Like many women of reproductive age, my friends and I frequently discuss contraception: what we’re using, what we’ve tried, what we’re curious about. Without a doubt, the most polarizing form of birth control among my cadre of confidantes is the intrauterine device, or IUD.

An IUD is a small T-shaped apparatus that, when inserted into the uterus, releases hormones or (in non-hormonal IUDs) copper to prevent sperm from fertilizing eggs. A favorite among gynecologists, IUDs are a long-lasting, low-maintenance form of contraception. Once placed, they last between three and 15 years.

Despite these upsides, one aspect of the IUD experience tends to garner negative attention: the insertion process. Is getting an IUD placed as painful as rumor would have it?

Answers vary — a lot. Anecdotally, a former roommate of mine said getting her IUD was memorably uncomfortable and that she bled continuously for weeks afterward. On the other hand, my current roommate only experienced three short cramps during the procedure and then went about her day. Research on IUD insertion is similarly inconsistent. In a 2011 study of 224 women who had never given birth, most participants rated IUD insertion as moderately painful (72 percent) or severely painful (17 percent). Only 9 percent reported feeling no pain. And a 2013 study found medical providers often underestimate how painful IUD insertion is for patients. A 2015 study, however, concluded that IUD insertion was less painful than patients anticipated. 

So why is getting an IUD harrowing for some patients, and no big deal for others? Can you do anything to reduce your chances of joining the “severely painful” group? With help from experts, we put together a primer on IUD insertion pain.

Consider your medical history

There are three different points during IUD insertion that might be painful, says Dr. Kristyn Brandi, an ob-gyn and assistant professor at Rutgers New Jersey Medical School. The first is when the doctor inserts the speculum, just like they would during a pap smear. The second point is when the doctor pushes the IUD through the cervix, the lower, narrow part of the uterus. Finally, you might feel pain at the moment the IUD reaches the top of the uterus (its final destination). This discomfort can feel like pinching inside the uterus, and may result in cramps that last anywhere from a few seconds to a few hours.

Thinking about your last pap smear can give you an indication of how you might tolerate IUD insertion. “Imagine a pap smear, but it [takes] maybe five to 10 minutes longer to place an IUD,” Brandi says. “If the pap smear experience is a really uncomfortable experience for people, and that happens for a lot of different reasons, then placing an IUD probably is not going to be a good experience.”

If you’ve never given birth vaginally, and haven’t had an abortion or any other procedure on your cervix, it can be particularly uncomfortable when the IUD is placed through the cervix, says Dr. Hana Reissner, the Complex Family Planning fellow at the American College Of Obstetricians and Gynecologists. “When you’ve had a vaginal delivery before, your cervix has opened,” she says. “While we don’t have the exact evidence for why discomfort may be different, when someone’s cervix has opened before, it’s likely easier to place the IUD.” Some good news if you already have an IUD: Replacing it may very well be a smooth experience, Brandi says.

For patients who haven’t had a vaginal birth, your doctor can potentially give you medication to help open your cervix a little, but it probably won’t help that much. “That medication is pretty crampy,” Brandi says. “It’s one of the medications we give to start labor. Even though it may help open the cervix, it’s still going to cause pain.”

While IUDs vary in size depending on the amount of hormone in the device (we’re talking millimeters here), Brandi says a larger IUD won’t hurt more to place.

Don’t psych yourself out

More often than not, fearing an uncomfortable IUD-insertion experience will result in, well, a more uncomfortable experience, Reissner says. A study from this year showed that people who anticipated more pain ended up having more pain, compared to those who expected insertion to hurt less. Black women tended to report higher levels of anticipated pain than women of other races, the study found.

Nervous jitters are normal before any medical procedure, which is why you should feel empowered to ask your ob-gyn any questions you have before they begin placing your IUD. “Developing a plan for what the communication style is like during placement might help ease some of those nerves,” Reissner says. Whether you prefer a step-by-step explanation of the procedure as it’s happening, or you’re more of a “just tell me when it’s over” type of patient, touching base with your doctor beforehand will help assuage your trepidations. 

If you have a diagnosed anxiety disorder, Brandi recommends taking any prescribed daily anti-anxiety medication before your appointment. For her own patients who are not prescribed anti-anxiety medications, Brandi sometimes prescribes a one-time dose if she thinks it would be helpful for the patient.

What you can do about potential pain

While IUD horror stories tend to monopolize the conversation, most patients get through insertion with minimal discomfort, Reissner says. But if you’re exceptionally worried about pain, ask your doctor if a paracervical block — a local anesthetic injected into your cervix — is a good numbing option for you, Brandi says. Although the injection itself can hurt, recent research shows that a paracervical block minimizes discomfort during IUD placement. For patients who have a history of sexual assault or conditions like vulvodynia (chronic pain in the vulva), doctors might administer general anesthesia ahead of IUD placement, Brandi says.

Another way to potentially minimize pain is to schedule your IUD insertion during your period, Brandi says. “What happens is your cervix opens a little bit to help pass [the] bleeding,” she says, “so sometimes that little bit of opening and the lubrication of the blood can make the IUD go in a lot easier.”

One of the best painkillers of all, a 2020 study shows, is talking. “I joke [that it’s] called vocal local,” Brandi says. Ask your doctor to chit-chat with you throughout the entire procedure to get your mind off the task at hand. But make sure to maintain bodily awareness, and to heed any signals your body sends you. Extreme pain can indicate that an IUD was displaced, meaning it could’ve embedded in the sides of your uterus, fallen into the cervix, or has perforated the uterine wall and is in your abdomen, Brandi explains. So keep an open dialogue with your ob-gyn and don’t be afraid to speak up.

In the end, if the thought of IUD insertion makes you skittish, you shouldn’t feel pressured to use one. IUDs have their advantages, and they’ve surged in popularity in recent years. But there are other safe, effective methods of birth control. (Shots, patches, rings — the list goes on.) Talk to your doctor about your concerns and your personal history. And, if you decide an IUD suits your needs, don’t let the horror stories scare you.

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