Updated guidelines on managing pain during IUD insertion were recently released by the Centers for Disease Control and Prevention (CDC). While doctors view this advice as a positive development, they believe it does not address all the sources of discomfort associated with the procedure.
IUDs, or intrauterine devices, are becoming an increasingly popular long-term birth control method in the United States. The insertion process for an IUD—a small T-shaped device placed inside the uterus—can be quite painful. With the rise of TikTok, many individuals have begun sharing their experiences regarding IUD insertion, often describing cramps, bleeding, and even fainting, sometimes recording their experiences live from the exam room.
The CDC’s recent guidance, published earlier this month, includes a key recommendation: patients should receive counseling on pain management prior to the procedure.
Given that IUDs are more than 99% effective in preventing pregnancy, healthcare providers face the challenge of helping individuals manage the pain associated with insertion, according to Dr. Deborah Bartz.
Particularly regarding the discomfort patients feel during procedures, many of us have acknowledged that women’s pain has not been sufficiently addressed historically,” Bartz explained.
The updated guidelines also introduce new options for pain management for the first time since 2016. That year, the CDC recommended a lidocaine injection into the cervix to numb the area and reduce pain. The latest update expands this to include topical lidocaine in the form of gels or sprays.
However, this approach addresses only a portion of the pain experienced during IUD insertion.
Understanding Pain During IUD Insertion
The insertion process begins with a pelvic exam, after which the healthcare provider uses a speculum to access the cervix, similar to a pap smear. A tenaculum is used to secure the cervix in position while the healthcare provider measures the depth of the uterus and inserts the IUD. This entire procedure usually takes less than three minutes.
Pain is experienced differently by each individual during the procedure, but doctors note that measuring the uterus’s depth and inserting the IUD often leads to significant cramping. Much of the focus on pain management has been directed at the tenaculum, a device that grasps the nerve-rich cervix during the procedure.
Bartz pointed out that while this part can cause discomfort, it is generally not the most painful aspect. A Swiss medical device company, Aspivix, has developed a new tool called the Carevix, designed to replace the tenaculum and minimize pain. Cleared by the Food and Drug Administration in early 2023, it uses suction to grasp the cervix rather than employing pincer-like forceps.
Results from a study conducted in Switzerland by Aspivix suggested that the Carevix may reduce pain and bleeding for some patients, and another clinical trial is currently underway in the U.S., led by researchers at Indiana University.
Aspivix has established plans for a commercial rollout by the end of 2024 , for a “soft launch” of its product. Dr. Beverly Gray, an OB-GYN at Duke Health in Durham, North Carolina, expressed interest in trying any new device, provided it is as effective as current options. However, she cautioned that no solution can eliminate pain for all patients.
Even lidocaine, as suggested in the CDC guidelines, has its limitations.
“The anesthetic is not a one-size-fits-all solution,” Gray stated. “It doesn’t ensure that everyone will find relief from their pain.”
Bartz mentioned that while lidocaine injections can themselves be painful, they primarily alleviate discomfort associated with the tenaculum. There is limited evidence to support that lidocaine injections or gels relieve cramps from the actual placement of the IUD.
Doctors acknowledge they are working with a limited toolbox of pain management options.
Currently, the only alternatives for alleviating cramps during insertion are nonsteroidal anti-inflammatory drugs like ibuprofen or conscious sedation, neither of which the CDC included in its recommendations.
“My usual recommendation is to suggest taking ibuprofen—600 or 800 milligrams—approximately half an hour before the procedure, as this is likely to be effective in alleviating cramping,” said Dr. Susan Reed.
When doctors do suggest ibuprofen before the procedure, some women may feel that their concerns are not being fully acknowledged.
Alessa Rodriguez, 37, postponed getting an IUD for three years due to concerns about pain. She emphasized the importance of finding a gynecologist who would address her questions and validate her feelings.
“I had a long list of questions, trying to understand what kind of pain I might experience,” said Rodriguez, who lives in New York City.“I understand that each person’s experience is unique, but I didn’t want someone to just tell me, ‘Take ibuprofen.’”
In underserved areas, where contraceptive care is often limited, options for pain management may be even scarcer.
The CDC guidelines are informed by existing research, which frequently lacks depth regarding contraceptive pain management.
“Are we doing adiquate research on women’s health? The answer is definitely no,” Reed remarked.
Updating these guidelines is a multi-year endeavor. Dr. Antoinette Nguyen, a medical officer in the CDC’s Division of Reproductive Health, explained that the group consistently reviews new research to determine when significant findings warrant a new recommendation.
In light of this research gap, Dr. Aaron Lazorwitz, a complex family planning specialist and professor at Yale School of Medicine, noted that gynecologists often feel as if they are missing crucial information.
The Importance of Pain Counseling
Pain experienced during gynecological procedures can intersect with experiences of discrimination, trauma, and anxiety, which is why personalized conversations about pain management are vital.
Rodriguez expressed disappointment upon learning that many women were not receiving important information before their appointments. After eventually receiving an IUD, she experienced side effects for months but regards it as one of the best decisions she has made.
Nguyen noted that the new CDC guidelines reflect a broader understanding of pain, but acknowledged that clinical trials are limited and cannot encompass every individual’s experience.
Madeline Morcelle, a senior attorney at the National Health Law Program, highlighted that discrimination and “coercive practices” regarding pain management are ingrained in the healthcare system. She expressed concern over the public backlash concerning the dismissal of IUD pain by healthcare providers, particularly among marginalized communities.
Even with limited tools, Morcelle stressed that counseling is essential.
While the CDC’s guidelines are not mandatory, she pointed out that denying pain counseling—especially if providers selectively offer pain management based on a patient’s identity—could violate anti-discrimination provisions of the Affordable Care Act.
“It can be strongly argued that failing to provide counseling on pain management options for IUD insertion or denying access to evidence-based pain management options endorsed by the newly issued CDC guidelines may amount to prohibited sex discrimination.”,” Morcelle stated.
New generations of gynecologists are being trained to take pain seriously, Lazorwitz noted, after centuries of neglect in the medical field. He advised that if a doctor dismisses concerns about pain, it may be time to seek a new provider.
Many practitioners report that pain counseling is already standard practice in their offices. Dr. Aparna Sridhar, an OB-GYN at UCLA Health in Los Angeles, believes that counseling should come naturally for well-trained doctors.
“I believe the CDC’s recommendation endorses best practices.,” Sridhar said. “If a procedure is known to cause pain, it’s logical and compassionate for healthcare providers to offer pain management options.”
