Addressing IUD Pain: How to Counsel Patients Before, During, and After Insertion

Announcer:
You’re listening to Advances in Women’s Health on ReachMD, and this episode is sponsored by Bayer. Here’s your host, Dr. Jennifer Caudle.

Dr. Caudle: 
Welcome to Advances in Women's Health on ReachMD. I’m your host, Dr. Jennifer Caudle, and joining me to share strategies for counseling patients on IUD pain and discomfort is Dr. Courtney Schreiber. Not only is she the Stuart and Emily BH Mudd Professor of Human Behavior and Reproduction, but she's also the Chief of Family Planning in the Department of Obstetrics and Gynecology at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. Dr. Schreiber, thank you so much for being here today.

Dr. Schreiber:
Well, thank you for having me. It's great to be with you.

Dr. Caudle:
Well, we're honored that you're here. So why don't we start with some background? How common is it for patients to experience pain or discomfort during and after IUD insertion?

Dr. Schreiber:
I think it's so important for providers to know that pain with the insertion process of an IUD is actually very common. The pelvic organs, of course, are innervated, so when we manipulate those organs or do a procedure for patients receiving an IUD, pain is a common physical response that people will have during that process. And our job is to help patients understand how to separate this physical sensation of pain from the experience of suffering that can come with pain since the response of pain is really to signal that there's something that may be harmful happening to the body. But in this elective procedure that patients are choosing to have, it's not associated with harm; it’s just associated with the experience of having the IUD placed. So there are many ways for us to try to mitigate that other experience, which is more emotional and reactive of suffering, and to acknowledge that 70 to 90 percent of patients will express that they experience some pain or discomfort with the procedure.

Dr. Caudle: 
Those are really good points. I appreciate you sort of going through that and delineating those things. In your experience, what concerns do patients typically have about IUDs or the procedure itself?

Dr. Schreiber: 
Patients are often concerned about what they're going to experience and if they will experience pain. And there are risk factors for experiencing higher levels of pain among certain patients. For example, those who have never given birth are more likely to experience a higher level of pain. So we’re able to use that information with patients—if somebody has had prior births, specifically vaginal deliveries, we’re able to tell them, ‘That's actually great, and that helps reduce the amount of pain that most people experience in your situation if they're having an IUD placed.’ And among those who've not given birth, we then acknowledge that and talk with the patient about what interventions or solutions we have to improve their experience with IUD insertion.

Beyond that, patients definitely worry about how they'll feel during the procedure. But with any gynecologic procedure, patients bring their lives into the exam room, so it's really our job to implement trauma-informed care, to listen to the patients, to elicit what it is that may be their top concerns, and take that time before doing a procedure with the patient to understand exactly where they're coming from.

Dr. Caudle: 
Those are really great points. And the family physician in me really is happy to hear you discuss this, certainly. You've actually answered a little bit of the next question, but I'd like to ask it anyway and see if you have any additional thoughts. How do you work with patients to address those concerns and set realistic expectations before the procedure takes place? Anything you'd like to add?

Dr. Schreiber: 
So I think being honest is so important and acknowledging all the steps that are involved with IUD placement and letting them know what they might experience during those steps and that they're in control. So if, for example, at the time of speculum placement, the patient needs a little break before going on to the next step of the procedure, give the patient the opportunity to say, ‘You know I need a little break.’ Have that two-way communication throughout the process, and letting the patients know in advance that they will be in control. They can say stop. They can ask for a pause. Before each step, we’ll let them know exactly what's happening next. Because, of course, they can't necessarily see what we're doing when we're doing a gynecologic procedure like an IUD placement. So preparing patients before each touch and each sensation they feel, I think, is really important.

And then as I mentioned earlier, just make sure that we understand their history and what they're bringing to the table. If they have specific concerns or a history with problems or if they've heard X or Y from friends or family about this, listen and then provide offerings of what we might do to improve their experience above what it is that they're bringing to you that day.

