The appeal of the IUD is undeniable: When you can get pregnant and don’t want to, 10 baby-free years feels like a miracle, something you’d be willing to suffer for at least a little. But for a lot of patients, the pain that comes with an IUD insertion is way more than “a little.” And worse, the pain is often downplayed by providers—if it’s even addressed at all. When  Rep. Amy Walen (D-48) accompanied a young woman to an insertion appointment, she found this lack of pain control horrifying. So horrifying that she’s prefiled a bill for the upcoming 2025 legislative session addressing it. House Bill 1077 would require clinicians to discuss pain management with patients before IUD insertions.

Walen hopes her bill will raise awareness about the very real pain that can accompany this extremely routine procedure: IUDs are one of the most popular forms of long-acting birth control on the market. She wants to keep other people from experiencing the intense pain she witnessed in the patient she accompanied, whose pain was intense and unrelenting. “It was really, really upsetting how painful it was for her,” said Walen.

With state legislatures across the country understandably focused on abortion access since the reversal of Roe v. Wade, it’s unusual to see policies like Walen’s, which specifically focus on IUDs.

But maybe it shouldn’t be.

If you’ve ever gotten an IUD—or talked to a fellow drunk girl in a bathroom line for just a little too long—the pain that can accompany an insertion is not new information. When I surveyed IUD users—or would-be users—about their experiences most recently, I was immediately flooded with responses describing “mind-bending pain,” prolonged failed insertion attempts, repeated uses of the word “brutal,” and comparisons to things like “a small dragon … trying to claw out of my body for 24-36 hours.” These were concerning, but they were also deeply familiar.

Stories like these are the subject of casual conversations over brunch or a beer. One friend of mine described pain that lingered for days after her insertion. Another, who fainted during her appointment, attempted to put a positive spin on things: “One shining silver lining was my nurse was a hot dyke and caught me when I fell off the table and I woke up in her arms,” she said. Removal was memorably bad, too, for a former colleague of mine. “When having it extracted, my doctor (and an intern) couldn’t get it out,” she said. “He spent 30 or 45 minutes yanking on it from various angles as I tried not to scream.”

My editor knows a woman whose first IUD insertion was so painful that years later, when she returned to get it replaced, she had a full-blown panic attack. Her body was so tense that they weren't able to safely complete the procedure.

Even women who’ve given birth describe the pain of IUD insertion on particularly gnarly terms. Elinor Jones, better known as the celebrity gossip columnist at our sister paper the Mercury, described an insertion attempt that had to be stopped because it was so painful it was “like knives.” Annie Jurrens, who’s been through two unmedicated births, described her IUD insertion as one of “acute pain, like being stabbed in an internal organ.”

Given the grim state of reproductive health care in America, stories like these—where things really devolved, but no one died or was permanently injured—might seem like minor inconveniences, hot nurse or not. And juxtaposed with the horrors visited upon people who had first-generation IUDs like the infamous Dalkon Shield, perhaps they are. A claw-like device with a sci-fi name, the Dalkon Shield’s design led so many users to develop pelvic inflammatory disease that it became the subject of one of the largest tort liability cases in history.

It’s an unqualified good thing that the Dalkon Shield is off the market, but its existence seems to have set the bar in hell for future IUD experiences. You wouldn’t know this from the next-gen IUDs’ branding, ensconced in the soft focus of marketplace feminism, with imaginary girls’ names that sound like they’re written in cursive on a wooden sign inside HomeGoods: Skyla, Mirena, Kyleena. (The eminently practical ParaGard is the only exception to this: As the oldest and only non-hormonal option in the gang, the copper T is like the used Subaru hatchback of IUDs, and I mean that as the highest praise.)

Despite this rosy marketing—and the very real pain they felt—the IUD users I spoke to said they received little or no advance warning that their procedures might be painful. Some were told just to take ibuprofen beforehand, others weren’t even given that advice. One was told scheduling the insertion during her period would make it easier, “but it just resulted in the whole fiasco being an absolute bloodbath,” she said.

There’s a reason for this bizarro dissonance between brutal patient experiences and provider attitudes toward pain management and support: Research suggests that patients and providers perceive the pain of IUD insertion differently. A 2015 study published in The European Journal of Contraception & Reproductive Health Care found that while most IUD insertions “appeared acceptable to most patients,” providers “tended to underestimate the degree of pain experienced by their patients during IUD insertion procedures.”

That could be changing. Earlier this year, the Centers for Disease Control and Prevention updated its guidelines for clinicians inserting IUDs to encourage conversations about pain management with patients before the speculum comes out. The CDC now recommends the use of topical or injected lidocaine, which numbs the cervix. Misoprostol, also used in medication abortions, may be helpful for some patients, but it’s not suggested for typical use.

It’s not clear what role, if any, legislative policies like Walen’s will have in advancing these updated clinical guidelines, beyond drawing attention to them. Sarah Prager, an abortion provider in Seattle, was skeptical of the approach. “There already exists a lot of guidance around offering/providing pain management for IUD insertions (including newer advice from the CDC within the Medical Eligibility Criteria (MEC) for Contraception Use (published updates this year),” she said. “I 100% agree expanded options for pain management should be offered/available, but I disagree that legislation is the appropriate vehicle for achieving this.”

But one thing is always worth remembering: A good doctor (the kind you deserve) will realize you’re in pain, and do something about it. “I was ready to power through,” said Jones. “I am grateful for my (female) doctor being like ‘You are in too much pain and I don’t recommend continuing.’” But if you’re at the doctor’s office and something is painful, you’re allowed to speak up.