic. They could react to that, that’s part of your informed consent process and

having the materials on hand the spinal needle a couple other things that you, you know

material wise that you need but other than that it can be pretty quick.

[Nina]: well I'm going to just ask you just a couple more questions. So I guess ultimately in

the future do you see anesthesia providers serving in a larger way with IUD insertions?

[Dr. Moss]: I mean I think that there will be a model of you know how we have sedation

dentistry I know I keep using that analogy but it feels very after apt that we have sedation

dentistry I think we'll have sedation gynecology and it will be much more acceptable. Imean I think what needs to happen is that we need to advocate because insurance

companies don't want to pay for this right because we've been doing this this way for a long

time where we just disregard women's pain and we do place the IUD's without blocks and

it's been seen as acceptable and it's really hard to get them to pay for something that has

been the standard you know it has not been standard of care and so that I think is a

challenge and I think it's changing I think we are getting more success than saying like

listen this patient just can't tolerate this in the office we're going to go to the operating

room and getting it covered but it's harder. And we also we need centers that can provide

high volume sedation for this type of minor procedure so that patients can have ready

access to it because it's also hard with staffing all the OR times booked in major academic

center so that makes that's a limiting factor as well.

[Nina]: Right

[Dr. Moss]: people don’t want to wait you know three months for your device because it's

hard to get booked into the operating room.

[Nina]: yeah I mean my question too in that in that realm is do you think it'll become more

of a thing where because I know there's CRNA’s and anesthesiologists that have practices

of their own that they essentially go into offices like dental practices and provide their

anesthesia services for these offices and really all the anesthesia that they provide do you

think that that's something that might grow as well?

[Dr. Moss]: Oh I think it's a great model I mean I think it's similar to the model that we have

you know for family planning care and you know abortion services and also for

reproductive endocrinology will often employ you know anesthesia part time to come in

into their office suite and help assist with procedures so that they are not reliant on OR

time or anesthesia in a bigger setting and I think that makes a lot of sense.

[Nina]: Right - Last question - what advice would you give to healthcare professionals in

training about managing pain and ensuring patients comfort during IUD insertion?

[Dr. Moss]: yeah I had a I had a professor in medical school who talked to us about how we

all sort of start out as golden retrievers when we're going into medicine like nobody goes

into medicine or I think it's rare that people go into medicine and don't want to help people

right we go and wanting to help people and having this like bright eyed bushy eyed or bright

eyed bushy tailed attitude about like wanting to help people and feeling a lot of empathy for

our patients and as we get worn down by the systems that prevent us from providing good

care we can become more like doberman pinchers right like we're just trying to protect

ourselves and get through the day and so I think it's just like worth reflecting on what you

would want if it was you and also like just thinking about the greater context of like just

because we can do it and and and it's acceptable within this system that's you know

broken in a lot of ways is it what we should do and so the the professor would always say

stay fuzzy stay like a golden retriever or stay thinking about your patients and loving them ina way that you would when you're first starting out and it's really really hard within the

systems that we operate in

CUE CLOSING DR. MOSS AND INTRODUCING CALLIE AND LAUREN

[Nina]: Dr. Moss made some incredible points, I think it's important for us as clinicians to

remember why we went into this field and to continue to strive to be the golden retriever I

want to further this conversation by hearing more personalized stories next we'll hear from

Lauren and Callie who share a similar experience to Lizzie

CUE LAURENS INTERVIEW

[Lauren]: like if they had told me what was to come or like what to expect I honestly feel like

that also would have kind of helped the pain too like if I did even decide to go forward

forward with it at that point like at least I would have known this is going to be really really

painful. They should have been like you need to take Advil beforehand at the very least like

not be like yeah yeah whatever it's no big deal because then also made me feel kind of

crazy because I'm like did something go wrong down there? I don't understand fully why I

guess maybe it is an insurance thing like they're like we can't put you to sleep or something

because of insurance or maybe there's some like and that's why they're just like OK like it's

going to all be fine in the end but we don't want to scare you out of getting it. I don't really

know what the motive is obviously behind. And I did end up even calling like I was calling

every week because it wasn't getting better and I really really truly thought because of how

much pain it was when I first got it in and the pain I was in after that something was wrong

like that it was like destroying my uterus or something or like they had put it in crooked I

had I thought that I needed to get it switched there was like no just let it ride it out for a little

bit longer and I was just like I'm scared of that I'm destroying my body accidentally.

[Nina]: Would you do it again?

[Lauren]: No, I would not do it again

[Nina]: What if you had anesthesia?

[Lauren]: If I had anesthesia, yes, I probably would because the one the nice thing about it

is like when I was taking birth control pills it's like I would forget and then everything gets

messed up like with your body and like you're going through like a month long period or I

don't know it's just it was hard to remember the pill so it's nice to not have to remember

anything and then two I don't get my period at all which I like so those are two like really

great positive benefits of the IUD but yeah the pain before and that's gonna be painful to

take out too and mine like they ended up years later I went to go get it checked the check

up to see if it's in the it's in the right spot they couldn't find it so I had to get an ultrasound to

see if it was in the right place which costs a lot of money I didn't realize it's going to cost

you so much money to get it checked ended up being in the right place but they're like nowwhen you get it taken out you will probably have to get like a minor surgery to get it removed

it's going to cost money too so it's like at the end of the day it's just so much simpler I feel

like to just take the pill or just not be on birth control at all then IUD so I don't know I would

have to weigh the options if I went back in time

[Nina]: So what would you recommend for women who are thinking about getting an IUD

placed?

