Dr David Gerber: Inserting an IUD with the Least Pain Possible
The new generation of IUDs offer many benefits. Gone are the days where one size fits all, where a woman must bear the pain during the insertion and then contend with side effects in the short and long term.
The new generation of IUDs offer many benefits. Gone are the days where one size fits all, where a woman must bear the pain during the insertion and then contend with side effects in the short and long term. Understandably, many women may worry about having an IUD inserted when reading online about other women’s experiences, especially regarding how painful it can be.
However, from over 20 years of experience, having inserted more than 2000 IUDs, Toronto-based gynaecologist Dr. David Gerber believes that there is a better way when inserting IUD’s to make the experience safer and with no pain or the least cramping or pain possible. In fact, IUD’s or intrauterine devices have become very popular during the past decade due to the amazing progesterone IUD’s now available, which often make heavier and painful periods a thing of the past. Moreover, there are also smaller and more flexible copper IUD’s that can be fitted into any size uterus without the trauma and pain of the past IUD’s. We can also be more creative by selecting the correct size and type of IUD for the right patient and her uterus. Indeed, IUDs have come a long way and are now viable, recommended options for many women.
There are 2 main groups of IUDs currently available:
• IUDs that contain the hormone progesterone, which make periods lighter, less painful and can sometimes even take your periods away while the IUD is inside
• Copper, non-hormonal IUD’s, which can sometimes make your periods heavier and sometimes more painful: everyone can have a different response
In consultation with his patient, Dr. David Gerber would select the best IUD based on the following questions:
• Are your periods light, normal or heavy? You can tell how heavy periods are by how often you change a pad, tampon or cervical cup based on how saturated they become. If you are losing a lot of period blood, then a Progesterone IUD may be the best option for you.
• Are your periods painful, from mild to severe? Painful periods can be gauged by if you need medication to manage the period pain or if you need to stay home due to the pain. Do you use Advil, Tylenol, or other pain relievers during your periods? A progesterone IUD is better if you have painful periods.
• What size uterus do you have? Is it big enough to fit one of the progesterone IUD’s which are wider than the smaller flexible copper IUD’s? More about this later.
• Do you have mood or depression concerns or acne? These conditions are sometimes aggravated with the Progesterone IUD, so that may not be the best option for you.
This is the way Dr. David Gerber inserts IUD’s (and he has inserted over 2000!):
Choose the right kind and size IUD. Not every uterus has the same shape or size. You cannot just insert any IUD and one size does NOT fit all. Here is a list of essential considerations:
1. Size, shape and position of the uterus:
Knowing beforehand what the inside size of the uterus (womb) is, is vitally important when choosing the correct IUD: That is where the IUD must fit, without damaging, pushing against or penetrating the surrounding muscle wall of the uterus (the myometrium). A common cause of pain during and after insertion occurs when the IUD is too large and the side arms push against or penetrate into the muscle wall.
We know that when the IUD side arms are open (deployed) in the uterus, in the shape of a T, a Kyleena Progesterone IUD is 28mm wide, and a Mirena Progesterone IUD in 30mm wide. Flexible Copper IUDs vary from 23 to 28mm but are flexible enough to fit into an even smaller sized uterus. Also, if the uterus is larger, a smaller IUD may drop down and put you at risk of an unintended pregnancy.
For these reasons, leading labiaplasty surgeon Dr. David Gerber always measures the uterus size while also checking for any abnormal shapes of the uterus before inserting an IUD. Is your uterus normal shaped? Do you have a heart shaped uterus or is the uterus formed with a wall down the middle? Do you have a rare-shaped uterus with 2 upper cavities for example. If there is an abnormal shaped uterus, then obviously an IUD may not be possible. If you don’t have a pre-insertion ultrasound, you will never know this, so they are an important part of the process.
Also, knowing exactly what shape, position, and size uterus you have makes the IUD insertion more precise and almost hazard free, with less pain because you know the position of the uterus (up or down or rotated) and you know what the correct direction is when putting in the IUD. An IUD can easily be pushed through the wall if you don’t know the correct position. Often, just doing an examination is not good enough to determine the position due to a number of factors. Fortunately, in 2022, we don’t need to guess; we can be careful and precise by using an ultrasound beforehand.
