Between the updated 2024 CDC Selected Practice Recommendations and increased media coverage, it finally feels like we– as health care professionals– are beginning to take seriously the importance of pain management for intrauterine devices (IUD) procedures. At the same time, it can feel overwhelming to sift through evolving recommendations and best practices. Consider this a recap of what you need to know to provide person-centered, evidence-informed pain management for IUD placements.
Understanding the Sources of Pain
IUDs are highly effective, long-acting, and reversible contraceptives, but pain during placement can be a significant barrier to their use. Pain can occur at several points: speculum insertion, tenaculum placement, cervical manipulation, uterine sounding and device placement. Pain is influenced by physiologic factors (e.g., cervical stenosis, uterine position), psychological factors (e.g., anxiety, history of traumatic pelvic exams), and procedural technique (often linked to provider experience).
While the growing emphasis on cervical blocks is a welcome shift, it is important to remember that they are one piece of a much bigger pain management puzzle. As Dr. Christine Henneberg aptly noted in her 2024 New York Times Op-Ed, “How nice it would be if this were a problem that could be solved by a bit of lidocaine. But it’s not that simple.”
Pre-Procedure Counseling for IUD Placements
A recent Contraception article highlighted the value of pre-procedure counseling, including walking patients through the steps of the IUD procedure and discussing pain options in advance. The findings of this study reinforce that the pain is one aspect, among many, of the overall experience.
Foundational counseling skills—active listening, validation, and belief in patients’ descriptions of pain—are essential. So is ensuring equitable access to pain management options for all patients.
Non-Medication Pain Management for IUD Placement
- Verbicane (“vocal local”): Use a calm, steady voice and engage the patient in conversation about something they enjoy.
- Distractions: Offer guided breathing, listening to music, scrolling on social media. If using headphones, ask patients to leave one earbud out so they can still hear you.
- Support People: Invite a trusted support person to accompany the patient for the procedure. If they came to the visit solo, see if another member of your team can come in to hold a hand or engage in conversation (if the patient wants).
Medication Management Options for IUD Placements
- Paracervical/Intracervical Blocks: Underused but highly effective. More and more research shows that these techniques can significantly reduce procedural pain. If not currently part of your practice, seek out mentorship or training to expand your skill set.
- NSAIDs: Less effective for procedural pain, but helpful for post-procedure cramping.
- Anxiety Meds: For patients with significant anxiety, a history of trauma, or previous painful pelvic exams, consider offering a prescription for a low dose of a benzodiazepine like lorazepam. Just make sure they have a ride home lined up.
- Sedation: Less commonly available, but valuable for certain patients. Know your local referral options if you don’t offer sedation in your practice.
- Topical Anesthetics: Some lidocaine gel formulations applied to the cervix may provide some numbing, but evidence is limited regarding effectiveness for deeper procedural pain.
What Doesn’t Work for IUD Pain
- Routine misoprostol: While miso might be helpful for patients that have experienced a failed IUD placement, evidence doesn’t support offering it routinely—especially since it can increase cramping and GI symptoms.
- Tenaculum Alternatives: Though there’s no harm in using an atraumatic tenaculum, head to head studies haven’t shown a significant reduction in pain over traditional tenaculae.
Set Them up for Success: Post-Procedure Support for IUDs
Proactively offer work or school excuse notes if needed. Counseling patients to use NSAIDs regularly for the first 24-48 hours, then as needed. Recommend heating pads– or suggest the DIY “rice-in-a-sock” method.
Clarify What's Expected vs Concerning:
- Expected: Mild to moderate cramping that improves with NSAID; some bleeding and spotting
- Concerning: Pelvic pain that doesn’t get better with meds, heavy bleeding or abnormal vaginal discharge–advise to seek immediate medical care
Key Points
- Pain management is about more than comfort—it’s about respect, autonomy, and support.
- Paracervical blocks are effective but underutilized, and should be offered more routinely—especially when paired with supportive strategies like anxiolytics, distraction, and trauma-informed care.
- Keep growing your toolkit and advocating for person-centered care. Seek out opportunities to add to your pain management toolkit.
