The IUD: A History

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Speaker 1: Welcome to Stuff You Missed in History Class, a production of iHeartRadio. Hello, and welcome to the podcast. I'm Tracy V. Wilson and I'm Holly Fry. This is one of a number of episodes that I've done on the show that was inspired by Internet behavior that I've been witnessing today. It is a history of the inter uterine device. Intrauterine device is how it's technically pronounced, but I always is going to come out of my mouth interuterine sort of slurred together. Probably we will be getting into the Internet behavior inspiration at the end of the episode. IUDs are under the umbrella of long, long acting reversible contraceptives. They are the oldest one of those that is in use today and an estimated one hundred and sixty million people around the world use them, but their popularity really varies from place to place. Some of that is connected directly to its history. This whole episode of our podcast is about inserting devices into the uterus to prevent pregnancy. I'm a person who feels pretty comfortable with my body. I have watched my share of gory medical dramas on TV. Sometimes Patrick will walk in the room and he will watch sort of the you know, the talking scene of doctors happening, and then there will be blood on screen and he goes. Nobody leaves. I keep watching. But some of the history that we are gonna talk about is like right on the edge of body horror to me, even with all that context. Huh. Also, this is not medical advice. We are not gonna be talking in any kind of great detail about like the benefits and risks of IUDs from today's understand It is about history, not like current medical thought on them. There are a couple of probably apocryphal stories about the beginnings of IUDs that show up pretty regularly in articles about their history. One is it hundreds or thousands of years ago, nomadic peoples would put stones into the uteruses of camels so they would not become pregnant during long journeys through the desert. The origins of this factoid are pretty unclear, but it only seems to show up in writing about IUDs. But that's generally writing that comes from North America or Europe. Yeah, I guess it's not completely impossible. It doesn't seem like something that's documented outside of this. Yeah. Uh, this conversation. Also, you can say it uteruses or uteri. Either way is fine, It's all good. There are also vague references to Hippocrates having written some thing about IUDs. The Hippocratic Corpus dates back more than two thousand years. It encompasses roughly sixty different Greek medical texts. Those were written over the course of about two centuries. I don't want to judge anybody too harshly for shorthanding all of that to just Hippocrates. I'm sure we have done that at some point. But in these IUD discussions, nobody really cites a specific source for whatever it is that Hippocrates supposedly specifically said. Classicists and medical historians Rebecca Philis and Helen King traced the probable origin of this to a passage in book two of the Hippocratic text, known as Diseases of Women that describes a method for opening the cervix. It does not describe placing anything in the uterus, and this also was not something that was described is being done to prevent pregnancy. So something else has been sort of misstated as being Hippocrates talking about IUDs. So the most likely precursor to the IUD is not Hippocrates or Stones in the uteruses of camels, it's the pesseai, which is one of the oldest medical devices still in use today. A pessai is used in the vagina to support the uterus. Today's pessies are typically made from soft, flexible materials like silicone or silicone coated rubber, and they come in a variety of shapes depending on exactly what they're intended to do. Historically, before we had those materials, pessaries were made with a range of other materials. In the sixteenth century, past podcast subject Moise Pier used hammered brass and waxed cork, as well as gold and silver. Other materials included sponges and wax. There's apparently a disc of using half a pomegranate as a pessary in book two of Diseases of Women. I was not able to directly confirm that, though it's not impossible that that's in there. That seems so problematic. That seems large to me unless it was a very small pomegranate. I'm also just thinking that like pomegranates have a lot of crevicey surface area, Yeah, where like bacteria could move in questions I have, yeah, many listen we don't know today, and historically pessaries have primarily been used to treat a pelvic organ prolapse. Depending on their shape, pessories can also treat some kinds of incontinence, or they can be used as part of the preparation for a pelvic surgery. Since a pestery can sit at the top of the vagina, next to the cervix, they've also been used as contraceptives, either alone or in conjunction with some kind of spermicide. So today most people call these kinds of devices diaphragms or cervical caps, but some of the earliest ones were billed as ecclusive pessories. While pessaries are used in the vagina, in the late nineteenth century, there were also intracervical pessaries. They's had a flattened out part like a disc or a button that was attached to a rounded stem. That stem went into the cervical canal and the disc rested against the outer surface of the cervix. And then there were intrauterine pessaries, which had a disc connected to a longer stem that went all the way through the cervical canal into the uterine cavity. In the simplest intrauterine pessaries, the stem was about five centimeters it's about two inches long, and