2. What are your periods like before the IUD?
Are your periods heavy, normal, or light? This is very important information. If you have heavy periods, there is a risk of iron deficiency from losing a lot of blood every time you have a period. By inserting a Copper IUD, this can become even worse. For this reason, I always find out exactly what your periods are like. If they are on the heavier side, I recommend an iron and hemoglobin test (to see if you are anemic from the monthly heavier blood loss, especially if you are vegetarian or vegan). If you have heavier periods as well as an iron deficiency, I recommend thinking about a Progesterone IUD, which makes your periods about 80% (or more) lighter.
If your uterus inside space is too narrow for a Progesterone IUD’s (more common in those women who have never been pregnant) or if you don’t want or can’t have a hormone IUD, then a smaller size Copper IUD together with a commonly used medication such as Tranexamic acid can be effective. The tranexamic acid will make the period lighter most often, with no hormones being used.
If you have painful periods, then a progesterone IUD is better if your uterus is big enough. A copper IUD can make the pain worse, but if you prefer to have no hormones, then a small frame Copper IUD with Advil and/or Tylenol like medication can still be a good option.
Limiting pain is one of Dr. David Gerber’s top priorities when inserting IUDs:
A quick read on social media tells a similar story: IUD insertion can be terribly painful. To alleviate this concern, I give medications that can help decrease if not alleviate pain. My nurses and I hear all too often about how painful the previous IUD insertion was when easy steps were not followed.
Dr. David Gerber recommends setting up the insertion carefully by following the best and most practical approach to avoid a painful experience. I have learned from inserting more than 2000 IUD’s that the best way is to maximize the use of pain medication and local anaesthetic beforehand. This is so obvious yet rarely practiced.
Dr. Gerber’s approach, which can be very effective, to the point that many patients say that they only felt mild cramping and almost no pain, is as follows.
1. Choose the correct IUD, taking into consideration information about your periods: are they light, heavy and/or painful. You choose which one you want after we discuss all the options with you using a diagram with information.
2. Know the size, position and shape of the uterus beforehand and choose the right IUD.
3. We always insert the IUD during a period: You call us on the first day of the period and we insert the IUD within a few days. This helps avoiding inserting an IUD when there may be an early pregnancy. Also, when you have a period, the cervix is often a little softer and open during, therefore making the insertion easier and safer.
4. We email information beforehand to remind you to take Advil and Tylenol like medication if you can, 1 hour before. This together with fluid such as Gatorade beforehand helps a lot. The fluid intake prevents you feeling faint after the procedure that can sometimes happen from nerve stimulation when inserting the IUD. (Drinking fluid beforehand helps prevent being dehydrated, which can make the fainting sensation worse.)
5. We give a local anaesthetic into the cervix in 4 places, to make the insertion much more comfortable and often without pain. The cervix is held still and slightly opened to allow the IUD to pass into the uterus. The IUD is then inserted in a very controlled methodical way, without the worry and stress of you being in extreme pain. If the IUD needs to be repositioned or replaced because it is not in the correct position, we can do it straight away, knowing that you already have the local anaesthetic in place. So much easier, safer and better tolerated!
6. We do an ultrasound there and then without you having to move, to see if the IUD is in fact in the correct position. It is not uncommon that I think the IUD went in well, only to see on ultrasound that it is not. A misplaced IUD can increase your risk of pain, a pregnancy or perhaps an ectopic or tubal pregnancy. In 2022, there should be no guessing or just hope, that the IUD has been inserted into the correct position. Ultrasound tells you immediately where it is and if it should be repositioned or replaced, which I do immediately. You can then go home feeling reassured and safe that the IUD is in the correct position.
7. We monitor you afterwards for about 30 minutes to make sure you are not feeling dizzy, lightheaded or in pain. We give you tea while you wait!
8. We see you 3 months later when we repeat the ultrasound to make sure that the IUD has not been expelled, dropped lower in the cavity or causing other problems or side effects.
Dr. David Gerber believes that when using the correct IUD, it is an excellent and reliable form of contraception and a great way to help make heavy and painful periods a thing of the past. The key is choosing the correct type and size IUD and to use adequate medication and local anesthesia to minimize the pain that many women talk about after having an IUD inserted. Using an US to determine the uterus size, shape and position is critical and repeating the ultrasound immediately after the IUD insertion to confirm that it is in the right place. Check again in a few months to make sure the IUD hasn’t moved down.