Dr. Caudle: 
Those are excellent points. For those of you who are just tuning in, you're listening to Advances in Women's Health on ReachMD. I'm your host, Dr. Jennifer Caudle, and I'm speaking with Dr. Courtney Schreiber about how we can counsel patients on IUD pain and discomfort.

Now, during the procedure, Dr. Schreiber, are there any counseling strategies we can use to help reduce a patient's anxiety and optimize their comfort?

Dr. Schreiber: 
Letting them know what the mitigation strategies are for discomfort can be very helpful. So let patients know they may want to take an NSAID like ibuprofen, for example, before coming in for the IUD insertion; that can reduce the sensation of uterine cramping that is very common with an IUD insertion. So saying, ‘We expect that you will have feelings. You will feel the insertion procedure; here are ways that we can decrease any negative experience to you with the insertion procedure.’ So as I mentioned, ibuprofen before the insertion procedure and having that on board is great. Offer patients other analgesics, such as lidocaine, either topically or as an intracervical or paracervical block, specifically and especially for adolescents and those who've not birthed a baby in the past; those have been demonstrated in the data to both clinically and statistically significantly reduce pain with IUD insertion.

So having all of those techniques available and talking to the patient about what you can do for them in advance can help reduce the discomfort that they'll feel and also their anticipation of their discomfort.

I was a part of a study in which we actually looked at risk factors for pain during IUD insertion, and anticipated pain is a risk factor for actually perceived pain among patients who have an IUD inserted. Interestingly, we also found that there were racial differences in the level of anticipated pain that patients brought into the exam room. Individuals of Black race were more likely to have higher levels of anticipated pain, and as a result, also higher levels of their own perceived pain. Recognizing that as a clinician and just talking about that up front can really start a great conversation with patients that you see them, you hear them, you're there as their partner in their healthcare, and provide them with options for reducing that sense of anticipated pain and thereby in reducing their actual pain experience with the IUD insertion.

Dr. Caudle: 
And what about after the procedure? What should we discuss at that point to ensure patients still feel supported?

Dr. Schreiber: 
Yeah. I appreciate you asking that question because often, after we do procedures, we just move on to our next task of the day or our next patient. But the patients need some information about what they should expect when they go home. And I think that it's very helpful to alert patients that they may have cramping for the next few hours or even couple of days. I think it's pretty typical to have some cramps and discomfort for the 48 hours or so after IUD insertion. So preparing patients for that is very helpful and letting them know that they can take analgesics as needed to reduce that discomfort. They shouldn’t suffer unnecessarily. Acetaminophen, ibuprofen, and other analgesics can be very helpful, and we should prescribe those for our patients in advance so they have ready access to those analgesics to reduce any discomfort so they can get back to their regular lives.

Dr. Caudle: 
Well, you've certainly given this a lot of really great tips, Dr. Schreiber. But before we close, could you tell us about how these proactive communication strategies can really impact the overall patient experience?

Dr. Schreiber: 
As I previously mentioned, patients really bring their lives with them into the exam room. So having a trauma-informed approach to the pelvic exam and the procedure of IUD placement really does improve the patient experience. And what we hope for and look for as healthcare providers is that our patients will trust us, will come back to us, and that when they have concerns, they'll bring them to us so that we could provide them with evidence-based information and allow them to make informed decisions about next steps in their healthcare in a shared decision-making model.

So we are able to bring the data as well as our wealth and breadth of clinical experience into the room, but patients bring their wealth and breadth of their own experiences into the room. So we want to meet in the middle and find the right strategy forward for the patient. And so enhancing that sense of trust is not just helpful for the contraceptive procedure, but also helpful for building the relationship going forward.

Dr. Caudle: 
Well, given the impact that proactive counseling can have, I'd like to thank my guest, Dr. Courtney Schreiber, for joining me to share these best practices for having patient-centered conversations on IUD pain and discomfort. Dr. Schreiber, it was great having you on the program.

Dr. Schreiber:
Thank you so much for having me. Wonderful to be together.                                                                                        

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This episode of Advances in Women’s Health was sponsored by Bayer. To access this and other episodes in our series, visit Advances in Women’s Health on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!