CDC Recommends New Pain Management Strategies for IUD Insertion

Offer patients topical lidocaine to reduce pain

By Melinda Young

The 2024 U.S. Selected Practice Recommendations for Contraceptive Use are the first to address the pain many women experience when they are having an intrauterine device (IUD) inserted.¹ This new guidance follows on the heels of social media posts over recent years in which women describe having excruciating pain when they received an IUD.²

There are multiple posts about IUD pain on TikTok, says Jenny Wu, MD, an OB/GYN resident physician at Duke University School of Medicine in Durham, NC. Wu studied TikTok videos related to contraception for a study she published in 2023.²

“I just got on TikTok the same time as a lot of millennials — at the start of the COVID pandemic,” Wu says. “I saw a video of a woman getting an IUD placed, and she was really uncomfortable. You could hear someone in the background saying, ‘It’s just a pinch,’ and the woman had tears in her eyes.”

The video was so dramatic that Wu imagined viewers would not want to get an IUD after watching this, and she decided to study it.

As a student preparing to be an OB/GYN and also as a young woman on TikTok, Wu recognized a disconnect between what was on TikTok and what physicians were recommending.

“We found that more videos were negative,” Wu says. “This was a paper to educate providers that there is a disconnect between what we as providers recommend vs. what patients are talking about.”

Some people say their personal experiences of IUD placement were not very painful, while others describe it as the worst pain of their lives, says Nidhi Bhaskar, MSc, a third-year medical student at Brown University in Providence, RI. Bhaskar wrote a MedPage opinion piece about IUD insertion pain.³

Bhaskar describes her experience of watching a close friend during an IUD placement appointment. Her friend described her pain as “a sharp poker piercing her insides.”³

“My friend was shocked at how intense the pain was,” Bhaskar says. “There are so many videos of people passing out and recording their experiences with getting the IUD, people screaming. It’s commonplace, and I want to know why that is necessary.”

Men have received pain management for vasectomies for decades. It says something about society and medicine in general that it has taken so long to recognize women’s pain with IUD insertion, she adds.

“It echoes this theme — more broadly — of female pain being systematically ignored or marginalized, or providers being less perceptive about it,” Bhaskar explains.

The Centers for Disease Control and Prevention (CDC) guidelines are important, but they could have been delivered earlier and they could be stronger, Bhaskar notes.

“All healthcare providers and policy assistants need to normalize and advocate for the management of women’s pain and advocate for whatever each individual person needs,” Bhaskar says. “There can never be one set of guidelines that speak to everyone, but there can be multiple guidelines or maybe even a blanket statement that can advocate for speaking with patients and taking their pain into consideration.”

Robert A. Hatcher, MD, MPH, Professor Emeritus of Gynecology and Obstetrics, Emory University School of Medicine in Atlanta, says, “Part of the recommendations I make to clinicians inserting or removing IUDs is the following: Every step in IUD insertion and removal should be done slowly and gently. If this is always uppermost in the mind of individuals doing pelvic examinations or placing IUDs, then IUD insertion and removal may be accomplished with great patient satisfaction.”

It is up to physicians to make sure those conversations are happening so their patients have as positive an experience as possible when they choose IUDs as their birth control method, Bhaskar says.

Media attention about pain with IUD insertion has increased in recent years, and this is raising questions physicians need to address.

“I wonder if that’s taken a part in the CDC’s change,” Wu says.

The CDC guidelines were updated to add topical lidocaine as a medication that might be useful to reduce patient pain during IUD placement, says Kathryn Curtis, PhD, a health scientist in the division of reproductive health at the National Center for Chronic Disease Prevention and Health Promotion at the CDC.

“We’ve added more language around counseling patients of potential pain during placement and talked about taking different risks,” Curtis explains. “It’s for having a patient-centered discussion about pain management.”

