The appointment before she got her first intrauterine device, or IUD, Ana Ni’s doctor asked about her pain tolerance. Low, she said; medium, if she’s being generous. The clinic had just begun offering nitrous oxide, or laughing gas, to patients to help manage pain during IUD placements and, given the alternative — to undergo the procedure sans anesthetics — she gladly accepted.

Before the insertion late last year, Ni, a 26-year-old health care consultant, took deep breaths of the nitrous oxide. She started to feel woozy. “Initially you just feel relaxed,” she says, “and then suddenly you get a bit of a head high, similar to when you would hit a vape. That kind of feeling, but intensify it more.” During the procedure, she continued to breathe the gas through cramping. Without the laughing gas, she suspects the pain would have been more acute.

“I know it’s a short procedure,” Ni says, “but I honestly cannot imagine it without the laughing gas.”

Ni’s experience is a far cry from some of the more graphic depictions of IUD placements on social media. Over the last few years, people have posted clips of themselves wincing and even crying on exam tables during IUD placements, shedding light on what was long-held to be a largely painless medical procedure. Research prior to 2016 found that patients described IUD placement as causing them “minimal discomfort” or “uncomfortable,” and rated it four on a pain scale of one to 10.

The reality is more complicated. Many patients felt they were lied to by their doctors whose only option for pain management was over-the-counter painkillers. Studies analyzing social media posts about IUD insertion found that almost all of them mentioned pain and discussed how this pain was minimized. Part warning, part public service announcement, these viral videos not only helped bring to light the real suffering patients were experiencing, but also shaped professional guidance regarding what pain management doctors should offer them.

Within the past year, the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists (ACOG) released updated recommendations for pain management during IUD placement. Both suggest clinicians offer local anesthetics like lidocaine spray, lidocaine-prilocaine cream, and paracervical block — an injection of anesthetic around the cervix. Other providers are going further, offering anti-anxiety medications or general anesthesia.

The most effective way to address pain is perhaps the most straightforward, and the most novel: talking to patients and hearing their concerns.

While the ACOG guidance found insufficient evidence to support nitrous oxide use, Ni remembers her doctor telling her how it helped other patients. She had a similarly positive review; she says she’ll request it again when she needs to replace her IUD. “Unless there’s some other medication then,” she says. “But I feel like the laughing gas will suffice.”

Over 6 million people in the United States currently use IUDs as contraception, and the evolving pain management standards around them show the medical establishment has moved to address women’s pain — and how much more work is left to be done. Aside from having a slate of pain management options on offer, the most effective way to address pain is perhaps the most straightforward, and the most novel: talking to patients and hearing their concerns. The shifting standards around IUD procedures point to the ways doctors are only beginning to see patients as experts of their own bodies, and to take women’s concerns seriously.

“This fits right into a movement that has really picked up steam, but I doubt is the norm across medical disciplines,” says Eve Espey, a professor and chair of the department of OB-GYN and family planning at the University of New Mexico. “But if you approach patient care in that way — in thinking about what a patient might experience with a painful outpatient procedure — [it] would dovetail very nicely into that much more patient-centered approach.”

A history of pain in gynecology

Intrauterine devices are a form of long-acting birth control that have grown in popularity over the last 30 years, especially among those between the ages of 25 and 34. There are two categories of IUDs: copper and hormonal, both of which prevent sperm from fertilizing eggs.

Part of the allure of IUDs is that, unlike the pill, which must be taken daily, an IUD is effective for anywhere from three to 10 years, depending on type. No upkeep, no prescription refills. Some users report less cramping and bleeding during periods and less endometrial pain; others stop getting their periods altogether.

“There’s also some literature that says if you tell people that something’s going to hurt, that it hurts more, which is true.”

Although the

© Vox