Expert Insights On Pain Management With IUD Insertion

Sheila Mody, MD
Family Planning Specialist
Associate Professor of Obstetrics, Gynecology, and Reproductive Sciences
UC San Diego Health
San Diego, CA

Rebecca H. Allen, MD
Family Planning Specialist
Professor of Medical Science and Obstetrics and Gynecology
The Warren Alpert Medical School
Brown University
Providence, RI

Contemporary OB/GYN^®: Please provide an overview of the pain often experienced by women during intrauterine device (IUD) insertion.

SHEILA MODY, MD: The pain that patients sometimes experience with IUD insertion is often related to going through the cervix. When the uterus has to be measured, there’s something called a sound that goes through the cervix, so that can be uncomfortable. The actual applicator of the IUD also goes through the cervix and can cause discomfort. Some patients do experience [cramping] pain afterwards, as…the uterus is reacting to [the inserted IUD].

REBECCA H. ALLEN, MD: The pain experienced by patients is very individualized, because everybody has a different pain tolerance, and everyone has [had] different experiences with medical procedures and pelvic exams in the past, so patients bring their own perspective. In general, studies do show that people who have had vaginal deliveries generally only experience mild pain with IUD insertions (≈ 3-4 of 10) on a 0 to 10 pain scale, whereas people who have only had cesarean deliveries could have increased pain (≈ 5-6 of 10). Then there are patients who have never had a delivery at all—nulliparous or nulligravid patients— who can, on average, experience moderate to severe pain, in the 6 to 7 of 10 range. Most people can tolerate the IUD insertion in the office with our standard interventions, but, of course, there may be patients who end up requiring IUD insertion under intravenous sedation. [These may include] those with a history of trauma, very young adolescents, [or] those with developmental delay or significant anxiety or pain disorders.

Contemporary OB/GYN: Are there notable variations and pain experiences between different patient populations? What other factors, including medical comorbidities, can influence a patient’s experience with pain?

SHEILA MODY, MD: The biggest difference of experience is if [patients] have had [vaginal] deliveries. If they’ve had vaginal deliveries, that cervix has been opened, so sometimes performing that measurement or placing the applicator through the cervix isn’t as painful for those patients [who] have had vaginal deliveries. For people who haven’t had deliveries, who we call nulliparous women, that can be uncomfortable, because that cervix has never been really open before. The biggest thing is when we decide [that] we should offer more pain control for people who haven’t had children before. The other things that can be risk factors for pain [can include previous] surgical procedures like LEEP [loop electrosurgical excision procedure] that can make the cervix more difficult to get through. That can cause more discomfort as well.

[It appears that there are] more nulliparous patients pursuing IUDs in the post-Dobbs world, because they [really want] to avoid pregnancy. Thinking about pain control for nulliparous women right now is important, because they’re motivated, they’re scared, and they want to use highly effective birth control. I think we need to meet them in terms of pain control for the procedure.

REBECCA H. ALLEN, MD: Other factors that have been shown in studies to influence pain perception include a history of severe dysmenorrhea, which can put you at increased risk for pain. In addition, patients who report higher levels of anxiety beforehand tend to have more pain. Also, if there has been a [long] interval between the patient’s last pregnancy and the IUD insertion, that can [result in] increased pain. Patients who are postmenopausal can have increased pain if they’re getting an IUD for noncontraceptive reasons. Timing of insertion according to different phases of the menstrual cycle does not appear to influence the pain experienced, however.

Contemporary OB/GYN: Can you please describe how IUD insertion pain is typically assessed by clinicians versus patients? Are there any limitations or challenges that may lead to these discrepancies and assessments?

SHEILA MODY, MD: Patients are sometimes motivated to get an IUD, because it’s a highly effective method, and they don’t have to remember to do things. They may not realize the aspects of the procedure itself, and [they may] go into it not knowing that they are going to have some discomfort with the procedure. Clinicians may or may not know what type of counseling that patient [received] before they saw them, so they might think that the patient knew there might be some discomfort. Sometimes [there may] be a difference between patient experience and [a] clinician not knowing [that there is a] need to counsel [the patient]. The patient may not know that there’s any pain associated with the procedure. Some clinicians think it’s a very quick procedure and, [because] it’s so quick, patients will tolerate it. But for patients, they’re building up a lot of courage to come in for the IUD insertion. So even if it’s a quick procedure, they are kind of scared of the pain associated with it. There is a difference between those perspectives.

