When you’re researching birth control options, an intrauterine device (IUD) sounds great: it’s more than 99 percent effective at preventing pregnancy, and once it’s placed, you don’t have to do anything for years. It can also treat heavy menstrual bleeding, even making periods go away completely for some.
But if you search for the term “IUD” on social media, you may become less excited about the option, as there are countless videos of women sharing their painful experiences with having one placed. A 2023 study found that 97 percent of the top videos on TikTok about IUDs highlighted pain, and 28 percent of videos mentioned distrust of healthcare providers.
“Providers should acknowledge IUD placement can be painful and provide a full scope of options,” says UNC Health OB-GYN Danielle Tsevat, MD. “We have options to reduce pain, but depending on where you go and who you see, the medications offered can vary significantly.”
Change is happening—both the American College of Obstetricians and Gynecologists (ACOG) and the Centers for Disease Control and Prevention have issued guidelines recommending that providers discuss pain management options with patients—but individual practices and medical centers may still be catching up.
We talked to Dr. Tsevat and UNC Health OB-GYN Kim Malloy, MD, about what you can expect and how to prepare.
How are IUDs placed? What can cause pain?
If you’ve had a pelvic exam as part of a well-woman visit, IUD placement begins the same way: You lie on your back, with your feet in stirrups. Your provider will determine the position of your uterus by inserting gloved fingers into your vagina and lightly pressing on your abdomen. Then, they’ll insert a speculum into the vagina, as they do when performing a Pap test, to hold the vaginal canal open.
Your provider will use a long cotton swab with antiseptic to clean the cervix and then insert a long, slender tool through the speculum to hold the cervix in place. Next, another slender tool is inserted to measure the length of your cervical canal and uterus, which helps your provider know where to place the IUD.
That tool is removed, and a tube containing the IUD is inserted. Once placed, your provider will cut the strings that extend from the IUD, through the cervix and into the vagina; those strings will be used when it’s time to remove the device. Everything else can then be removed.
The entire process doesn’t take long—typically less than 15 minutes—but that can feel like an eternity if you’re in pain.
“Placing the speculum alone can be uncomfortable and painful for some,” Dr. Tsevat says. “The most painful parts are measuring the uterus and placing the IUD, when instruments go through the cervix to the uterus, triggering severe cramps and pain.”
There may also be pain after the procedure.
“Once the IUD is inserted, it has to settle into the uterus, which can cause cramping for a week or two,” Dr. Malloy says. “The pain will be at its worse in the first 48 hours, but with nonsteroidal anti-inflammatory drugs (NSAIDs), it should lessen each day. If pain increases or get worse, we’d have concern about if it was in the proper position.”
A rare complication is IUD expulsion, when the IUD comes out of the uterus, either partially or completely.
Removal of an IUD is typically much less painful, Dr. Malloy says. Your provider inserts a speculum and uses a tool to gently pull on the strings of the IUD.
“Sometimes, the strings aren’t visible, and then removal can be a bit more painful, because you have to reach inside the cervix,” Dr. Malloy says.
Is IUD insertion always painful?
Pain is different for everyone. Two people could stub their toe the same way and have very different reactions. That’s true for IUD placement as well.
Dr. Tsevat, who studies gynecologic pain, says her research has yielded a variety of descriptions about what it feels like.
Some compared it to bad period cramps, while others said it was like being stabbed.
“For some patients, the pain is so severe, so fast, that they may have significant nausea,” Dr. Malloy adds.
While it’s extremely painful for some, others say they experienced only light cramping.
“I have a number of patients who say it’s not as bad as they thought it would be,” Dr. Malloy says.
It’s not easy to predict who will experience a more painful insertion, but Dr. Tsevat says there are some known risk factors that could increase the chances of pain: being younger than the age of 20, not having experienced a vaginal delivery, and a history of pelvic pain or an anxiety disorder. Just being anxious about the procedure itself can increase the sensation of pain.
How can I prepare for an IUD insertion?
If you’re interested in an IUD but worried about the potential for pain, stop scrolling TikTok and talk to your provider.
“There can be a misbalance on social media,” Dr. Tsevat says. “Most people won’t post about a positive experience, so it is self-selecting. But watching these is going to cause more anxiety, which increases the risk for pain.”
You may benefit from two visits, Dr. Malloy says: one to talk about the IUD placement process and your concerns and a second for the actual placement.
“It’s important to remember that you guide the process,” Dr. Tsevat adds. “There are other options for contraception, so you don’t have to do this. You can also tell your provider to stop the procedure at any point.”
If you’re anxious, your provider might consider prescribing a benzodiazepine to be taken before the procedure. You can also talk about what might help you during the placement, such as bringing a family member or friend or listening to music. By reducing anxiety, you potentially reduce your risk for pain.
What are options for pain relief during IUD insertion?
For now, a paracervical block—an injection of local anesthesia into the tissues of the cervix—is the most widely available pain management option for IUD insertion.
“The injection does have a pinch and a burn, but it helps with the pain during placement,” Dr. Malloy says. “We can offset that pinch and burn with vaginal lidocaine before the injection to numb the vaginal tissue.”
A paracervical block is administered after the speculum is placed, and you have to wait a few minutes for the anesthesia to take effect, so it does increase the amount of time you lie there with a speculum inserted.
Your provider can also apply topical lidocaine, in the form of a gel, cream or spray, to the vagina and cervix. This option doesn’t have as much evidence for reducing pain as the injection, but still works well for some, Dr. Tsevat says.
You may have been told that scheduling your IUD placement when you’re having your period can make it less painful, but there is little evidence that the timing of the placement affects the pain. Misoprostol, which is used to dilate the cervix before other gynecologic procedures, has not been shown to reduce pain of IUD placement either.
Depending on where you live, you might be able to have an IUD placed while you’re under sedation, but this option is not widely available.
While ibuprofen might not help as much with pain during insertion, it can help with the cramping afterward.
Even if you choose to not use any of these options, it’s still important to discuss them with your provider, and to find one that will validate the potential for pain.
“It’s important to counsel all patients, make sure their concerns are heard and explain the options we have,” Dr. Tsevat says. “Then, there needs to be work to expand those options.”
If you want to learn more about your options for contraception, talk to your doctor. If you need a doctor, find one near you.