[Lauren]: Really just weighing the options like weighing the pros and cons some of the pros

are so great especially for women that have really terrible periods and they don't want to

get them anymore like that is a great reason to get an IUD you don't have your period

anymore or can't remember the pill and like you're with somebody that you want to make

sure that you're protected another great reason but what I'm saying is just like create a

pros and cons list and really really think about it more deeply than just letting the doctor

whoever is talking about it just make it seem like it's some simple quick easy and painless

thing because that's what happened to me and I'm kind of stuck with this thing for years

CUE CALLIE’S INTERVIEW

[Nina]: And then on to Callie's experience

[Nina]: Give me kind of the background with you experience with the IUD placement and

then you know let me know if you had any pre medications offered, proper warning or if you

felt like you were adequately warned about what you kind of might experience

[Callie]: Yeah definitely, so the reason I was getting an IUD in the first place I was on the pill

from when I was like 14 to 19 I guess and then I realized it was just like really not working

for me just hormonally it made me feel crazy. So I went off of it for a few months but then it

was the summer between my sophomore and junior year of college I was like OK I need to

be back on birth control like I can't just be completely off. I was living in Charlottesville for

the summer so my options were limited just because it's like not where I’m from and I

didn't really know so I went to Planned Parenthood because I was just like the easiest

option and nothing against Planned Parenthood because they do what they can with what

they have. But I had literally no idea like the structure of the appointments or even that I

was getting it placed that day. Like I thought it was a consultation where they were going to

walk me through my options and then tell me about sort of what it would be like and they

just put me in the chair and they're like alright all we have in the fridge today is Mirena. Is

that OK? And I had no idea what that meant I was like that's the hormonal one right? And

they're like Yep. So they just did it and I was so taken aback I was like Oh my God I literally

didn't think this was happening today so I had no Tylenol or anything or even an idea of like

what the process would be like. I blacked out it was horrific

[Nina]: Really?[Callie]: Yeah, she was like OK you're going to feel some pressure and I was like Oh my God

what is your definition of pressure like that is the craziest pain I've ever felt in my entire life

and then she did it again and I was like actually going to throw up and then I just passed

out.

[Nina]: You passed out?

[Callie]: Yeah

[Nina]: Did they say anything afterwards? Like after you passing out?

[Callie]: They were like ohh that's normal like it just kind of surprises some people because

it's a lot more than they were ready for and it feels different for everyone so it's like hard to

really prepare people for that and I was like fair enough I guess I would have taken at least a

Tylenol if I knew I was even doing this today.

[Nina]: Sounds like they did not prepare you for that at all I'm sorry about that experience.

That sounds very traumatizing.

[Callie]: Yeah thank you honestly in hindsight it probably was they were just trying to get me

in and out as quickly as possible they were like we want to minimize the number of times

you have to return to the office. That's fair so they have their reasons.

[Nina]: Yeah, but have you had to have it replaced since then?

[Callie]: It was in 2018 and when I got it in it was good for five years and then during the

time that I've had it in it has now been approved for seven.

[Nina]: Oh OK OK

[Callie]: I’m at year six right now and I'm going to need to get it replaced soon. Which is

really timely for this interview because I'm so scared.

[Nina]: OK so have you talked to your OB about options? Like talked to them about what

they could offer you because of how scared you are about this?

[Callie]: Yeah no one's been able to really tell me anything other than this office doesn't

provide any kind of pain management and we can't necessarily refer you to any offices that

do but we can recommend that you take a couple Tylenol before you come in

[Nina]: How many offices have told you that?[Callie]: Probably at least three and I'm talking to my primary care as well because I figure

she might have some referrals because that's what they do but she doesn't really know

either so I’m just kind of at a loss but I’m ultimately going to suck it up and do it

CLOSING STATEMENTS:

[Nina]: Much of what I heard in these women's stories is something we as clinicians should

strive to prevent. Our patients shouldn't feel as though they need to mentally prepare for a

procedure, they should feel comforted knowing we'll do everything in our power to make

them comfortable. Not to say we can prevent 100% of the discomfort, but we should

advocate for these women. And to the women listening I hope you will also hear these

stories and the current research available and advocate for yourself.

[Nina]: I wanted to thank you all so much for listening. I also want to thank Dr. Moss for

providing her expertise and I want to thank all of the women who felt comfortable sharing

their story. I hope this podcast sparks interest in future research - a potential topic I'd love

to see in the literature is the comparison between paracervical blocks and MAC sedation. I

think that randomizing individuals to each group could really help us to understand if

sedation could be effective for IUD insertion and get us just one step closer to a

standardized approach. Again, thank you all so much for listening and please, please don't

forget to fill out the survey.