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TaghinejadiN, etal. BMJ Sex Reprod Health 2024;0:1–7. doi:10.1136/bmjsrh-2023-202011
Pain experiences during intrauterine
device procedures: a thematic
analysis oftweets
Neda Taghinejadi ,1,2 Helene- Mari van der Westhuizen,1
Francis Ifeanyi Ayomoh,1 Wasim Ahmed ,3 Trisha Greenhalgh,1
Anne- Marie Boylan1
1University of Oxford Nuffield
Department of Primary Care
Health Sciences, Oxford, UK
2Oxfordshire Sexual Health
Service, Oxford University
Hospitals NHS Foundation Trust,
Oxford, UK
3Newcastle University Business
School, Newcastle upon Tyne, UK
Correspondence to
Dr Neda Taghinejadi, University
of Oxford Nuffield Department
of Primary Care Health Sciences,
Oxford OX3 7LF, UK; neda.
taghinejadi@ conted. ox. ac. uk
Received 14 September 2023
Accepted 16 April 2024
To cite: TaghinejadiN, van der
WesthuizenH- M, AyomohFI,
etal. BMJ Sex Reprod Health
Published Online First: [please
include Day Month Year].
doi:10.1136/
bmjsrh-2023-202011
Original research
© Author(s) (or their
employer(s)) 2024. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
ABSTRACT
Introduction In June 2021, high- prole
testimonials in the media about pain during
intrauterine device (IUD) procedures in the UK
prompted signicant discussion across platforms
including Twitter (subsequently renamed X). We
examined a sample of Twitter postings (tweets)
to gain insight into public perspectives and
experiences.
Methods We harvested tweets posted or
retweeted on 21–22 June 2021 which contained
the search terms coil, intrauterine system,
IUD or intrauterine. We analysed the dataset
thematically and selected illustrative tweets with
the authors’ consent for publication.
Results Following deduplication and screening,
we included 1431 tweets in our analysis. We
identied testimonials with descriptions of
varied pain experiences. Twitter users reported
that clinicians had not warned them that pain
could be severe or explained the options for pain
relief. Some raised concerns about pain being
minimised or dismissed and linked this to the
management of women’s pain in medicine more
broadly. Twitter users described connecting to
an online community with shared experiences
as validating and used this as a springboard for
collective action.
Conclusions While we acknowledge the
limitations of our sample, this study highlights
important perspectives and accounts relating
to pain during IUD procedures. Our ndings
attest to the need for strategies to improve the
patient experience for those opting for IUD as a
clinical priority. Further research should explore
IUD users' experiences, expectations and wishes
around pain management.
INTRODUCTION
The intrauterine device (IUD) is an
umbrella term for a range of copper and
hormonal devices which act as effective,
long- acting, reversible contraception.1 All
types of IUDs, which have an estimated
159 million users worldwide,2 require
insertion by a provider. Pain is a recog-
nised risk of IUD insertion, with users’
experiences of pain varying from minimal
to high.3 4 Improving experiences of pain
during IUD procedures has been iden-
tified as a national healthcare priority
in England, as laid out in the Women’s
Health Strategy.5
A series of events in 2021 prompted
public discourse about the management
of pain during IUD procedures in the UK.
Activist Lucy Cohen created a petition to
health ministers in England, Scotland and
Wales advocating for changes in practices
around counselling about pain and anal-
gesia provision during IUD procedures,
which was circulated in a newsletter by
WHAT IS ALREADY KNOWN ON THIS
TOPIC
⇒There are gaps in the research literature
on patient experiences and expectations
of pain management during intrauterine
device (IUD) procedures.
WHAT THIS STUDY ADDS
⇒Our analysis highlights important
perspectives and accounts relating to
IUD procedures, including concerns
about missing information about pain
and analgesia options, and dismissal of
pain.
HOW THIS STUDY MIGHT AFFECT
RESEARCH, PRACTICE OR POLICY
⇒These findings should inform quality
improvement strategies and highlight
the need for more research exploring
patients’ lived experiences.