it was wider at the far end to keep it from slipping back out through the cervix. More complex intrauterine pessees had a loop that rested inside the uterus or a pair of legs, kind of picture a wishbone. These parts would be squeezed together and encased in a gelatine capsule for insertion, and then that capsule would dissolve in the uterus so those legs could expand out. We've been assuming that everyone in the audience right now has a basic understanding of the anatomy of the female reproductive system. But we're gonna pause for a second here because I realized while working on this that my mental image of the cervix does not line up with reality, and that made the size of these intracervical and intrauterine pessories really confusing, because I thought that the cervix was sort of like a dense muscular valve, maybe a centimeter or too thick, and that meant that the stems on these pessaries seemed like they were way too long. The cervix, though, is really more like a tunnel. It is closer to three centimeters or a little over an inch long, although that changes significantly during portions of pregnancy. I mentioned by confusion on this to some, and they were also confused. Basically, the only person in the group chat who had a correct understanding of the cervix was the midwife. So it sort of seems like it might be a common enough misconception to clear up here, since it would not otherwise really make sense in the context of these pessories. I blame vague illustrations that don't really differentiate between the cervix and the lower part of the uterus like other pessories. In the nineteenth and early twentieth centuries, intracervical and intrauterine pessories were primarily used to support the uterus. They were also used to treat conditions ineffectively, for things that they just would not have had any kind of impact on, like irregular menstruation and conditions that have no foundation in medicine, like our good old favorite hysteria. And since they blocked the cervix and in the case of interuterine models, occupied the uteruss, people used them to try to prevent pregnancy or in some cases, to try to terminate pregnancies. Gynecologist, surgeon and pathologist Mary Halton, who was the only woman doctor in this whole episode, was regarded as the foremost expert on these devices for contraception in the US in the early twentieth century. She said she had used them on more than seven hundred patients in her practice in New York. So whatever these were being used for, in most cases not very effectively. They apparently weren't that great at preventing pregnancy either. In my opinion, these sound terrible. Most of them were made from gold, silver, aluminum, or hard rubber, and then they sat in the cervical canal or went all the way through it. So, having experienced like the temporary sensation of an IUD insertion and the discomfort of many years worth of PAP tests, I just can't imagine that having a piece of metal going all the way into or through my cervix would be comfortable at all, especially since the stems on some of these things were not smooth. They were shaped like springs or coils. Also, a lot of these were meant to be used for a month or two at a time, and then removed and cleaned and reinserted. Halton talked about having to let the cavity heal before it could be reinserted. The intracervical model that we described here was placed by a doctor at the end of someone's menstrul period, and then the patient was supposed to remove it just before the start of the next one. But the intrauterine models had to be inserted and removed by a doctor, So there was just like a lot of very uncomfortable seeming doctor visits involved with this. James Frier Cooper's nineteen twenty eight technique of Contraception The Principles and Practice of Anti Conceptional Methods, describes the disadvantages of intracervical pessaries as including infections, irritation, being extremely difficult to adjust except by a doctor, and quote it does not entirely occlude the cervical canal so that pregnancy may take place, so also ineffective. He describes the intrauterine pessory as unreliable as a contraceptive and says that reports from both London and New York associate them with infections and even deaths. So quote from a health viewpoint, this type of pessory is therefore undesirable. Even so, these pessories were in use as contraceptives until around the nineteen thirties. At this point, these concerns about infections were well founded. Antibiotics had not been invented yet. If one of these pessaries was inserted in a non sterile way, or if pathogens traveled along it from the vagina to the uterus, or if it caused injury to one of these organs, any infection that developed could be life threatening. But this association with infections would continue after the development of true IUDs, and it was initially because of their connection to these pessaries. We will get to the first actual IUDs without a part that stayed outside the cervix after a sponsor break. The first published description of an IUD was by physician Richard Richter in an article in the German Medical Weekly magazine in nineteen oh nine. Its title translated to a means of preventing conception. Richter described using two threads of silkworm gut tied in a simple loop like a very loose overhand knot. The free ends of the silkworm gut were encased in celluloid so that they would not damage the lining of the uterus. A bronze wire was connected to the bottom of this loop that held the two threads together, and it also made the device visible on an X ray and facilitated its eventual removal. This loop was inserted into the uterus using a