1. Background
Intrauterine devices, commonly known as IUDs, are among the most effective forms of long-acting reversible contraception (LARC). Following the reversal of Roe v. Wade in 2022, IUDs have become increasingly popular, as they are a reliable method of preventing pregnancy while voluntary abortions are not always accessible. However, many studies have shown that the fear of pain with an IUD insertion is a barrier to many women pursuing this form of contraception, and others reflect on their insertions without the block as extremely painful (7). Additionally, nulliparous patients, often adolescents, struggle to feel comfortable in a gynecological setting and need in-depth communication with their providers.
1.1 History of IUDs
An IUD is a T-shaped device placed into the uterus to prevent pregnancy. Out of the five FDA-approved IUDs, four are hormonal devices that release varying amounts of levonorgestrel. The fifth is a copper intrauterine device, which is a non-hormonal form of contraception (6). Each IUD has a different approved period of efficacy, from three to twelve years.
1.2 Insertion Process
First, a provider inserts a speculum into the vagina for visualization. A single-tooth tenaculum is used to puncture the cervix and stabilize its position. The provider then inserts a uterine sound through the cervix to measure depth. The IUD insertion device is placed through the cervix, and the IUD is released in the uterus (6).
1.3 IUD Insertion Pain and Relief Options
Generally, since nulliparous patients have never experienced cervical dilation with childbirth, they tend to report the highest levels of pain with IUD insertions. Patients typically experience sharp pain and cramping (2). Pain relief methods for IUD insertions include OTC medications, topical lidocaine-prilocaine cream, a lidocaine paracervical block, and anesthesia. Due to limited past research in the United States on pharmaceutical options for IUD insertions, international studies are a large source of current knowledge. In a 2019 study from Cairo University, a lidocaine paracervical block was proven to be more effective than the topical application of lidocaine-prilocaine cream. Patients typically reported a better experience with the cream, likely due to the burning sensation of the lidocaine with paracervical injection. Patients reported no improvement when given NSAIDs, with no effect from the type or dosage (1). A 2020 study conducted in Thailand used lidocaine spray. A randomised, double-blind, placebo-controlled trial of 124 women found that the 10% lidocaine spray group reported a significantly lower average pain estimate than the placebo group (5).
A literature review from the University of Wisconsin investigated the causes of patients’ anxiety and pain with IUD insertions. Relaxing environments and verbal analgesia were found to be helpful. The Valsalva maneuver, a forced exhale against a pinched nose and closed mouth, was just as effective as tenaculum placement during IUD insertions (8).
1.4 Gender Bias and Pain
It is a long-standing belief that women’s pain goes largely unheard by medical professionals due to gender bias—IUD insertions included. The main tool in IUD insertions is the tenaculum, invented by French surgeon Samuel Jean Pozzi in the late 19th century. The Pozzi tenaculum is a forceps with pointed edges that puncture the cervix to stabilize it. At the time of invention, Dr. Pozzi believed the cervix was devoid of sensory nerve endings and therefore could be punctured with no pain for the patient (3).
Gender bias influences medical providers’ perception of patient pain. A 2024 study from Colorado shows that physicians often believe that women exaggerate their pain while men downplay their pain to seem more “masculine.” This can often lead to women not receiving enough pain treatment, while men are overtreated (4).
Ultimately, it is clear that there are extreme gaps in the research surrounding pain relief and the use of analgesics with IUD insertions. The normalization of limited pain relief for IUD insertions is due to a lack of research, gender bias, and historical inaccuracies about female anatomy. Despite studies revealing that patients experience lower levels of pain with topical lidocaine or injections, no changes have been made to the current standard of care. As IUDs are a common choice of birth control for younger patients, further investigation must be done into how to make this procedure as comfortable and painless as possible.
2. Methods
2.1 Design
This was a qualitative study that utilized semi-structured interviews to explore the experiences of nulliparous women undergoing IUD insertions. A small quantitative component was included, with participants using numerical scales to rate their pain and anxiety.
2.2 Participants & Recruitment
Participants were nulliparous people, assigned female at birth, aged up to 25 years. All participants had previously received at least one IUD. Recruitment was conducted via flyers on a college campus and word of mouth, but was not limited to students. A total of 10 individuals participated in the study.