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Original research
Figure 1 Flowchart of data screening.
author Caroline Criado Perez and has since had over
35 000 signatories.6 7 Following this petition, public
figures within media and broadcasting in the UK
including Caitlin Moran and Naga Munchetty shared
personal accounts via news outlets and radio of their
experiences of severe pain during IUD procedures.8 9
There was a substantial response to these events on
multiple online platforms including Twitter (subse-
quently renamed X), with many IUD users sharing
their own experiences of insertion and/or removal.10
In this study, we set out to examine Twitter posts
(tweets) shared online at the time of this public conver-
sation about pain during IUD procedures. This study
is situated within a growing body of research high-
lighting the possible benefits of analysing social media
data about contraception, including the potential to
explore healthcare experiences and inform quality
improvement.11–13 Recognising and addressing indi-
viduals’ reports of negative healthcare experiences or
care which did not meet expected standards also offers
the opportunity to critically examine current practices
and to support public trust in the healthcare commu-
nity.12 14 Our analysis is driven by the overall aim of
sharing, considering and learning from accounts shared
by Twitter users with an open and reflexive approach,
in the interest of improving patient care for those who
opt to use IUDs.
METHODS
We collected publicly available tweets shared following
high- profile testimonials discussing pain during IUD
procedures. We identified appropriate search terms by
hand- screening 50 relevant tweets to identify common
words and phrases used by Twitter users. This process
resulted in the following search terms: coil, intrauterine
sytem (IUS), IUD and intrauterine. We used NodeXL
to harvest all tweets containing any one of these search
terms from Twitter’s application programming inter-
face (API). We limited our search to tweets shared on
21–22 July 2021. This period was chosen to capture
the peak of discussion immediately following Naga
Munchetty’s discussion of this subject on BBC Radio
5, which has a weekly listenership of over 5 million.15
We downloaded data into Microsoft Excel for dedupli-
cation and screening. One author (NT) hand- screened
this dataset to remove tweets which did not contain
any reference to IUDs.
Four members of the research team used reflexive
thematic analysis to analyse the resulting dataset of
tweets.16 Each read the entire dataset and independently
coded 50 tweets to construct an initial draft codebook,
which was discussed and agreed by the whole team.
Each researcher then used this codebook iteratively to
code a quarter of the overall dataset using qualitative
analysis software (QSR NVivo). We used regular group
discussions to reflect on our individual responses to
the data, refine the codebook (e.g., incorporating new
codes) and develop themes and subthemes.
We illustrated thematic findings with selected quota-
tions, for which we obtained informed consent. This
aligns with best practice for social media research since
users may be identifiable from their data, and quoting
tweets in research may draw attention to users beyond
what they would normally expect from their use of
Twitter.17 To request consent to quote, we contacted
users from a designated Twitter account created
for this study via direct message, or a tweet in cases
where direct messaging was not enabled; we sent a
maximum of one further reminder where there was no
response. Prior research has taken the same conserva-
tive approach to the reporting of Twitter data.18
RESULTS
Our initial search resulted in 8093 tweets; we excluded
5056 duplicate tweets (retweets) and 1606 tweets
which contained no reference to IUDs. This resulted in
1431 unique tweets from 1276 unique accounts which
we analysed (figure 1).
Table 1 summarises the themes and subthemes devel-
oped through analysis of our sample of tweets with
illustrative quotes.
Pain testimonials
In response to high- profile testimonials about pain
during IUD procedures, Twitter users shared their own
experiences or those of their peers, providing descrip-
tions of varied levels of pain:
“I consider myself to have a really high pain threshold,
I’ve sat for hours and hours of tattoos and broken
countless bones but I can still safely say my IUD
being inserted was the most painful and traumatic
experience of my life”
“I actually really love my coil and didn't experience
that much pain when it was put in. But I've heard so
many horrible stories from friends who were in agony
that it is clearly an issue that is not being adequately
dealt with”
Many tweets described IUD procedures as mildly
painful or uncomfortable. However, in our sample,
such experiences were outweighed by accounts of pain
described as severe or the worst pain.