hollow probe, and the end of the wire was snipped off close to the outer surface of the cervix. Richter said he had been testing this for several years and that the silkworm threads irritated the mucous membranes of the uterus enough to keep an egg from implanting, but not so much that the patient could feel it. He said the longest that one of his patients had kept one in place was four years, and that after the device was removed, his patients were able to conceive and had uncomplicated pregnancies. He didn't give any specific details about how many patients he had treated this way or data on how effective this method was. In nineteen twenty three, Carl Post published an article in the same journal with a title that translated to a use protection for women. He said that he had treated more than four hundred patients with a similar device that also had some of the traits of an intrauterine pessari. Poost described it as a pessari in the paper. In addition to a loop of silkworm gut that sat inside the uterus, this device had a tail made of silk that extended out through the cervix. The tail was attached to a button made of borisilicate yana glass, which is heat and shock resistant. This button rested against the surface of the cervix. Pooste claimed that there had been no serious complications in any of those four hundred plus patients, and that more than twenty thousand of these devices were in use around the same time. Also in Germany, gynecologist Ernst Grafenberg started experimenting with intri uterine contraceptive devices in his private medical practice. Like Richter and Poost, his first attempts a loop of silkworm suture, although he doesn't seem to have been aware of their earlier work. His loops were prone to being expelled from the uterus, so he tried wrapping the suture in silver wire, creating a flexible ring. Pure silver was absorbed by the patient's bodies, causing them to develop argeria or a blue tinge around their gums. He switched to an alloy of copper, nickel, and zinc that's known as German silver. The copper probably provided at least some of the contraceptive effect of this ring, although that connection wasn't discovered until much later. Grafenberg gave a presentation on his intrauterine ring at a course presented by birth control advocate Margaret Sanger in nineteen twenty eight, and then at the nineteen twenty nine International Sexual Reform Congress in London, and then at the nineteen thirty one German Congress of Gynecology in Frankfurt. He published his work on this device in nineteen thirty one, as well, reporting a failure rate of only one point six percent, but other gynecologists denounced the Grafenberg ring as unsafe. Grafenberg was using sterile procedures when inserting these rings, and they didn't have a portion that extended through the cervix, but they were still associated with the infection risks of intracervical and intra uterine pessaries. Grafenberg's work was happening alongside a movement for birth control and sexual reform in Germany. This was during the period that's known as the Weimar Republic. We've talked about it a few times lately. It was a time of both political turmoil and social and artistic freedom. This was also when Magnus Hirschfeld was operating the Institute for Sexual Science in Berlin, which conducted research and training on sex, sexuality, and gender and developed a massive library on those subjects. Many of Hirschfeld's patients would be described as gay, lesbian, bisexual, or transgender today, although most of those terms were not in use or they were not used quite the same way at the time. Our episode on Hirschfeld and the Institute ran as a Saturday Classic in April of twenty twenty three. The Weimar era ended with the rise of Nazi Germany. In nineteen thirty three, Nazis raided the Institute of Sexual Science and burned its entire library of an estimated twenty thousand books. Hirschfeld was both gay and Jewish, although he had not been observant since his childhood, and Nazi propagandists used him as an example of degeneracy. Ernst Grafenberg was also Jewish, and he was fired from his position at a hospital in Berlin for that reason in nineteen thirty three. He remained in Berlin though, until he was arrested in nineteen thirty seven. He was eventually released with the help of Margaret Sanger, and he fled to the United States in late nineteen forty If you have been wondering, this is the same Grafenberg that the g spot is named for that was based on a publication of his from nineteen forty four. Gravenberg continued to work as a gynecologist in the US, although because of perceptions of iud's as dangerous, he shifted his contraceptive focus to diaphragms and cervical caps. A somewhat similar trajectory took place in Japan starting in the nineteen twenties. Birth control advocate Margaret Sanger made her first of several visits to Japan in nineteen twenty two. Contraception was both illegal and culturally taboo in Japan, and initially the Japanese government barred Sanger from visiting. When it did happen, that visit was tightly controlled and Sanger was banned from discussing contraception, but afterward Japanese women started their own birth control movement. One of its key figures was Shizuei Kato, who had met Sanger in the United States in nineteen twenty and who had acted as her guide during that nineteen twenty two visit. In nineteen thirty three, Japanese gynecologist tenrai Ota introduced an iud he called the Preshia ring. This was an English Japanese neologism meaning pressure. He had experimented with a range of contraceptive techniques starting in the late nineteen twenties. His first attempts at an intrauterine