Many women are opting not to have their painful IUDs removed

No pain management, no removal: Ami Claxton’s birth control method — an intrauterine device — expired 14 years ago. But she has been too scared to have it removed because of the excruciating pain she experienced the last time she had it replaced. This summer, the 55-year-old asked her gynecologist for options to help manage the pain during removal, but was told there weren’t any. “So I said, ‘Forget it. I’m not going to get it out,’ ” said Claxton, of Chandler, Ariz.

The more information, the better women do: Some women say that their worries about pain have deterred them from getting IUDs removed or replaced when needed, and they have become reluctant to return to the gynecologist, even for different procedures. Most patients fare better when their health-care providers are transparent about the procedures, the possibility of pain and any available pain control options, said Nichole Tyson, a clinical professor and division chief of pediatric and adolescent gynecology at Stanford University.

It’s causing mistrust: At 16, Andrea did not expect her IUD placement to hurt and her clinician didn’t warn her, she said. But during the procedure, she was crying and squeezing the hand of the medical assistant. The experience has made her wary of other gynecological care, said Andrea, now 27, of Sacramento, whom The Washington Post is identifying only by first name for privacy. “I guess I have some mistrust there,” she said.

Taking an IUDs to the grave: Christine Romano was so excited to get an IUD in 2012 that she didn’t think about possible pain. It was so severe that she screamed. “It exceeded any kind of pain that I’ve ever experienced,” said Romano, 41, of Queens. The experience left her traumatized and unwilling to consider getting it removed. “This is going to die with me,” she said.

The removal process: During an IUD removal, the clinician inserts a speculum into the vagina and looks for the IUD strings, which are typically about two to three centimeters long. If the strings are visible, forceps are used to grasp the strings and remove the device. Unlike an IUD placement, which usually takes several minutes, the removal takes only a few seconds. The removal can be uncomfortable, but it’s not usually as painful because it doesn’t require manipulation of the cervix, said Eve Espey, chair of American College of Obstetricians and Gynecologists’ Contraceptive Equity Expert Work Group.

But…: But sometimes, the strings are not visible, or in rare cases, the device is embedded in the uterus. When this happens, the procedure requires additional steps, which can cause more pain for some people, Espey explained. Data on pain during removal are sparse. In studies, between 5 and 18 percent of IUD users had missing strings. Espey said embedded IUDs are even more uncommon.

The pain management disagreement: For routine IUD removals, most clinicians do not offer pain management. But for complicated removals or when patients request pain control, the options are the same as for IUD insertions. Aside from over-the-counter anti-inflammatory medications, numbing agents such as a lidocaine spray or gel, or a lidocaine injection in the cervix, called a paracervical block, are the most commonly used. Some physicians said anti-anxiety medications before the procedure such as Xanax or Valium can help. Sedation and general anesthesia are rarely considered because of the risks, as well as the need for special equipment and supervision by an anesthesiologist.

Removal discomfort is “quick and manageable: Espey, chair of the OB/GYN department at the University of New Mexico, said the discomfort of IUD removal typically is quick and manageable. She said clinicians should be trained to talk to patients about their preferences and concerns before the procedure. If complications arise or the patient asks to stop, clinicians should pause and be willing to abandon it or use pain control, she said. Patients who are anxious or who have had negative experiences with IUD procedures should discuss pain management options before the next procedure, said Aileen Gariepy, director of complex family planning at Weill Cornell Medicine. “People don’t have to have the procedure without any medication, but it does need a conversation.”

Limited risk to delay removal: Research shows that while hormonal IUDs lose effectiveness after their duration of intended use, some physicians said there is limited risk associated with leaving them in long term, assuming fertility is not a consideration. There are rare case reports of pelvic infection associated with IUDs, but many people keep in the devices without issue, physicians said. Depending on the brand, hormonal IUDs are approved for use for up to eight years, and copper IUDs up to 12 years.