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Original research
Table 1 Themes, subthemes and additional illustrative quotes
Themes Subthemes
Pain testimonials Varied pain experiences
“Reading the discourse today around IUD insertion pain really shows how differently women react to the procedure.”
Negative impact of painful IUD procedures on mental and physical well- being
“… I had a very traumatic time having a coil fitted, meant to prevent painful periods. Both a trainee & GP ”had a go”. I
was in excruciating pain & my body went into shock with low heart rate. My husband was called to collect me. I was told i
was ”unusual” ”
Feeling at fault following painful experiences
“…I was told it was my fault I fainted from the pain - and I believed that for quite a long time too…”
Missing or misleading
information about pain
Insufficient information about pain
”I received more information about the coil fitting from friends than my doctors! I was not prepared for the pain it caused,
my doctors hadn’t told me to take painkillers before hand and like so many others was told to expect “slight discomfort”.“
Insufficient information about pain relief options
“…My GP said that IUD fittings 'don't hurt'. She only offered a local anaesthetic (for this 'painless' thing!) once I'd
refused due to pain…”
Loss of trust in providers
“Does the RCOG not know what its own members are doing to women? IUD fitting is painful. Doctors lie about it, do not
discuss pain relief options and carry on despite women being in pain. Is this genuinely the first they've heard of this? ”
Dismissal of pain Minimisation or dismissal of pain
“The IUD pain gaslighting ”
Lived experiences not recorded or valued
“Not convinced 'experts' have spoken to women or clinicians. I'm on my 3rd coil. Insertion, removal & really painful each
time despite taking pain relief. BTW [by the way] being forced to hold the nurse’s hand for comfort doesn't help”
Sexism in medicine
“…I vomited when I had a coil fitted and I had had a child by that point. No one cared as it was a woman’s problem! If
men had coils fitted or took contraception pills they would be better than those on offer to women!”
“It’s both empowering and heartbreaking to see more women speaking about their IUD experiences. It’s 2021 and we
must start taking gynaecological pain seriously - that we don't is such an insidious chapter of the patriarchy”
Validation through collective
experiences
Sharing testimonials as validating
“Just got to wait for a second opinion with gynae. Still can’t believe the clinic said that having an IUD fitted causes ‘only
ever mild discomfort’. Hearing that I’m not the only woman who experienced excruciating pain is so validating.”
[In response to a testimonial] “…It’s made me realise there was no need for me to be so embarrassed as I sobbed while
the GP removed my coil…”
Peer advice as a helpful resource
“This brings back horrible memories about my first IUD fitting - the most painful thing I've experienced followed by 6
months of painful, heavy periods. I only found out you could get anaesthesia via forums - asking for that (plus great new
doctor) made a HUGE difference…”
Calls to action
“The coil may be ‘worth it’ for many people, but why is it normalised for (often very young) women to go through this
level of pain with no anaesthetic or sedation? So happy to finally see this topic in the nationals.”
GP, general practitioner; IUD, intrauterine device; RCOG, Royal College of Obstetricians & Gynaecologists.
Accounts of the negative impact of painful IUD
procedures on mental and physical well- being were
shared, with some Twitter users reporting that they
subsequently avoided gynaecological procedures or
examinations, including removal and reinsertion of
IUDs and cervical screening. Others shared accounts
of enduring negative consequences following painful
IUD procedures, including a sense of trauma:
“My failed coil insertion was without a doubt the
most physically painful thing I’ve ever experienced,
I felt so shocked and the feeling of violation lingered
for ages. I didn’t expect that sort of pain for such a
‘routine’ procedure.”
Evident in some accounts was a sense of feeling to
blame for experiencing pain during an IUD proce-
dure. Linked to this, examples shared of communi-
cation from providers when debriefing with patients
following a painful IUD procedure reveal how certain
language may lead to patients feeling at fault for expe-
riencing pain, or other adverse outcomes:
“…The aftermath has been relatively ok, but thanks
to my “reluctant uterus” the fitting was bloody awful
I've had 3 kids, I was told this would help and I'd
probably get it fitted OK, I was not ok!!”