device were gold balls. Having heard a similar story to the one about the stones and the camels, he had heard that cows would not become pregnant if a gold ball was placed in their uterus, but he found that these gold balls did not stay in the human uterus well. When he learned about the Grafenberg ring. He combined these two ideas and to what looked kind of like a stylized wheel with an outer rim made of suture wrapped in wire and three spokes connecting the rim to a gold ball in the center. He tried to market this as a contraceptive, which also became known as the Ota ring. And had some initial success, but not long after he developed the device, the Japanese government started reimposing restrictions on contraceptives. We have talked about connections between the eugenics movement and the birth control movement on the show. Before eugenicists, including Margaret Sanger, thought contraceptives could keep the so called wrong people from reproducing for the betterment of the human race. Japan's eugenics movement had a slightly different nuance. The easy access to contraception might mean the purportedly right people would not reproduce enough. There were also concerns about ID specifically, including worries about negative health effects and claims that they terminated pregnancies rather than preventing them. Japan defined the IUD as a harmful contraceptive in nineteen thirty six and banned contraception outright. After allying with Fascist Italy and Nazi Germany, Outa had to take on a new name and go into hiding. He returned to his work and opened a birth control clinic after the end of World War Two, at which point the Japanese government started to promote contraceptives due to fears of overpopulation. Iud's were not licensed in Japan until the nineteen seventies, though although there were individual doctors who worked with IUDs at this point, the medical community as a whole did not trust them. They were still associated with, and sometimes confused with, the intr uterine pessaries that we talked about earlier. Only one paper on IUDs was published in Western medical literature between nineteen thirty four, after the fall of the Weimar Republic and nineteen fifty nine, after developments in plastics led to innovations in the field. That nineteen forty eight paper was by Mary Halton, Robert L. Dickinson, and Christopher Titza. It described the use of a gelatine capsule to insert a device made of sterilized silkworm gut into the uterus. According to the paper, only one point one percent of patients using this device became pregnant. Later on, Titsa described the paper's content as so subversive at the time that he would not have put his name on it without Dickinson's encouragement. Dickinson had written numerous books and served as president or director of a whole collection of medical societies, so he had some safety to his credentials that TITSA, maybe didn't. Yeah, there were some new developments in the world of IUDs in the post World War two years, and we will get to those after a sponsor break. In nineteen fifty nine, two papers helped lift some of the stigma around IUD. Doctor Villi Oppenheimer, who worked at a hospital in Israel, published an article in the American Journal of Obstetrics and Gynecology saying that he had used variants of the Grafenberg ring in three hundred and twenty nine patients, changing those rings out every nine to twelve months for a total of eight hundred sixty six rings. He said one of his patients had used rings for twenty years and another for twenty seven. He had seen no pelvic inflammation of any kind among any of his patients, and no cancer or endometriosis. The devices had also been very effective, with a failure rate of one point three percent for silver rings versus two point four percent in the original silkworm design. The other paper was by Atsumi Ishihama in the Yokohama Medical Bulletin. He reported his observations of nine hundred seventy three patients that he had personally seen and more than eighteen thousand other patients across almost one hundred and fifty hospitals in Japan. His results were similar to Oppenheimer's. Only one point four percent of his own patients became pregnant and about two point three percent of patients across the other hospitals, and there had been no pattern of serious side effects. These two papers did not flip some kind of light switch going from Iud's being condemned to being accepted, but they did spark some researcher's interest, and they made it a little easier for people to publish new research without it just immediately being dismissed. In nineteen fifty nine, doctor Lazar Marghulis, a Polish immigrant to the United States, started experimenting with loops of silkworm gut inserted using a gelatine capsule, similar to what had been described in that paper that Mary Halton had co authored. But he was disappointed and how often this was expelled from the uterus and how painfu full the insertion was for his patients. So he developed a spiral made from polyethylene tubing, filled with a solution that would make it visible on an X ray and sealed this spiral could be straightened out and inserted through a narrow tube and it would return to its spiral shape in the uterus, so what needed to be inserted was a lot smaller. In nineteen sixty two, gynecologist Jack Lippies of New York developed a polyethylene IUD shaped like a double s, larger at the top than at the bottom, and this was similarly straightened out for insertion. This shape approximately filled the uterine cavity, which reduced the likelihood that the uterus would expel it. It also had nylon strings that exited through the cervix, which could be