Participant Demographics
Participant ID |
Number of IUDs |
Age @ insertion |
Type of IUD |
Participant alone during insertion |
|---|---|---|---|---|
P1 |
2 |
16, 20 |
Mirena x2 |
Yes, No |
P2 |
1 |
19 |
Kyleena |
Yes |
P3 |
1 |
19 |
Mirena |
Yes |
P4 |
1 |
17 |
Mirena |
No |
P5 |
1 |
16 |
Skyla |
Yes |
P6 |
2 |
18, 20 |
Paragard, Mirena |
No, Yes |
P7 |
1 |
19 |
Paragard |
No |
P8 |
1 |
18 |
Paragard |
No |
P9 |
1 |
17 |
Mirena |
Yes |
P10 |
1 |
16 |
Mirena |
No |
2.3 Data Collection
Interviews were conducted in person or on Zoom in private study rooms and lasted approximately 30 minutes. All interviews were audio recorded and transcribed verbatim with participant consent.
2.4 Interview Guide
The interviews began with an open-ended question asking participants to describe their IUD experience from their first appointment through the IUD removal (or current day if participants still had the IUD). Follow-up questions probed participants’ interactions with their provider, their insertion experience, pain perceptions, and emotional response. Participants rated their pain and anxiety using the NRS-11 scale and VAS-A scales, respectively.
2.5 Data Analysis
An inductive thematic analysis method was used to code the qualitative data. Initial codes were generated for each transcript based on significant parts of participants’ provider-patient interactions and other experiences, physical or emotional. These codes were compared across transcripts and grouped into broader themes to reflect shared experiences.
After initial coding, multiple researchers independently coded the data, yielding similar results. The codes and themes were improved via an iterative process to best reflect participants’ experiences. Google Sheets was used to generate visuals for the quantitative components.
2.6 Ethical considerations
The study was approved by the Health Sciences and Behavioral Sciences Institutional Review Board at the University of Michigan (HUM00274106). All participants were informed of the intent of the interviews before participation and consented. Interview audio recordings were immediately transcribed and stored on a password-protected device, and all recordings were deleted. Participants were assigned pseudonyms during transcription, and all identifiers were removed.
3. Results
3.1 Prior Patient Knowledge
3.1.1 Why Patients Want an IUD
Participants shared difficulties with oral contraceptives—taking a pill every day was hard, and the fear of decreased effectiveness was evident.
[My provider] also suggested the birth control pills, but I am not good at taking pills consistently, so I was worried about that not being effective. Mostly, I was just really interested in like the 99.8% effectiveness [of the IUD]. (P2)
Some participants also displayed a desire for non-hormonal birth control, leading them to the copper IUD, Paragard, which is one of the most prevalent non-hormonal contraceptives.
3.1.2 External Influences on Patient Knowledge and Expectations for Pain
Reasons for wanting an IUD were the area in which participants displayed the most forethought. Participants conducted varying levels of research on IUD insertions, influencing their expectations of insertion pain. Many took to social media to investigate, while others asked friends and family.
My sister had [an IUD]. My sister said it hurt really bad, but it was like, it was okay … I was expecting it to hurt really bad, but I would be fine. (P5)
I just searched ‘IUDs’ and ‘IUD insertions’ on TikTok … I just saw a bunch of videos of girls crying, getting them in, and how it was the worst pain of their lives. (P6)
This line of questioning established the baseline of patient knowledge, indicating the amount of patient education necessary, which many participants felt was lacking.
3.2 Provider-Patient Education & Provider Behavior
3.2.1 Lack of Communication
Participants shared that their providers did not properly communicate regarding their procedure, leading to increased anxiety. P1 had no prior knowledge of IUD insertions, and her provider offered no information, so she rated her anxiety a zero but her pain a 9, as shown in Figures 1 and 2, respectively. Despite this experience, P1 elected to get a second IUD—before this, her anxiety was a 9 and directly impacted by her previous lack of information.
I had so much anxiety … it was taking so long to get me settled down to even spread my legs for it, and while she was trying to insert it … I think I blocked a lot of it out because it was just, it was horrific. (P1)
Other participants shared that they were also uninformed about what to expect during and after their insertions, affecting trust levels with providers.
3.2.2 Feelings of Dismissal
Participants also highlighted that during their IUD journey, they felt dismissed. Providers were quick to push IUDs without discussing all options, while others neglected to provide strong pain relief even when participants requested.
P6 had a negative experience with her provider. She went into her appointment anticipating a lot of pain, having seen stories online, so she requested pain relief from her provider. Instead of assuaging her fears, P6’s provider refused to provide her pain relief.