Tweets in our sample contained descriptions of
the benefits of IUDs and expressions of support for
its use including in cases where insertion experiences
had been negative, distinguishing the device from the
procedure:
“Both my coil fittings were deeply unpleasant to
the point of screaming pain, and while having
contraception w/o hormones was one of the best
things I've ever done for my body and MH [mental
health] and I'd go through the hideousness again
NOBODY SHOULD *HAVE TO*. They should offer
pain relief ”
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Missing or misleading information about pain
Twitter users shared accounts of receiving incom-
plete information about pain from providers. Some
commented that the risk of pain was minimised, or that
the full spectrum of possible pain experiences was not
adequately reflected in the counselling they received
pre- procedure, leading to a mismatch between the level
of pain they expected and their actual experiences:
“…The coil is the best contraceptive that’s worked
for me but I was completely unprepared for the pain
when it was fitted, I was in tears during the procedure
and got no forewarning other than “make sure you
eat and maybe take a painkiller” from my doctor.”
Some commented on a disparity in the quality of
information they received from providers versus
through their social networks. In addition, we identi-
fied descriptions of Twitter users receiving misleading
information about their risk of pain based on their
history. Advice from providers that a patient would
experience little or no pain on account of their parity
was one such example:
“Me, getting my first IUD inserted 7 months after
giving birth. Medic: “Oh, you’ve had a baby, so you’ll
be fine getting this without anaesthetic’” Reader, I
was not fine.”
Twitter users also reported that they had not been
given any information about pain relief prior to inser-
tion. There was evidence that omission of informa-
tion about pain or pain management eroded trust in
providers and in professional practice:
“My new doctor is pushing me pretty hard to get an
IUD and my biggest concern is that she said it was
quick and easy and they do them in office and didn't
mention pain at all. Feels like a trap”
Dismissal of pain
Tweets included reports of pain being ignored or not
taken seriously by providers during IUD procedures.
The term gaslighting was used to describe the minimi-
sation or dismissal of pain by the healthcare profession.
Some expressed that their experiences, or the experi-
ences of others who had undergone IUD procedures,
were not recorded. Linked to this were concerns that
the lived experiences of IUD users were not valued as
evidence by the medical community or used to inform
clinical practice:
[Responding to a news article] ““For most women,
it’s a little bit uncomfortable. It’s a bit like period
pain.” Working hypothesis nobody has actually asked
'most women'. I've had 2 babies. Coil fitting is 'take
the rest of the day off' horrible, 'a little bit' is not the
phrase.”
Comparisons were drawn with the management of
men’s pain during medical procedures, with Twitter
users expressing the view that men’s pain and women’s
pain were not acknowledged or treated equally.
Contraception use was framed as a gendered issue,
with some sharing the perspective that things would be
different if men were to use same methods as women:
“…Men get more pain relief for having a catheter
inserted than women do for getting a coil fitted. Treat
womens health and womens pain equally to mens
”
IUD procedures were related to other gynaecolog-
ical procedures including cervical screening, hysteros-
copies and surgeries involving mesh. Some commented
that the management of pain for IUD procedures was
part of a broader legacy of sexism and misogyny within
gynaecology:
“There’s a genuine streak of misogyny in gynaecology
and I'm glad to see it finally being exposed with
not only mesh but IUD fitting, hysteroscopy,
endometriosis, Essure, etc.”
Validation through collective experience
For some, their experiences of pain and how that pain
was managed during IUD procedures were linked to
feelings of embarrassment, shame and disempower-
ment:
“I have no words for how angry and powerless
these experiences left me feeling. As someone with
endometriosis I know I have many more procedures
ahead…”
By contrast, the activity of sharing, relating and
compassionately responding to one another’s testi-
monials created a sense of collective experience and
community:
“I can relate to this, IUD fitting is the most painful
procedure I’ve ever had done – even compared to
my recent spinal surgery – women deserve properly
controlled pain relief #IUD”
Connecting to this community was a way for some
to have their pain legitimised and to make sense of
their experiences – a process which was described as
validating:
“I finally feel validated with my own horror story of
an IUD fitting. As the pain ramped up past 10 and I
was screaming the house down I was told scar tissue
was to blame. Surely someone should have noticed
that before the point of no return?…”
This community was a way to access information
and guidance from those with lived experience. Peers
shared requests for information, offered advice and
encouraged self- advocacy during IUD procedures:
“Also, any ladies reading this who are now crapping
themselves at the thought of getting an IUD inserted
– it’s still worth it. You might feel okay. You can
always ask them to stop, or use a smaller speculum
(ignore those who say you can't; I do). Just don't put
up with any shite.”