felt to make sure that the IUD was still in place, and they could also be used to remove it. The first International Conference on Intrauterine Contraceptive Devices, sponsored by the Population Council, was held from April thirty first to May first of nineteen sixty two. As that name suggests, at the time, the Population Council was focused on the purported dangers of over population in the wake of the post World War two baby boom. The book Population Bomb would be published later on in the decade. This was one of the driving forces behind research into iud's At the time, there were multiple papers about the Grafenberg ring, the Marguley spiral, and the Lippy sloop presented at this conference. Participants included doctors from Japan, China, England, Israel, Pakistan, Egypt, Mexico, India, Chile, and the United States, including Puerto Rico, including several of the IUD developers that we have mentioned. In nineteen sixty nine, doctor Howard Tatum, who had a medical degree as well as other multiple degrees related to medicine like chemistry, tried to develop a smaller IUD with the hope of resolving issues with pain and cramping after the device was inserted. The general idea was that an IUD had to occupy the uterus to prevent pregnancy and to reduce the likelihood of it being expelled, but an IUD that was too big could cause ongoing discomfort or even injury to the uterus. Tatum thought that a t shaped IUD with arms that could be folded flat for insertion and then spring back out inside the uterus might be more comfortable. Tatum's first designs did seem to be more comfortable, but they were also less effective than other IUDs. Then he met physician and scientist Jamie Zipper while on a sabbatical in Chile in nineteen sixty eight. Zipper had discovered that a copper wire had a contraceptive effect when placed in the uterus of rabbits. Tatum and Zipper developed the Copper T two hundred, a T shaped plastic device with copper wound around the central stem. This was the first copper IUD. In nineteen seventy, doctor Antonio Scomegna, who was born in Italy and first came to the US as a Fulbright scholar in nineteen fifty four, developed progest Assert, which was a T shaped IUD with a capsule that released progesterone. One of the unwanted side effects of IUDs was increased menstrual bleeding, and he thought the progesterone would reduce that bleeding. This was the first hormone releasing IUD, although its popularity was limited by the fact that it was only approved to be used for a year at a time. So we're not going to mention all of the specific IUDs that were developed at this point because they fall into those two broad categories copper or hormonal. At least in the US, some hormonal IUDs are FDA approved to treat heavy menstrual bleeding. By the nineteen sixties, IUDs becoming more widely accepted, although there were still some questions about safety, especially about whether IUDs carried an increased risk of infections or pelvic inflammatory disease. In the United States, IUDs really surged in popularity after the Senate held hearings on the safety of oral contraceptives in nineteen seventy. We covered the Nelson Pill hearings on the Show on May fifth, twenty twenty one. The first oral contraceptive had been approved in nineteen sixty and those early pills had much much higher levels of hormones than they do today. There were reports of blood clots and other potential health concerns, and reporting around these hearings led to increased fears of birth control pills among the general public. One of the speakers at the Nelson Pill hearings was Obguin Hugh Davis, who developed an IUD called the Dalkon Shield with engineer Irwin Lerner. The Dalkon Shield had been introduced in nineteen sixty eight, and by nineteen seventy more than six hundred thousand had been sold in the US. The ah Robins Company bought the design from Davis and Lerner in nineteen seventy one, and by nineteen seventy four more than two point two million of them had been sold. The Dalkon shield was made of flexible plastic with a membrane across the middle, so if you're looking at a picture, it looks almost like a solid thing. It was flexible, though it had five downward pointing prongs along the edge, meant to reduce the likelihood of it being expelled by the uterus. Looked a little bit like a horseshoe crab. By this point, it was common for IUDs to have some kind of strings that exited through the cervix, both for a person to be able to confirm that it was still in place and to eventually allow it to be removed. Because the Dalkon shield was designed to be more difficult to lodge, it needed a stronger string. That stronger string was made up of multiple filaments within a sheath. There were reports of health problems associated with the Dalkon shield. It came preloaded in a sterile inserter that extended past the top edge of the IUD, and there were reports of this protruding bit perforating the uterus during insertion. There were also reports of infections and pelvic inflammatory disease, which were blamed on the unsealed multifilament strings. The Dalkon shield was blamed for at least eighteen deaths, and more than three hundred thousand lawsuits were filed against ah Robins. The company pulled the Dalkon Shield off the market in the US in nineteen seventy four and suspended sales worldwide in nineteen seventy five. Ah Robins ultimately filed for bankruptcy in nineteen eighty four. There was a widespread ad campaign encouraging anyone who still had a Dalcon shield to have it removed, and then there was a nineteen eighty nine legal settlement that created a two point five billion dollar trust to pay off claims against the