‘Just a pinch’: Women frustrated as medical community downplays pain of IUD insertion

Bridget Irwin, a 28-year-old teacher, was told she would experience “some pressure” during her IUD insertion at Women’s College Hospital in Toronto, and that it would be very fast. Instead, it was so painful that she nearly passed out. “We had to Uber home because I couldn’t walk,” she says.

“I remember laying on the floor of the doctor’s office in pain. They just kind of left me and didn’t ever check in again,” says Jada Gannon-Day, a 23-year old student and researcher at Carleton University.

“She made me feel dramatic and stupid for fainting,” says Emilie O’Neil, a 26-year-old architectural designer in Toronto. “She seemed annoyed when I stuck around in the hall to calm down.”

For the 20 per cent of women who use an IUD, these stories are extraordinarily common. The excruciating pain a generation of women have endured during their IUD insertions has even become a subject of poetry. “Don’t complain when a t-shaped copper device is put into your uterus with no pain relief,” Chloe Grace Law writes in her poem It’s Not That Bad. The poem was liked and shared thousands of times.

Thousands of TikTok rants, viral tweets, a change.org petition signed by more than 36,000 women and peer-reviewed studies have all documented the grossly insufficient pain relief offered for IUD insertions by practitioners.

So, what is the response from Canadian medicine to this public outcry?

The answer is, there has been practically none.

Astonishingly, despite mountains of evidence, Canadian clinicians in gynecology, obstetrics and family medicine are continuing to proceed with business as usual, providing patients with only an Advil for pain management. No new pain protocol has been developed and clinics across the country and physicians continue to falsely inform women the insertion will be “just a pinch,” failing to uphold a principle of informed consent.

I spoke with Greg Hare, an anesthesiologist at St. Michael’s Hospital in Toronto, to get an idea of the policies doctors follow when managing pain generally. Hare notes that standard protocol is “pain is subjective and acute procedures will result in pain at different levels. The bottom line is: If you’re in pain and it’s an acute procedure, we treat the pain with the modalities we have. The person’s history and what they’re telling you is 98 per cent of what you need to know. The default is: How do we manage this.”

Hare explains there is no “unreasonable” amount of pain for a patient to be in. When patients experience pain that their doctors have not prepared them for, doctors need to adjust, either because they misinformed the patient, underestimated the patient’s sensitivity to pain or overestimated how effective their pain treatment was. “You adjust your treatment to that person’s actual perception of pain,” he says.

Unless there is a documented reason not to trust the patient, whatever the patient is feeling is what should be addressed, says Hare, regardless of whether that falls within the typical amount of pain a procedure causes. It is also vital that clinicians remain aware of how much pain the average person experiences during a procedure, and the full range of reactions, so patients can provide informed consent.

Scientific documentation that pain treatment for IUD insertion has been negligent occurred as early as 2006, when a peer-reviewed, randomized controlled, double-blind, placebo-controlled trial published in the American Journal of Obstetrics and Gynecology in 2006 demonstrated that Advil or ibuprofen did not reduce the pain of IUD insertion more than a placebo. In 2013, a peer-reviewed, randomized control study of 200 patients in the international reproductive health journal Contraception reported that, while clinicians estimated the pain of insertion to be a three on a 10-point scale – mild to moderate – patients reported the pain at an average of six to seven – severe to very severe. Standard pain treatment for medical procedures that typically result in severe to very severe pain would be a morphine IV drip or local anesthetic, not an Advil. A comparable procedure is a root canal. The authors of the study recommended that clinicians change practices around IUD insertion to match the degree of pain experienced by patients.

Hare says standard practice for pain management in medicine proceeds as follows. First, practitioners should ask themselves if they can make the pain better. If that’s not possible, then transparent disclosure is an imperative part of duty of care. “If it’s that painful, when you’re doing consent you have to say, ‘This is actually for the short-term, perhaps a very painful procedure … do you still want to proceed? Or should we do it under different conditions?’ It’s part of the consent process,” says Hare.

As the Canadian Medical Protective Association writes, informed consent is fundamental to the practice of medicine: “The patient must have been given an adequate explanation about the nature of the proposed investigation or treatment and its anticipated outcome as well as the significant risks involved and alternatives available.”