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This community was also viewed as a springboard
for collective action, with the power to generate new
evidence, challenge societal norms around the manage-
ment of pain during gynaecological procedures and
advocate for improvements in clinical practice:
“I would also encourage women who had bad
reactions to the IUD itself to report it via the Yellow
Card Scheme as their doctor probably won't. You can
report any drug or device…”
“Well. I didn't expect to become the spokesperson
for uteruses this year, but it'll be a title I'm proud to
hold… Speak up. Sign the petition…”
While the tweets in our sample overwhelmingly
contained messages that supported those who shared
testimonials, we also identified tweets containing
misogynistic and racist content.
DISCUSSION
Our study findings highlight important experiences and
expectations around how providers counsel patients
about pain and analgesia prior to IUD insertion.
Twitter users shared reports that they were not coun-
selled about the full spectrum of possible pain experi-
ences prior to IUD procedures or about available pain
relief options. While it is not possible to predict any
individual’s experience of pain,19 some users shared
accounts of their risk of pain being minimised on
account of characteristics such as parity, resulting in a
mismatch between their expectations and experiences.
These accounts align with other qualitative research
demonstrating that some users of long- acting revers-
ible contraception (LARC) report receiving incom-
plete information about associated risks, and that this
limits their ability to make an informed choice.14 Our
findings support guidance from the Faculty of Sexual
& Reproductive Health (FSRH) that all potential IUD
users should be advised that insertion pain can range
from none to severe, and that analgesia should be
discussed and offered.19 Further research is needed to
evaluate counselling practices and uptake of this guid-
ance in current clinical practice.
A second key finding relates to role of lived expe-
rience in this public discourse about pain during IUD
procedures. While Twitter users expressed a sense of
validation and community through sharing and relating
to one another’s testimonials, they raised concerns
that lived experience of IUD procedures is not valued
as evidence or used to inform clinical guidelines and
practice. Prior qualitative research has explored patient
experiences of LARC removal requests,14 20 21 LARC
self- removal22 23 and IUD insertion for postpartum
patients specifically.24 However, there is a dearth of
qualitative medical research exploring patient’s expe-
riences of the fitting procedure once they choose
this method, or of the removal procedure in medical
settings.
IUDs are a safe and effective method of reversible
contraception, with high levels of satisfaction reported
among users.25 26 Echoing this, tweets in our sample
described the benefits of IUDs and shared support
for its use. However, our study also reveals accounts
of substantial negative consequences in cases where
patients reported pain that they were not adequately
prepared for, or that was not appropriately acknowl-
edged or responded to. These included avoidance of
future gynaecological examinations and procedures, a
sense of disempowerment, embarrassment, and erosion
of trust in professional practice. These accounts attest
to the need for strategies to evaluate and improve the
patient experience for those opting to use IUDs as a
clinical priority.
Strengths and limitations
The major limitation of this study is sampling bias,
since IUD users who experienced substantial pain may
have been more inclined to share tweets in response
to pain testimonials. Hence this study cannot inform
questions about the incidence of pain in IUD proce-
dures (nor did we set out to answer that question). The
nature of the sample was such that we did not know the
geographic origins or any demographic data of Twitter
users whose posts we analysed. There is evidence that
demographic characteristics including race may influ-
ence how providers counsel patients about IUDs27 and
how clinicians assess and manage pain in general,28
and there is a need to explore this in future research.
A limitation of using Twitter data to gain in- depth
insights is that tweets are short by nature and may lack
important additional context. Unlike with interview
studies, for example, it is not possible to make further
enquiries to gain additional information which may
be relevant to interpretation of the data. Our search
was limited to tweets shared across a 2- day period; we
therefore may have missed other important narratives
that are relevant to this public discourse.