company. Multiple case control and cohort studies suggested that Dalkon shield users had a much higher rate of pelvic inflammatory disease than other ied users, but clinical trials weren't quite as definitive. Researchers also found that the Dalkon shield had a higher failure rate than what the manufacturer had claimed, and those pregnancies had a higher risk of complications. All of this had an immense impact on the acceptance of IUDs in the United States. Multiple other IUDs were pulled off the market in the face of the Dalkon shield's bad publicity. In nineteen seventy six, Congress passed the Medical Device Amendments, which gave the FDA authority to regulate medical devices and established three risk categories those devices. IUDs were placed in Class three, which was the highest risk category. In nineteen seventy about ten percent of women in the US who were using contraception were using an IUD. I have some questions about exactly how that number was derived. That's just how it was described in the paper that I was reading. In the year two thousand, that number had plummeted. It was less than one percent. But in other parts of the world not affected by the Dalkon shield, IDs became a popular form of contraception. By nineteen eighty five, an estimated sixty million people around the world were using IUDs, and forty million of them, or about two thirds, were in China. That brings us to one of the contradictions around IUDs. If you live in a place where you have autonomy over your own body and your fertility, and access to a doctor and money or health insurance or universal health care, and you want to get an IUD, you probably can, and that might feel liberating, a long lasting contraceptive method that you don't have to think about and a partner doesn't even have to know about. But if you live somewhere where that is not true, or if you are in an abusive or a controlling relationship, an IUD is something that can be imposed on you or refused to you. While it's at least theoretically possible for a person to remove their own IUD, most arts do not recommend doing that, and not everyone is actually even able to. China is one of the most populous countries in the world, which is part of the explanation for these numbers of how many IUD users are in China, but it's also because of the Chinese government's One Child policy, which was announced in nineteen seventy nine. Under this policy, couples who had more than one child faced fines and other penalties. After having a child, Chinese women were expected to get an IUD or to be permanently sterilized, unless their husband got a asectomy. China changed that to a two child policy in twenty sixteen, and in twenty twenty one that number was increased to three children. This kind of coercion can happen on both a societal and an individual level. Another recent example is the Britney Spears conservatorship case. In twenty twenty one, she gave a statement to a probate judge in which she said she had an IUD that her team would not allow her to have removed. As for the Internet behavior that inspired this episode, it is the way that pain during IUD insertion has been reduced almost to a meme that pain is absolutely real. A twenty twenty three study in the European Journal of Contraception and Reproductive health Care assessed more than a thousand patients and reported the two point five percent of them had no pain with IUD insertion, but forty nine point seven percent, or almost half, had intense pain. The highest pain scores were among people who had never given birth or whose children had been born via cesarean section. But this reality of pain has gotten kind of condensed into a weird shorthand, like they don't even do pain management for IUD insertion. What do you expect? And this is thrown around in conversations about someone's actual painful IUD experience, or about endometriosis or PAP tests or uterine fibroids or menstrual cramps, all kinds of other things that can also be painful. And then the comments also fill up with people saying that they are afraid to get an IUD, or to get their existing IUD replaced, or maybe to go to the doctor at all because of this. So here is a PSA to say, at least in the United States, doctors who are not discussing pain management with their patients beyond recommending over the counter pain relievers for an IUD insertion are not following the current guidelines. In twenty sixteen, the US Centers for Disease Control published an updated version of its Selected Practice Recommendations for contraceptive use. That update included this statement quote paraservical block with lytakane might reduce patient pain during IUD insertion. The World Health Organization's most recent Selected Practice Recommendations for Contraceptive Use, published in twenty twenty five, say that paraservical blocks can be routinely offered for IUD placement, as can topical anesthetics like lytacane gels, sprays, and creams. That's in addition to recommendations for over the counter pain relievers. The most recent US recommendations are adapted from these and they have the same basic language. The current World Health Organization recommendations also say this quote. Before IUD placement, all patients should be counseled on potential pain during placement, as well as the risks, benefits, and alternatives of different options for pain management. A person centered plan for id placement and pain management should be made based on patient preference. Barriers to IUD use include patient concerns about anticipated pain with placement and provider concerns about ease of placement, especially among noliparis patients that means somebody that hasn't had