The IUD, Breast exams & One Key Question

Health

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Reproductive health has been on all of our minds as we step into a new political climate where the word “pussy” appears on the CNN runner. Planned Parenthood’s resources are under siege, and the battle over a woman’s right to choose has been resurrected with new momentum. In an effort to arm us with the most up-to-date and approachable information on pressing reproductive health questions, women’s health nurse Lucille Towers answered questions from Nightingale peers.
“I have heard stories about significant pain associated with the IUD placement and removal. Is it a myth? What causes the pain? Are there things I can do to manage or prevent pain during this procedure?” -Austin, Chicago, IL
There is a spectrum of experiences with IUD insertion, from painful to hardly noticeable, with most people experiencing something in between. The sensation is often compared to strong menstrual cramps. The procedure is only a few minutes long, and discomfort is usually associated with three specific moments within that time: when the tenaculum (an instrument used to position and stabilize the uterus) is placed, when the sound (an instrument used to measure the inside of the uterus) is inserted, and when the IUD itself is inserted.

There are a lot of things you can do to make sure your IUD insertion as comfortable as possible

A number of things, both physical and emotional, can affect your IUD insertion experience, including the position and shape of your uterus, your natural pain sensitivity, the experience level of the provider, your relationship with your provider, a past history of sexual trauma, your level of comfort/anxiety regarding the procedure, the coping skills you bring with you into the experience, and the use of medications to reduce discomfort. Some of these factors may not be modifiable, but many are.
There are a lot of things you can do to make sure your IUD insertion as comfortable as possible. You will likely have an appointment with your provider before the IUD insertion to talk about what to expect. If you have never been pregnant, your provider might recommend scheduling your appointment during your menstrual period, when your cervix may naturally be more open, or might prescribe a medication to help soften and open your cervix. They also might not! People who have never been pregnant can absolutely get IUDs, and many don’t need to do anything extra for their cervix to be open enough. A lot of clinics have a third person, sometimes called an escort, in the room during IUD insertions so that the provider can focus on the procedure and someone else is available to focus on your comfort. If this isn’t a routine at your clinic, you can usually request it. You can take an over the counter pain medication before your appointment. Make sure to take it far enough ahead of time that the medication will be effective during the procedure, and don’t exceed the recommended dose.
There are also a lot of non-pharmacological things you can do to prepare ahead of time. Brush up on some relaxation skills, such as breathing techniques or visualizations. Pick some relaxing music to listen to in the waiting room, or even during your procedure. Talk with a calm and supportive friend. Maybe bring your calm and supportive friend with you, or have them pick you from your appointment. Plan something fun and relaxing to look forward to afterwards, like a movie night with your favorite dessert. Remember that you don’t have to do all of this, or even any of this, and your IUD insertion should still be fine.
The biggest takeaway I can leave you with is this: concern about pain during the insertion process should not be a barrier to getting an IUD. If you think the IUD might be a good method for you but you’re concerned about the insertion, talk with your provider about it. For patients more at risk of an uncomfortable insertion, such as people with anxiety, high pain sensitivity, or a history of sexual trauma, most providers are willing to prescribe anxiety or pain medication to help make sure that the insertion process is as comfortable as possible.
It seems like Gardasil lost popularity somewhere in the last five years. What is the latest stance on immunization that prevents HPV? What are obstacles to vaccination from a public health perspective? –Nazanin, Nashville, TN
Au contraire! HPV vaccination rates continue to increase across the country (Reagan-Steiner et al., 2015). Gardasil is a safe vaccine that protects against some of the most dangerous strains of HPV, which can cause genital warts and cancer in people of all genders. It has been adopted more slowly than other vaccines because of persistent myths about its safety and because of a (disproven) perception that because HPV is transmitted sexually, vaccinating against it could promote adolescent promiscuity. Despite these challenges, use of the vaccine continues to increase. There is even a new version of the vaccine, Gardasil 9, that protects against more than double the number of HPV strains than the original vaccine. And Gardasil is extremely effective: four years after the original vaccine was released, the prevalence of vaccine-targeted HPV strains among female adolescents had decreased by 56% (Markowitz et al., 2013).
Reagan-Steiner S, Yankey D, Jeyarajah J, et al. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2015. MMWR Morb Mortal Wkly Rep 2016;65:850–858. DOI: http://dx.doi.org/10.15585/mmwr.mm6533a4.
Markowitz, L. E., Hariri, S., Lin, C., Dunne, E. F., Steinau, M., McQuillan, G., & Unger, E. R. (2013). Reduction in human papillomavirus (HPV) prevalence among young women following HPV vaccine introduction in the United States, National Health and Nutrition Examination Surveys, 2003–2010. Journal of Infectious Diseases, jit192.
I have a history of breast cancer in my family. At the age of 25, I am too young to get a mammogram and I don’t have annual physicals. What can I do to be proactive? – Kate, Omaha, NE
Recommendations for a mammogram screening are written for healthy patients without an immediate family history. For patients with a personal history of cancer or an immediate family history of breast cancer, screening is individualized based on the clinical judgment of the provider and the patient preferences.

Mammograms can be less accurate for younger patients due to higher breast tissue density, so getting a baseline mammogram early can make it easier to identify changes later on.

For women with a known breast-cancer associated genetic mutation (BRCA is the most well known, but there are others and we’re discovering more all the time) or an immediate family history of cancer, screening typically begins at 5 years younger than the youngest breast cancer diagnosis in the family (Tirona, 2013). As a personal example, my mom had breast cancer at 25, so I got my first mammogram at 20. Mammograms can be less accurate for younger patients due to higher breast tissue density, so getting a baseline mammogram early can make it easier to identify changes later on.
Breast cancer prevention comes down to promoting your overall health and avoiding carcinogenic chemicals where you can. Early detection is key, so know your boobs! Be familiar with the normal texture and appearance of your breasts and see a healthcare provider about any changes.
Maria Tria Tirona. Edwards Comprehensive Cancer .Center, Huntington, West Virginia. American Family Physician. 2013 Feb 15;87(4):274-278.
I’ve seen flyers for something called “one key question” posted on hospital advertisements and in doctors offices. What is that and what is the purpose behind it? – Marc, Brooklyn, NY
“Would you like to become pregnant in the next year?” That’s the question this initiative wants healthcare providers to ask reproductive-age women (and others capable of becoming pregnant) in order to open conversations about either contraception or preconception care, so that more pregnancies are “wanted, planned, and as healthy as possible.” The push to encourage proactive conversations about family planning has been very well received in the healthcare community. I’d love to see the initiative go even further by creating a more gender-neutral approach. There is a tendency in our culture to place the responsibility for family planning on those who would carry a pregnancy, and in doing so we miss the opportunity to engage half of the people contributing to pregnancies. Family planning is for everyone!
Do you see a future in which there are more options for male birth control? Abbi, Portland, OR
Absolutely. There is a big demand for more options for men (and others with semen), and in particular for LARCs: long-acting reversible contraceptives, like IUDs. The Male Contraception Initiative (https://www.malecontraceptive.org/) is a great resource for new developments. Some of the most promising options are RISUG in India and Vasalgel in the US. Getting a new birth control method developed, tested, approved, and onto the market is an expensive process. Through this site you can get up to date progress reports, contribute to specific projects, and even find out about your eligibility for upcoming human trials.

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Lucille is a nurse-midwifery student at OHSU and currently working as a nurse in dementia and end-of-life care. She has a BS in organismal biology and has spent several years volunteering as a sexual assault support advocate, international health volunteer, and labor doula.

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