The CDC’s recommendations say, “barriers to IUD use include patient concerns about anticipated pain with placement and provider concerns about ease of placement, especially among nulliparous patients.”¹

The CDC also advises providers to recognize that the experience of pain is individualized and might be influenced by previous experiences of trauma and mental health conditions, including anxiety and depression.¹

The recommendations also say misoprostol is not recommended for routine IUD placement because there is no evidence that using misoprostol reduces patient pain, adverse events, or need for adjunctive placement measures, such as cervical dilation. In fact, some evidence suggests misoprostol may increase patient pain and preplacement abdominal pain or cramping.¹

The guidelines are a start in changing the conversation about IUD placement pain. OB/GYNs who dismiss the pain as being minor at worst are missing the point, which is that each patient is different. Some women who have never given birth may experience more pain with IUDs, but so might women who have had children.

“There is a lot online about medical gaslighting and doctors not offering anything for pain,” Wu says. “Offer something. This is a painful procedure.”

There is a wide range of experiences and symptoms, but physicians have options to make it better for patients. Women may not even tell their physician about how uncomfortable it was for them even as they later share that information online.

“I saw that it was discouraging a lot of people from getting an IUD because of what they see on social media,” she says. “It’s a fascinating trend that aligns with concerns women have, and I’m really excited to see the changes in the CDC guidelines.”

In her practice, Wu offers patients preemptive pain relief.

“Offering something for pain is something we should be doing for all patients,” Wu says. “Pain is so personal and informed by other things — not only a person’s experience with vaginal delivery, but it’s also informed by a history of trauma, so it’s hard to say who should be getting something for pain and who shouldn’t.”

Physicians trained in the language and understanding of trauma-informed care may provide contraceptive counseling that acknowledges women’s different experiences with pain. Younger OB/GYNs have friends who have described their own experiences with IUDs, and this contributes to empathy for patients.

“I hope our next generation of gynecologists care about this issue and are talking about this issue,” Wu says.

Those who ignore or dismiss the prospect of patients finding IUD placement painful should keep in mind that their patients are paying attention to this and may select a different contraceptive when an IUD would otherwise be their first choice.

“I practice in North Carolina, and we have a big change around hormonal birth control and IUDs, where [some] people are not interested in birth control. And we have limited abortion access,” Wu explains. “We want contraceptive autonomy, but we also live in a state where it’s a lot more complicated to provide abortions, and that’s where the unintended [consequence] of these things on social media impact the care we provide.”

Addressing pain management with IUD placement begins with contraceptive counseling, according to the updated CDC recommendations.¹

“All patients should be counseled on potential pain during placement and the risks and benefits and different options for pain management,” Curtis says. “There should be a person-centered plan for pain preferences.”

Physicians should prepare patients to know what to expect and to give them enough pain control ahead of time, Bhaskar says.

They can explain that each woman experiences this procedure differently. For some, there is minimal pain, and an ibuprofen or a nonsteroidal anti-inflammatory drug (NSAID) would be enough to mitigate it. Others may desire a lidocaine block or topical lidocaine, Wu and Bhaskar say.

“For the right patient, I can even offer an anxiolytic so long as they have a driver to take them home,” Wu adds. “For some patients we offer sedation.”

There are many positives to IUDs as contraception, including how they provide pregnancy prevention for six to 10 years and can give women the peace of knowing they have taken agency over their own health, Bhaskar says.

“That should be rewarded, and we should at least make it easier for women who make this decision,” she adds. “Access is already an issue — access to competent birth control services; once people are there, do not deter them and be cognizant of their needs.”

REFERENCES

1. Curtis KM, Nguyen AT, Tepper NK, et al. U.S. Selected Practice Recommendations for Contraceptive Use, 2024; Recommendations and Reports. MMWR Recomm Rep 2024;73:1-77.
2. Wu J, Trahair E, Happ M, Swartz J. TikTok, #IUD, and user experience with intrauterine devices reported on social media. Obstet Gynecol 2023;141:215-217.
3. Bhaskar N. I’ve Seen the Extreme Pain of IUD Insertion — CDC’s new guidance is a good first step, but more is needed to acknowledge women’s pain. MedPage Today. Aug. 15, 2024. https://www.medpagetoday.com/opinion/second-opinions/111535