She was very dismissive and was just like, ‘It won’t hurt that bad, you won’t need anything.’ The actual insertion was the worst experience of my life. (P6)
Despite her previous difficult experience, P6’s provider would still not offer substantial pain relief for her second IUD after her first fell out. These stories display how difficult it is for patients to get what they need, despite advocating for themselves.
3.2.3 Providers’ Descriptions of Pain & Accuracy
Participants’ providers described the pain they might experience during insertion using verbiage like “a quick pinch,” “cramping,” and “some pressure.” However, many participants felt inadequately prepared for their insertions, expecting minimal pain based on their providers’ descriptions. Like most participants, P2’s provider described her insertion mildly. However, P2 had an extremely different experience.
[It was] not very accurate. I wasn’t expecting it to be that horrible … I feel like they were just like, ‘It’s a standard procedure, whatever. Take some Tylenol, you’ll be fine. You can drive.’ And then, yeah, I was not expecting it to be that painful. (P2)
Many others had similar stories and felt that their providers’ descriptions were inaccurate. In order to determine if provider communication eased or aggravated pre-procedure anxiety, participants were asked to rate their anxiety before and after speaking with their provider on a scale of 1–10. Half of the participants reported either the same or higher levels of anxiety after their provider described the IUD insertion process.
This figure displays participant anxiety ratings for first IUD insertions only on a scale of 1–10 using the VAS-A scale.
3.2.4 Mistrust in Providers & Patient Comfort
Some participants shared that their overall experience was negatively affected by the invasive nature of the IUD insertion, along with the presence of people besides their provider. For an adolescent, a stranger present during a procedure like this can often raise anxiety. A medical student was present for P2’s insertion, with P2’s consent. However, it was the medical student answering her questions following her insertion, not P2’s physician. While this is necessary for students, P2 was expecting—and preferred—that her physician also be present.
P4 also had another person in the room alongside her provider, helping with the insertion. While describing the worst part of her insertion experience, P4 mentioned this assistant:
P10 also spoke about feeling “vulnerable and exposed.” Ultimately, many participants felt like another person in the room increased their anxiety.There was another person in the room as well because I was a minor who was helping her … I felt very exposed and vulnerable. I did not have my privacy. (P4)
3.2.5 Positive Experiences
Increased levels of communication improved participant comfort level during IUD insertions, despite high pain levels. P3 discussed how the technicians who inserted their IUDs made an effort to continue communication throughout the procedure.
My techs were communicating with me the whole way … It was very nice talking with them and also them explaining ‘okay, this is what I’m doing next,’ or ‘is it okay to proceed?’ It made me feel in control of a situation I didn’t have much control in. (P3)
P4 shared a similar experience, talking about how her provider explained the insertion in depth, calming her anxiety. Her provider offered music during the procedure, which gave her something external to focus on that distracted her from the pain. Participants whose providers did not offer detailed explanations throughout their procedure expressed that communication would have improved their experience.
3.3 Pain & Pain Management
3.3.1 Pain Perception
Participants’ perceptions of pain varied greatly—a few said they had a near-painless experience, while others were in immense pain. P2, who was offered only Tylenol, felt that she was in intense pain during and after her insertion, describing it as the worst cramps of her life. P5 had a particularly traumatic experience, rating her pain a 10, as seen in Figure 2. Her provider not only neglected to offer pain relief but also struggled to insert the IUD, resulting in a prolonged and painful IUD insertion.
This figure displays participant pain ratings for first IUD insertions on a scale of 1–10 using the NRS-11 scale.
And [the insertion] was like the worst experience ever. So, the nurse practitioner’s trying to put [the IUD] in, and I’m not screaming obnoxiously, but I’m obviously in immense pain, and I have a pretty high pain tolerance … Then they say we’re done, and they show me everything’s out. And I was having the worst pain. It felt like something was happening. Like they were still in there, but they weren’t. I could tell they weren’t. I could see them, and I couldn’t, like I was on my back and I couldn’t even sit up. I could barely move. I was crying hysterically. (P5).
Like the others, P6 had a painful insertion and was offered minimal options for pain relief. P6 felt that the uterine sound was the most painful, causing her to pass out. Other participants also identified the uterine sound and tenaculum placement as the two most painful parts of the procedure, describing the pain as sharp stabbing, cramping, and pinching.
In order to quantify pain levels, participants were asked to rate their pain during and immediately after their IUD insertion on a scale of 1–10 utilizing the NRS-11 scale. 60% of participants reported pain levels of 8 or higher during their IUD insertion.
