This past week I had all kinds of IUD insertion experiences. It is amazing to me how the same procedure can cause vastly different amounts of pain and discomfort among women. Some women talk about their afternoon plans and chat pleasantly as if there’s nothing going on below the waist, and for some women the process is excruciating, traumatizing, and vomit-inducing.
Everyone is different, everyone has a different pain threshold, and as someone who had an IUD insertion that made me seriously take pause about being able to have children without some serious medication someday I have deep empathy for all my patients. But differences in pain threshold is not the only force at work here.
The fickle Vagus nerve, one of the twelve cranial nerves, innervates the crevixes of roughly 30% of women. I talk to patients about this unfortunate innervation as bad wiring.
As a student, IUD insertions were terrifying and mystefying. I watched preceptors confidently determine the position of the uterus, sound (measure) quickly and place those little devices with precision.
Now it is my job to be confident and sure, as well as train medical residents to place IUDs smoothly. But this does not take away the absolute terror I have of hurting someone, or worse yet, perforating (going through the uterus on insertion) someone’s uterus.
As a new provider I have handily adopted a “fake it till you make it” attitude regarding my confidence, so I invite you all, dear readers, to take a peek into my brain during an IUD insertion:
Alright, bimanual. Where’s her uterus? Is there more pressure hitting the front of back of my hands here? Front? I’m pretty sure front. Cervix is pretty posterior, so…..she’s anteveted. Yeah. Definitely anteverted. Ok, hands out, now speculum!
Alright. Great view of the cervix. Check in now, is she doing ok? Yes? Ok great. Numbing medicine on the cervix now. I know the research says any lidocaine or hurricane jelly does absolutely nothing to decrease discomfort, but hey, I think it makes both the IUD inserter and insertee feel better.
Alright, now the tenaculum. Oh god this thing is like a medieval torture device. (If you’ve never seen one of these things, Google it. I’ll wait. Terrifying, right?) Pull it quickly out of the line of sight. No one should still use these things.
“Ok, cramp one of three here!” Tighten down tenaculum, hope the woman doesn’t leap off the table or break the medical assistant’s hand. Make mental note to personally hunt down the inventor of the tenaculum. If men got IUDs there’s no way we would still use these things.
Alright. Sounding. Take plastic rod and insert into cervix until you hit resistance. “Alright, cramp two here, doing great! Deep breaths!” Cramp? Cramp? More like earth shattering pit of your stomach melting horrific radiating awfulness. But I could never talk people into getting such a great birth control method if I told them what it feels like. Or at least what it felt like for me. But, like childbirth, I don’t really remember the specifics.
“Is it in yet?” The woman sheepishly asks.
Almost! I make my baseball joke now. “We are rounding third base here, almost done almost done, you’re doing great!”
I feel her groan. I feel you, I think to myself. Now I get the IUD ready. Here we go. Alright. Don’t fuck it up. These things are really expensive.
“Last cramp here! We’re almost there” I start inserting the device, which is larger in diameter than the sounding rod. I hit resistance at the internal os (the inner opening to the uterus). I start to sweat. Everything feels hot. Ok. A little more pressure. I can put a little more pressure. Oh god why did I wear so many layers today?
I continue the pressure, my heart starts pounding in my ears, my medical assistant tells her to visualize windows and doors opening. I feel the os give and push through to the top of the uterus. It worked! I swear the internal os has a mind of its own.
I release the device “Ack!” Or more commonly, “Holy shit!” the woman exclaims. Well, that’s how we know it’s at the fundus! (When the IUD hits the top of the uterus, the fundus, it creates the most unpleasant sensation in the world).
And now, you’re the proud owner of a brand new Mirena! (Or paraguard, whichever device the lady has chosen).
I trim stings, alright, everything looks great. No one passed out. She’s feeling better. Phew. Another successful insertion!
This week I had a patient give me no fewer than three high fives after her IUD went in. Another, after a particularly tearful and painful insertion joked about making sure her mascara looked fine still.
So, many lessons here, my dear friends: even the most confident of your medical providers gets nervous sometimes, and, even though I’ve made IUD insertions sound like hell on a platter, the pain passes, you end up with a great story and more charachter and a bad ass contraceptive device.