REBECCA H. ALLEN, MD: I agree that [study results] show that providers are notorious for underestimating the amount of pain their patients experience during office gynecologic procedures, and IUD insertion is no exception. As providers, we need to be aware of this and counsel patients about what the true anticipated pain levels are and what interventions we can offer. Patients should be reassured that they can pause or stop the procedure at any time and that they’re in control of the process. There definitely can be a difference in how patients perceive the process versus clinicians.

Contemporary OB/GYN: What is your perspective on the currently viral TikTok videos regarding painful IUD insertion?

SHEILA MODY, MD: There have been a lot of [videos] on TikTok recently about patients’ pain [and their] experiences, their own ideas with their own IUDs, and [advice for] other individuals about what] they could experience with the procedure. I also think there are some TikTok [videos] about pain management options, so I think it’s a powerful thing to have social media talking about this. It’s important for patients to advocate for what they’re experiencing, and it’s insightful for clinicians to know their perspective about it. I do think there’s a middle ground. I think we can meet in the middle and hear patients and then also [consider] the most evidence-based options that we can provide these patients.

REBECCA H. ALLEN, MD: I haven’t personally seen the TikTok videos, but I have read about them in journal and newspaper articles. I think it’s valid for patients to discuss their IUD insertion experiences as they see fit, and I do think these videos have highlighted a need for us to better address patients’ pain. I think nowadays, [when] more and more patients [including people who have never had deliveries before] are using IUDs,…there’s a whole new population of patients getting IUDs, [and] maybe their experiences haven’t been well addressed. I do think it’s important to note that there is a negative review bias in our society, meaning that people are more likely to post negative reviews of products and experiences than positive reviews. There was a recent study published in Obstetrics & Gynecology specifically on the IUD TikTok videos that showed that 95.6% of videos [that conveyed] patient experiences highlighted pain and other [adverse] effects related to IUDs. But we know, based on our clinical experience, that 95% of our patients are not having negative experiences with their IUD insertion. Just because there aren’t positive reviews out there about IUD insertions doesn’t mean that they don’t exist.

Contemporary OB/GYN: Can you please elaborate on the potential consequences of clinicians underestimating the pain experienced by women during IUD insertion? How can this affect trust between clinician and patient?

SHEILA MODY, MD: I think anyone [who] has a pelvic procedure [is] in a vulnerable situation. If clinicians [do not counsel patients sufficiently], the patients might have some cramping, [and] then I think that can impact trust. [Conversely], if clinicians are very open about the discomfort and at what points of the procedure [this may occur] and have a lot of instructions for afterwards, like what to do for pain and for cramping, I think that would build a more trusting relationship. A lot of clinicians are really well meaning, and they [want] to be able to offer a highly effective method [of birth control]. They may not recognize how scared some of these patients are [during] the actual procedure. Having more time and TLC (tender, loving care) around pain control can be very beneficial.

REBECCA H. ALLEN, MD: If [physicians] do not address our patients’ pain, and we minimize our patients’ pain, that can lead to the consequence of the patient mistrusting their health care provider and the health care system. It is important for us to develop trust with patients. That is why it is important to be honest about IUD insertion pain [and offer] strategies to minimize that pain as much as possible. We do need to validate patients’ concerns and ensure that they do not think we are minimizing their pain or gaslighting [their experiences].

Contemporary OB/GYN: Do you find it helpful to prescribe something before insertion to manage potential pain? Can you review the current standards of care that rely on pharmaceuticals?

SHEILA MODY, MD: In the past, we thought [that use of] misoprostol would help with pain during placement of IUDs for nulliparous women, but we have had multiple studies showing [that] it doesn’t help with pain. It potentially causes more adverse effects and pain. I don’t routinely recommend or teach giving misoprostol ahead of time. I do think misoprostol helps with facilitating placement, so if you have [a] failed placement, there’s a role for it. The thing that people have always [told] patients to take ahead of time is ibuprofen. However, there [have] been [study results showing] that that’s not as effective for pain with actual insertion. Naproxen [use] has been shown to help with the cramping afterwards, and ibuprofen can help with the cramping afterwards. But for the actual placement of the IUD, there’s not a lot you can do ahead of time. There is something you can do, in terms [of using] lidocaine, for the actual procedure itself. I always tell patients to make sure they eat [before an IUD placement procedure], because some [patients] can feel a little lightheaded afterwards. Make sure that they come with a support person, if that’s going to be helpful for them. It’s not a requirement,... [but] I recommend not making major plans [for] afterwards.

