What Medical Guidelines (Finally) Say About Pain Management for IUD Insertion

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2 days ago

Intrauterine devices, or IUDs, are an extremely effective and convenient form of birth control for many people—but it can also very painful to get one inserted. Current medical guidelines say that your doctor should be discussing pain management with you, and they also give advice to doctors on what methods tend to work best for most people.
The newest set of guidelines is from ACOG, the American College of Obstetricians and Gynecologists. These guidelines actually cover a variety of procedures, including endometrial and cervical biopsies, but today I'll be talking about the IUD insertion portions. And in 2024, the Centers for Disease Control and Prevention's released new contraceptive recommendations that include a section on how and why providers should help you with pain relief.
Before we get into the new recommendations and what they say, it's important to keep in mind that that not everybody feels severe pain with insertion—the estimate is that insertion is severely painful for 50% of people who haven't given birth, and only 10% of people who have, according to Rachel Flink, the OB-GYN I spoke with for my article on what to expect when you get an IUD. (She also gave me a great rundown of pain management options and their pros and cons, which I included in the article.)
I'm making sure to point this out because I've met people who are terrified at the thought of getting an IUD, because they think that severe pain is guaranteed and that doctors are lying if they say otherwise. In reality, there's a whole spectrum of possible experiences, and both you and your provider should be informed and prepared for anything along that spectrum.
Your provider should discuss pain management with you
The biggest thing in both sets of guidelines is not just the pain management options they discuss, but the guideline that says there is a place for this discussion and that it is important! You've always been able to ask about pain management, but providers are now expected to know that they need to discuss this with their patients. The ACOG guidelines say: "Options to manage pain should be discussed with and offered to all patients seeking in-office gynecologic procedures." And the CDC says:
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 IUD placement and pain management should be made based on patient preference.
'Person-centered' means that the plan should take into account what you want and need, not just what the provider is used to doing or thinks will be easiest. (This has sometimes been called 'patient-centered' care, but 'person-centered' is meant to convey that you and your provider understand that they are treating a whole person, with concerns outside of just their health, and you're not only a patient who exists in a medical context.)
The CDC guidelines also say: '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.' The ACOG guidelines, similarly, say that talking over the procedure and what to expect can help make the procedure more tolerable, regardless of how physically painful it ends up being. (Dr. Flink told me that anti-anxiety medications during insertion are helpful for some of her patients, and that she'll discuss them alongside options for physical pain relief.)
Lidocaine paracervical blocks may relieve pain
There's good news and bad news about the recommended pain medications. The good news is that there are recommendations. The bad news is that none of them are guaranteed to work for everyone, and it's not clear if they work very well at all.
The CDC says that a paracervical block (done by injection, similar to the numbing injections used for dental work) 'might' reduce pain with insertion. Three studies showed that the injections worked to reduce pain, while three others found they did not. The CDC rates the certainty of evidence as 'low' for pain and for satisfaction with the procedure. The ACOG guidelines also mention local anesthetics, including lidocaine paracervical blocks, as one of the best options for pain management.
Dr. Flink told me that while some of her patients appreciate this option, it's often impossible to numb all of the nerves in the cervix, and the injection itself can be painful—so in many cases, patients decide it's not worth it. Still, it's worth discussing with your provider if this sounds like something you would like to try.
Topical lidocaine may also help
Lidocaine, the same numbing medication, can also be applied to the cervix as a cream, spray, or gel. Again, evidence is mixed, with six trials finding that it helped, and seven finding that it did not. The ACOG guidelines note that sometimes topical lidocaine has worked better than the injected kind. Unfortunately, they also say that it can be hard for doctors to find an appropriate spray-on product that can be used on the cervix.
The CDC judged the certainty of to be a bit better here compared to the injection—moderate for reducing pain, and high for improving placement success (meaning that the provider was able to get the IUD inserted properly).
Other methods aren't well supported by the evidence (yet?)
For the other pain management methods that the CDC group studied, there wasn't enough evidence to say whether they work. These included analgesics like ibuprofen, and smooth-muscle-relaxing medications.
The ACOG guidelines say that taking NSAIDS (like ibuprofen) before insertion doesn't seem to help with insertion pain, even though that's commonly recommended. That approach does seem to work for some other procedures, though, and may help with pain that occurs after an IUD insertion. So it may not be a bad idea to take those four Advil if that's what your doc recommends, but it shouldn't be your only option. Or as the ACOG paper puts it: "Although recommending preprocedural NSAIDs is a benign, low-risk intervention unlikely to cause harm, relying on NSAIDs alone for pain management during IUD insertion is ineffective and does not provide the immediate pain control patients need at the time of the procedure."
Both sets of guidelines also don't recommend misoprostol, which is sometimes used to soften and open the cervix before inserting an IUD. The ACOG guidelines describe the evidence as mixed, and the CDC guidelines specifically recommend against it. Moderate certainty evidence says that misoprostol doesn't help with pain, and low certainty evidence says that it may increase the risk of adverse events like cramping and vomiting.
What this means for you
The publication of these guidelines won't change anything overnight at your local OB-GYN office, but it's a good sign that discussions about pain management with IUD placement are happening more openly.
The new guidelines also don't necessarily take any options off the table. Even misoprostol, which the CDC now says not to use for routine insertions, 'might be useful in selected circumstances (e.g., in patients with a recent failed placement),' it writes.
Don't be afraid to ask about pain management before your appointment; as we discussed before, some medications and procedures require that you and your provider plan ahead. And definitely don't accept a dismissive reply about how taking a few Advil should be enough; it may help for some people, but that shouldn't be the end of the discussion. You deserve to have your provider take your concerns seriously.