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.
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.
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.
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
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.
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.
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.
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 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.
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