3.3.2 Pain Relief Options
Most commonly, participants took pain relief pills, like Tylenol or NSAIDs. Dosing regimens varied: some participants were instructed to take the pills before insertion, some after, and others both. Some participants were offered these pain relievers by providers, but most took the pills on their own due to external knowledge. Participants who made use of these options generally felt they were ineffective. Many also expressed surprise at the lack of pain relief in comparison to other regular outpatient procedures.
In comparison, like getting a cavity filled or whatever, they give you a shot for numbing pain or stuff like that. So, the fact that there were actual metal instruments, there was a tray, there was a lot of blood, it was very surprising that I didn’t receive anything. (P4)
Some participants were offered extensive pain relief, like a lidocaine paracervical block or even anesthesia. These participants, even those who were offered but did not utilize more pain relief, had much better experiences and lower pain ratings. P3 was one of these participants.
Knowing that even if I did tap out ‘cause of my pain, there was another option to get the help I really needed made me feel less anxious about the pain because it didn’t feel like a factor that could hold me back from getting what I needed. (P3)
P6, after a traumatic IUD insertion, insisted on better pain relief for her second IUD. After much difficulty and switching providers, she was able to receive anesthesia for her second insertion. Her pain rating for this insertion was a 0. P7 was given a paracervical lidocaine block. While she had some pain associated with the block, her rating of 5, was lower than many other participants’ ratings of their insertion pain. Her insertion pain was a 0, as seen in Figure 2, due to the numbing.
3.4 Consequences of Painful Insertions for Sexual & Gynecologic Wellbeing
3.4.1 IUD Removal Anxiety
The majority of participants expressed that they are notably anxious about getting their IUDs removed, fearing that it will be a painful experience. Most seemed very uninformed about the IUD removal process. For example, P1 had frequent recurring ovarian cysts that would regularly rupture and needed to get her IUD removed, but was too afraid.
I wanted the IUD removed, but they wouldn’t put me under or anything. And I was just so scared to get it removed because of how painful it was to go in. (P1).
Almost all of the remaining participants expressed similar sentiments, sharing that they, too, were extremely anxious to get their IUDs removed.
3.4.2 Effects on Gynecologic Health-Seeking Behavior
Some participants expressed that they were anxious about all future gynecologic experiences. Most of the participants were adolescents when they received IUDs, and are fast approaching the recommended age, 21, for a Pap smear, a cervical-cancer preventative screening exam. P5 shared this:
Not only are painful IUD insertions traumatic experiences for young patients, but they can affect attitudes towards healthcare entirely, including refusal of necessary preventative testing.I don’t know if I can ever go to the doctor. I just turned 21 yesterday, actually. And I know, like I have to start getting Pap smears, and I don’t know what I’m gonna do. I’m gonna have to take anxiety pills before I go because I’ll get shaky, and it will freak me out. Because just the thought of a [speculum] coming anywhere near me, no thanks. (P5)
3.4.3 Impact on Sexual Behavior
Many participants displayed hesitation towards sexual encounters following their IUD insertions, with a few detailing how they were nervous to engage in any sexual activity, and others saying that their IUD imposed issues with their partners.
4. Discussion
This study focuses on IUD insertion experiences in nulliparous biological women, focusing on communication with providers, pain perceptions, and long-term effects.
Participants’ reasons for committing to an IUD converged on reliability, length of effectiveness, and lack of necessary daily management. It was enlightening to discuss with participants how they built their expectations for their insertion. This opens an avenue for further research to investigate the role of social media in patients’ expectations for medical procedures.
Detailed communication with providers was correlated with better participant experiences. This is consistent with previous studies’ findings that verbal analgesia, or continuous communication in a smooth tone, lowered patient anxiety (8). Also, participant anxiety lessened while listening to music, another technique previously shown to improve patient fear (8). Therefore, providers should make consistent communication and lowering patient anxiety a priority during IUD insertions.
Participant discomfort was often exacerbated by their age, lack of gynecologic experience, and the presence of a third person in the room. Ultimately, given the intimate nature of procedures like IUD insertions, providers should pay extra attention to making their patients comfortable, considering patients’ individual experiences and anxieties.
Most participants had extreme pain with their IUD insertions and received minimal options for pain management. Results were consistent with previous studies, with participants reporting no change in their pain levels upon NSAID administration, regardless of type or dosage (1). Also congruent with previous studies was the improvement in participants’ pain levels when given a paracervical lidocaine block (1). The contrast of experiences with and without pain relief exemplifies that options like a paracervical block and anesthesia should be readily available to patients. Just the existence of choice, even if not utilized, can help improve pain and anxiety, bettering patient experiences.