There have been several studies looking at various interventions for pain control, and lidocaine gel has not been helpful in many of them. [Results of a recent] randomized controlled study showed that there was decreased pain of the IUD placement with a paracervical block. The IUD placement pain without the block was 54 mm [on a] 100-mm point [visual analog] scale [of pain.…With] the block, [the score] was 33 mm. When I asked [patients], “What’s [your] pain during the placement?” they often say, “Three of 10.” It’s very real-world that they’re experiencing a lower amount of pain with a block. I get a lot of questions about [whether] the block is going to be painful. On a scale of 1 to 10, the paracervical block is very low. In terms of discomfort, it’s about a 3 [of 10]. I tell patients [to] breathe in and breathe out during that process. I tell them when that is going to occur, but that it is going to decrease the pain with the procedure. Most patients totally tolerate that. [The other question I often receive is], “Do you see the benefit of it?” The pain control that you get from the paracervical block is beyond the duration of the actual placement; it also lasts about 5 minutes afterwards. A lot of clinicians seem hesitant to do it, because they feel like it’s going to interrupt with their clinic flow by drying up the lidocaine. But I will say patients are really out the door quicker, because they’re not lying on the exam table in pain as much afterwards. I haven’t seen an [interruption in] clinic flow at all. I’m really hoping more clinicians [will] offer the paracervical block. I’ve seen such a benefit for my patients.

REBECCA H. ALLEN, MD: I do think it’s beneficial to have patients take a nonsteroidal anti-inflammatory drug. That could be oral naproxen, ketorolac, or ibuprofen prior to IUD insertion, usually at least 30 to 60 minutes in advance. It may not help with the actual insertion itself. [There are] mixed data on that, but it can help with the cramping the patient may experience afterwards. We haven’t found that oral narcotic agents seem to add any benefit to reducing pain in the procedure. The most effective intervention we do have is the paracervical block, which includes administration of local anesthetic at the tenaculum site. This has been shown to decrease pain with IUD insertion in multiple studies, especially for nulliparous patients. It is true that there is some discomfort with the injection, and it may prolong the procedure; this should be discussed with the patient, but, in my opinion, the benefits of a paracervical block outweigh these downsides. Other agents that have been studied include topical anesthetic agents to the cervix. Studies have shown mixed results with these. They have to be applied between 5 and 15 minutes beforethe procedure, and many offices don’t stock these kinds of products, like EMLA (lidocaine, 2.5%, and prilocaine, 2.5%) cream or lidocaine, 10%, spray, whereas most clinics do stock injectable lidocaine for various procedures. The paracervical block is an intervention that is more available to providers. Other studies looking at, for example, intrauterine lidocaine infusions have not really shown significant benefits, and studies on nitrous oxide have been mixed in terms of their efficacy in reducing IUD insertion pain. [Additionally], nitrous oxide delivery systems are, again, not available in most standard offices.

Contemporary OB/GYN: What do you do for nonroutine patients such as those with high levels of anxiety? Are there any additional measures that you might consider?

SHEILA MODY, MD: I don’t routinely offer any type of sedation or antianxiety medications. If I have someone [who may] have had a traumatic placement in the past and is really petrified of having it placed, I have the benefit of having oral Versed (midazolam) in my clinic. Sometimes we’ll offer that with the understanding that it is not going to help with pain, [but] it may help with anxiety. [It is important to make] sure they are clear about that. In terms of other things that we do, we put relaxation music in the room—we play spa music. We turn the lights down a little bit just [to] calm the room. I think that helps the patients, but it also shows that I care about the patient’s experience. And so I think that goes a long, long way for patients. Then I think we’ll probably talk about this, but I do offer lidocaine for the procedure for nulliparous women.