Eleven years have passed since the 2013 study, yet, as of 2023, only around six clinics in Canada offered local anesthetic as part of their standard practice for IUD insertions. None of these clinics were in Ontario.

“It’s like going to the dentist and getting a root canal or a tooth extraction and not being offered freezing.”

I spoke with Renee Hall, medical co-director at the Willow Reproductive Health Centre in Vancouver, which offers pain management counselling as a required part of its protocol for IUD insertion. In her training, “we were taught it’s just a simple little procedure” that was not severely painful, she says. “It can be simple in some cases, [for example for] someone who’s had multiple children.”

But IUD insertion is often a complex procedure, and doctors should be trained “more like the way we train our surgeons,” rather than treating the procedure almost like piercing an ear. As it stands, Hall says, training is grossly insufficient and many doctors are making medical errors, taking up to 30 minutes for a process that should be three minutes at most,

Armas Enriquez, a family doctor in Nanaimo, B.C., told CTV that having an IUD inserted without pain-management is “like going to the dentist and getting a root canal or a tooth extraction and not being offered freezing.” Applying a local anesthetic can reduce the pain of insertion by 70 to 80 per cent, she states.

Hall says there needs to be more research into pain management techniques, but that, “what we’ve come to so far is really an individualized multimodal approach.” The Willow Clinic offers oral medications, injections, freezing and inhaled methods. But in other practices, particularly in Ontario, says Hall, pain management is not a routine part of counselling patients.

“Appropriate informed consent is not being given,” Hall says. “You have to counsel to expectation.”

Part of obtaining consent is explaining the complete range of experiences of pain the procedure causes. Hall tells patients that she has “had people come do this at lunch and go back to work; other people leave here and feel like they’re giving birth to something.”

She says there is a perception among contraceptive providers that if their patients are not on the most efficient method of birth control, they have failed as doctors. Providers think the IUD is what is best for patients and don’t want to scare them off. “I don’t know why we feel we need to diminish [the pain] and say it’s going to be fine.”

The practices followed at the Willow Centre – mandated counselling for pain and pain mitigation, informed consent that explains the full range of reactions to the procedure, and adjustments to pain management – are consistent with what Hare describes as standard protocol for dealing with pain. But as of 2023 only a handful of clinics in Canada were meeting this standard by offering local anesthetic as part of their standard counseling for IUD insertion.

“I normally have really high pain tolerance, but the IUD insertion was one of the most painful things I have ever experienced,” says Liz Faria, a web developer from Toronto who cannot find a clinic that will replace her IUD with anesthetic.

A simple Google search finds dozens of Canadian health-care resources that downplay how painful IUD insertion is. HealthlinkBC – a governmental service offering non-emergency medical information – states that the patient “may be asked to take Advil or ibuprofen” before coming in. “The IUD will be carefully guided into place using a very thin tube. You may feel some cramping,” says the website. “The whole process takes just a few minutes.” The website for Sunnybrook Hospital in Toronto says, “while every woman’s pain tolerance is different, there should not be excessive discomfort. You may have some cramping during insertion.”

The Society of Obstetricians and Gynaecologists of Canada (SOCG) issued a statement in 2022 around pain management for IUDs. “IUD insertion can be painful for some patients,” the statement says. “Anxiety, as well as anticipated and actual pain related to the procedure, are important barriers to the use of IUDs.” The statement offered no mandated change to pain protocol and offered no formalized change to medical education that continues to misinform students that IUD insertion is simply uncomfortable. The statement offered no plan for addressing the dearth of research around best practices for insertion and reducing pain.

Guilt, confirmation bias, the systemic devaluation of women’s pain, dysfunctional billing practices that don’t cover freezing and medicine’s history of denying the side effects of birth control methods may offer partial explanations for what is happening.

But what is certain is that a generation of women have undergone a medical procedure under conditions for which they did not provide informed consent. Urgent action is needed to prevent this from happening to anyone else and to preserve whatever degree of trust women in Canada still have in reproductive health care.