The study also found that participants felt that tenaculum placement and the uterine sound were the most painful parts of the insertion procedure. This opens a door to improving dated practices. The tenaculum has been causing women pain for years and should be targeted for design improvement. One study has found that the Valsalva maneuver can replace the tenaculum to achieve cervical immobilization, with the same efficacy and much lower patient pain (8). Additionally, ultrasounds can be used to measure the depth of the uterus instead of a uterine sound. This could immensely improve patient experiences.
Surprisingly, a few participants reported low levels of pain with no pain management provided. Although painful IUD insertions cannot be generalized to the whole population, the intense pain experienced by the remaining participants cannot be disregarded.
Most importantly, the study found that many participants felt that their IUD insertion was a significant moment in their lives and had a lasting impact. While sexual history and trauma were not specifically addressed in these surveys, negative IUD insertion experiences can add to existing trauma. Additionally, negative IUD insertions increased gynecological care avoidance. This shows that negative IUD insertion experiences can have long-term consequences.
4.1 Limitations
This study had limitations that must be considered when discussing the implications. The study is based on a small sample size (n=10), with the subject pool restricted to college-aged individuals. This may limit the generalizability of the findings. Many participants had their IUDs inserted two or more years ago, which could impact the participants’ ability to recall the details of their experience. While the study focused on nulliparous individuals, many who elect to get IUDs have experienced vaginal childbirth, which must be considered when developing clinical guidelines. While not discussed in detail in this study, providers’ pain management options are impacted by insurance policies, as providers and patients can face increased costs when offering paracervical blocks or anesthesia
4.2 Clinical relevance
The insights in this paper may help providers reevaluate their clinical standards for IUD insertions. It is important to consider each patient’s story when developing a plan of care, including their expectations and anxieties, along with physical symptoms. Additionally, it is clear that informative communication and extensive options for pain management lead to lower levels of pain and anxiety, indicating that this practice must be incorporated as a standard.
5. Conclusion
A multitude of factors impact a patient’s perception of an IUD insertion, including their prior knowledge of the procedure, level of comfort, communication with their provider, and pain perception. It is also important to consider the lasting impacts IUD insertions have. Intrauterine devices have been and will continue to be a popular choice of birth control. Therefore, it is important to abolish the barriers that prevent many individuals from pursuing this option.
Author Note
This research was conducted as an independent study at the University of Michigan under the guidance of Dr. Cynthia Gabriel, Department of Women’s and Gender Studies. There are no known conflicts of interest to disclose. Correspondence concerning this article should be addressed to Sania Hasan, saniahas@umich.edu.
References
1. A. Samy, A. M. Abbas, M. Mahmoud, A. Taher, M. H. Awad, T. E. Husseiny, M. Hussein, M. Ramadan, M. A. Shalaby, M. E. Sharkawy, D. Hatem, A. A.-E. Wali, S. M. Abd-el-fatah, A. H. Hussein, H. Haggag, Evaluating different pain-lowering medications during intrauterine device insertion: A systematic review and network meta-analysis. Fertil. Steril. 111, 553–561 (2019).
2. D. Cucci, IUD insertion pain: What to expect and how to prepare. NewYork-Presbyterian (2025).
3. D. de Vignemont, The medical instrument behind 135 years of women’s pain. New Lines Mag. (2024).
4. G. A. Paganini, K. M. Summers, L. ten Brinke, E. P. Lloyd, Women exaggerate, men downplay: Gendered endorsement of emotional dramatization stereotypes contributes to gender bias in pain expectations. J. Exp. Soc. Psychol. 109, 104520 (2023).
5. N. Panichyawat, T. Mongkornthong, T. Wongwananuruk, K. Sirimai, 10% lidocaine spray for pain control during intrauterine device insertion: A randomized, double-blind, placebo-controlled trial. BMJ Sex. Reprod. Health 47, 159–165 (2021).
6. S. Long, L. Colson, Intrauterine device insertion and removal. Prim. Care Clin. Office Pract. 48, 531–544 (2021).
7. T. Hunter, S. Sonalkar, C. Schreiber, L. Perriera, M. Sammel, A. Akers, Anticipated pain during intrauterine device insertion. J. Pediatr. Adolesc. Gynecol. 33, 27–32 (2020).
8. V. Ovsepyan, P. Kelsey, A. E. Evensen, Practical recommendations for minimizing pain and anxiety with IUD insertion. J. Am. Board Fam. Med. 37, 1150–1155 (2024).