New Recommendations to Make IUD Insertion Less Painful

In the last couple of years, there have been a lot of stories on social media about IUD insertion. The main concern is whether doctors are downplaying the pain involved with the procedure. Some stories feature people who were told by their provider that IUD insertion wouldn’t hurt—but who describe the procedure as very painful. They also say that their provider dismissed their pain. Several patients said that the only pain management offered was over-the-counter ibuprofen. By drawing attention to this issue, these patients have helped usher in change in the guidelines that health care providers follow.

Last year, the Centers for Disease Control and Prevention (CDC) issued updated recommendations for providers. CDC acknowledged that lidocaine (a topical anesthetic) “might be useful” in IUD placement. While this stopped short of recommending the use of pain management, the guidance did recommend that providers counsel IUD patients on pain management options before the procedure. This represented a big shift in care as many providers never thought to have these discussions.

An Acknowledgement that Providers Underestimate the Pain of IUD Insertion

Now, the American College of Obstetricians and Gynecologists (ACOG) is building on this progress. ACOG has issued new guidance on pain management for procedures such as IUD insertion and biopsies. ACOG acknowledges that providers often underestimate the pain patients feel during their procedures. The organization says there is “an urgent need for health care professionals to have a better understanding of pain-management options.”

The guidance document discussed a number of pain management strategies. These include lidocaine sprays, creams, and injections. They also discuss the use of anti-inflammatory drugs such as ibuprofen before the procedure. Which strategy works best varies by procedure (LEEPs and hysterotomies are more painful than IUD insertion). They also vary by person, since everyone experiences pain differently. Again, the most important change to the guidance is the suggestion that all patients receive counseling about pain-management options.

“What I hope clinicians will take away from this guidance is the absolute importance of comprehensive pain management counseling—not just for mitigating pain in the moment but also for improving trust with our patients and ensuring better access to gynecologic health care for every person.”

Dr. Christopher Zahn, Chief of Clinical Practice and Health Equity and Quality at ACOG

The recommendations also acknowledge the role of systematic racism and bias in how health professionals treat patients. Historically, Black patients have been less likely to be offered pain management strategies than white patients undergoing similar procedures. Similarly, women are less likely to be offered pain relief than men. ACOG hopes these recommendations will help.

“… systemic racism and bias as to how pain is experienced and who experiences it also has, unfortunately, influenced pain management considerations. This guidance is an important step toward both identifying evidence-based approaches to pain management and reducing those biases by offering all patients more autonomy in deciding how to best approach the pain they experience.”

Dr. Christopher Zahn, Chief of Clinical Practice and Health Equity and Quality at ACOG

Working with Patients to Decide How to Manage Pain

One of challenges in providing the best pain management strategies to all patients is that each patient responds to pain differently. Research on IUD insertion is based on participants’ very personal experience of pain or discomfort. It’s not surprising that studies on best practices in pain management may contradict each other. This is why ACOG is suggesting pre-procedure counseling and shared decision-making. This allows the provider and patient to work together on a pain management plan.

Dr. Kimberly Hoover, the coauthor of the ACOG guidance, explained it this way: “Patients know their own bodies best and know what their priorities are for a procedure—whether they want it to be completed as quickly as possible, whether their priority is reduction in acute pain, or whether they’d prefer to be able to pause the procedure if needed to try a different intervention.” She went on to say: “I have some patients for whom the paracervical block, for example, is quite helpful for their IUD insertion experience. I have other patients who would prefer to avoid needles and may want to try another approach. Presenting patients with all the options and using shared decision-making is best practice.”