REBECCA H. ALLEN, MD: For patients with anxiety, I do think it’s worth using an anxiolytic before the procedure if they have a ride home. I use 2 mg of sublingual lorazepam, but other benzodiazepines can also work. There are also patients, as I mentioned before, [who] may require intravenous sedation for IUD insertion. Since most offices are not set up to offer that on site, the patient may have to go to a sedation suite, a surgery center, or a hospital operating room to have the procedure done under sedation, depending on what is locally available. Sometimes, this process can take much longer than an office visit, depending on the site. For example, the only site I have access to for sedation is the hospital operating room, so booking a case there will involve the patient being in the hospital for 4 to 6 hours all told with the [preoperative] area, the procedure, and the [postoperative] care.

Contemporary OB/GYN: Can you please give an overview on nonpharmacologic options and your perspective on their efficacy in comparison to the use of pharmaceuticals?

SHEILA MODY, MD: It’s a bit of a data-free zone. We haven’t studied music for this procedure, so there have been other [studies], but not for IUD placements. We don’t know if that is helpful or not. [Additionally, for] heating pads, we don’t have a study showing whether that’s helpful or not, although we do offer that. There [haven’t] been a lot of studies about nonpharmacologic ways to help with experience. I will say, just from my clinical experience, that the patients really do appreciate all those measures. They’re very low cost and low effort; playing some spa music or turning the lights down doesn’t take much time or effort to do.

REBECCA H. ALLEN, MD: I think [that] nonpharmacologic options [used] in combination with other approaches are best; a multimodal approach often works better. Verbal analgesia and distraction is very important in making our patients feel comfortable throughout the process. Support staff can hold the patient’s hand during the procedure and distract them with conversation or positive imagery. Gentle language from the provider during the procedure can be helpful….[Use of] hot packs or cold compresses [has not decreased] pain in randomized controlled trials, but [it] can provide distraction and [is not] harmful. The same [is true] with music in the background or aromatherapy. Again, a lot of these have not been proven to reduce pain, but they can provide distraction and a more comfortable environment during the procedure.

Contemporary OB/GYN: Could you elaborate on how procedure alterations (eg, using different forceps) may influence the pain experience for the patient?

SHEILA MODY, MD: [In terms of using] the speculum [and] making sure to use the appropriate speculum, there is a smaller speculum called the Peterson as opposed to a Grey speculum for nulliparous [patients]. I use the Peterson; it’s smaller for the nulliparous individuals. A metal sound is the traditional tool to measure the uterus. I tend to use a plastic sound or an endometrial biopsy pipelle, and I think that may decrease a little bit of the discomfort with the sounding process. There isn’t a lot of equipment that we use for the placement, but those are the ways to alter them.

REBECCA H. ALLEN, MD: Unfortunately, [study results] have not shown that using an atraumatic tenaculum or ring forceps decreases pain during the procedure compared with the standard single-tooth tenaculum. I don’t think [the] type of tenaculum you use makes a difference, per se. We know that the tenaculum is an important part of the procedure, because it does allow you to straighten out the angle between the cervix and the uterus and allow for proper placement of the IUD. That’s why numbing the cervix at the site of tenaculum placement is the best intervention that we have.

Contemporary OB/GYN: Given the broad variability and pain experience across each patient, how can clinicians optimize their ability to assess incoming patients and select the pain management strategy that best meets individual needs during IUD insertion?

SHEILA MODY, MD: It’s hard to tell who is going to have discomfort or not. I will say, if you had to pick 1 risk factor, it would be nulliparous vs multiparous. I do think the experience is very different for those 2 groups. I routinely offer paracervical lidocaine block for all of our nulliparous patients; most will opt for it. [It is important to consider counseling. Patients] are anticipating so much pain, and the lidocaine block helps them so much. [For] multiparous women, the block may not be worth it. There is a little discomfort with the block itself. We do give lidocaine for multiparous women at the tenaculum site, because I do use a single-tooth tenaculum; just [giving] a little bit of lidocaine does decrease the pain for [the patient] at the tenaculum site.

REBECCA H. ALLEN, MD: It’s definitely a shared decision-making process with the patient as you’re counseling them about the IUD insertion process.…Patients should be alerted to the available options, such as using nonsteroidal anti-inflammatory drugs beforehand and the availability of a paracervical block. Some patients may not want the paracervical block, because it involves a needle and additional time with the speculum in place, but others may want to [use] it. In talking to the patient, you may discover that [she is] a person who actually needs intravenous sedation…to tolerate the procedure. We just need to have various options available for patients and have the patients involved in choosing options [that] work best for them.