A strength of this study is that multiple coders (NT,
FIA, A- MB, H- MvdW) collaboratively performed the
analysis, each with different backgrounds in terms of
discipline and experience. NT is a community sexual
and reproductive health doctor; A- MB is a qualita-
tive health services researcher; H- MvdW is a medical
doctor and social science researcher, and FIA is a public
health doctor. Some members of the research team
have varied personal and professional experiences of
IUDs as users and as providers. Given that in reflexive
thematic analysis, researchers are active in the research
process and interpret data through their individual
lenses, we consider this multidisciplinary approach to
be a strength of the study. Although all coders read the
entire dataset of tweets for familiarity with the data,
tweets were not formally ‘double- coded’ (though such
an approach is not universally recommended in quali-
tative research).29 30
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Original research
CONCLUSIONS
In this study we set out to understand the nature of
public conversation on Twitter about pain and ‘the
coil’ following media coverage of high- profile testimo-
nials. Notwithstanding the limitations of our sample,
we address a gap in medical qualitative research and
report important findings about public perspectives
and experiences of pain during IUD procedures. Our
findings support the need for strategies to improve
the patient experience as highlighted in the recent
Women’s Health Strategy for England.5 Central to the
accounts and perspectives shared on Twitter is the need
for patients to be well- informed about the full range
of possible pain experiences and available analgesia
options, and for pain to be appropriately acknowl-
edged and responded to. We call for more research
which places the experiences, expectations and wishes
of those with lived experience of IUD procedures at
its centre.
X Neda Taghinejadi @drnedatnejadi
Acknowledgements The authors thank the Patient and Public
Involvement (PPI) group including Lucy Cohen and Rebecca
Carey, and all the Twitter users who contributed to this study.
They are grateful to Julia Shefras, Sharon Dixon and Ruth
Holman for comments on earlier drafts.
Contributors NT conceived and designed the study, performed
data screening, led thematic analysis and drafted the
manuscript. WA performed the data collection and contributed
to the manuscript. H- MvdW and FIA contributed to the study
design, thematic analysis and manuscript. TG contributed to
the study design and manuscript and provided supervision.
A- MB contributed to the study design, thematic analysis and
provided supervision. All authors have read and approved the
final manuscript. NT is the guarantor.
Funding The authors have not declared a specific grant for this
research from any funding agency in the public, commercial or
not- for- profit sectors.
Competing interests None declared.
Patient and public involvement We formed a patient and public
involvement (PPI) group including people with lived experience
of IUD procedures, some of whom have shared testimonials
on social media platforms. This group reviewed and gave their
input on the study methodology and recruitment materials.
The details of this publication have been shared with Twitter
users contacted via the study Twitter account; this account is
now private to protect the privacy of users contacted.
Patient consent for publication Consent obtained directly from
patient(s).
Ethics approval This study involves human participants and
the authors obtained ethical approval for this study from the
University of Oxford Medical Sciences Interdivisional Research
Ethics Committee (Ref: R77414/RE001). Participants gave
informed consent to participate in the study before taking part.
Provenance and peer review Not commissioned; externally
peer reviewed.
Data availability statement Data are not available.
Author note NT is a National Institute for Health Research
Academic Clinical Fellow (NIHR ACF) in Community Sexual
and Reproductive Health and is supported by the Oxford
University Clinical Academic Graduate School (OUCAGS),
University of Oxford. A- MB is funded through the Evidence
Based Health Care teaching programme, University of
Oxford.
Open access This is an open access article distributed in
accordance with the Creative Commons Attribution Non
Commercial (CC BY- NC 4.0) license, which permits others
to distribute, remix, adapt, build upon this work non-
commercially, and license their derivative works on different
terms, provided the original work is properly cited, appropriate
credit is given, any changes made indicated, and the use is non-
commercial. See: http://creativecommons.org/licenses/by-nc/4.
0/.
ORCID iDs
Neda Taghinejadi http://orcid.org/0000-0003-2646-0390
Wasim Ahmed http://orcid.org/0000-0001-8923-1865
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