a baby. When considering patient pain, it is important to recognize that the experience of pain is individualized and might be influenced by previous experiences, including trauma and mental health conditions such as depression or anxiety. Although these recommendations for provision of medications for IUD placement are based on the best available evidence, not all populations or patient excit experiences are represented in the literature. Additionally, the American College of Obstetricians and Gynecologists issued a new clinical consensus for pain relief in twenty twenty five, which covers IUD insertion and a range of other procedures involving the cervix and uterus. They include anesthetic sprays, creams, and paraservical blocks. Various medical bodies have also recommended anti anxiety medications or sedation if patients are anxious about the procedure or have other factors that might necessitate that. The shorthand of like they don't even do pain management for IUD insertion absolutely grew out of medical sexism and decades of reports about pain not being taken seriously enough, not just with ID insertions. Some of the slow evolution of these guidelines is because of a lack of clear evidence about what actually helps, But in my opinion, it took way way, way too long to get guidelines that very clearly reference pain relief. While I was researching this episode, I found papers on the use of topical lydokane and paraservical blocks to make IUD insertion more comfortable. Going back to the nineteen eighties, forty something years ago. The frustration around this is all incredibly valid, but I do personally wish that we had landed on an expression for that frustration that was empowering instead of scaring one another. And I will also talk about my own personal experience with IUD insertion in our Friday Behind the Scenes. Do you have listener mail in the meantime, I do. I have listener mail from Hannah, and Hannah wrote hey y'all, which is honestly one of my favorite ways to open an email. I hollered with joy when I saw you release an episode about Francisco Menendez and Fort Mose. I was so excited I almost started writing this email before actually listening to the episode. I'm a lifelong Florida resident who visited Fort Mose a few years ago after hearing about it on Florida Frontiers, the podcast of the Florida Historical Society. The museum has a small footprint, but it's one of the most well designed and accessible exhibits I've ever seen. I remember how incredible Francisco's story was just from the brief overview given by an informational plaque. I highly recommend any Saint Augustine visitors to stop by, especially since it's only a ten minute drive from the Castillo. On a completely unrelated note, this email gives me a chance to share a stuffy miess in history class Easter egg of sorts. In February of twenty twenty three, I got a free tote bag at a local festival. The artist included a small eighteen seventy four Kitty Knox button on the subject's backpack. This was only a month after you released Kitty's episode. This little edition adds so many layers to the scene depicting a black woman using public transit while watching a rocket launch over the mangroves of the Inner coastal. I like to think she's an astronaut continuing Kitty's legacy on her way to Cape Canaveral in lieu of pet tax, I'm adding photos that represent the wildlife residence of Fort Mosee. May have encountered a wrinkly baby manatee, two river otters, and the only bird endemic to Florida, the endangered Florida scrub jay. Scrub days are highly specialized, intelligent birds with big personalities. Hence why one landed on my head during an annual population survey. There's so much more to my home state than theme parks, wacky headlines, and beaches. I encourage anyone who visits to explore our natural and cultural heritage beyond the tourist hotspots. If y'all ever want outing recommendations around the Orlando area, let me know. Thank you so much for the work you do. It is truly an invaluable public service and has enriched my life for well over a decade. I wish you both nothing but peace, good food, and laughter. Warmest regards. And then there's also a final episode request, thank you so much Hannah for this email. We have a picture of a bird just hanging out on Hannah's head. I love it. We also have a picture of this tote bag which is decorated with an illustration that says, rethink your commute, and the commuting person has this backpack with the Kiddie Knocks button on it. A baby manatee also very cute. And then River otters so favorite, and a picture from Fort Moose. So thank you, so so so much for sending this and all of these pictures and this great email. I loved it and that's all I have to say about it. We love a river otter. Yeah, I would look at river otters all day long, every day. They're funny. I have many great stories of the ones at the aquarium here because I used to do animal husbandry, and some of those stories are not suitable for this podcast. Yeah. Anytime, anytime I'm anywhere that I know that they live, I'm on the lookout for them. What if I get to see one? So thank you again Hannah for this email. If you would like to send us a note where at history podcast at iHeartRadio dot com. You can find our show notes with all our source lists on them at our website, which is Missed Inhistory dot com, and you can subscribe to our show on the iHeartRadio app and anywhere else you'd like to get your podcasts. Stuff You Missed in History Class is a production of iHeartRadio. For more podcasts from iHeartRadio, visit the iHeartRadio app, Apple Podcasts, or wherever you listen to your favorite shows.