Patients often hear scary stories about painful IUD insertions from friends or, even more commonly, on social media, so it’s not surprising they might be concerned or anxious about pain when getting an IUD. It’s true, many people experience pain during IUD insertion, however individual experiences with pain vary widely and there are many aspects to pain and discomfort with pelvic exams and procedures, including pain from the speculum and uterine sound, underlying anxiety, trauma history, or scarring. Generally, the pain associated with inserting an IUD lasts for a few minutes during IUD placement and improves once the IUD is placed, however, it’s possible pain and uterine cramping can continue for a few hours after IUD placement. While the individualized nature of pain makes it impossible to create a one-size-fits-all approach to managing IUD insertion pain, we’ve got you covered with evidence-informed strategies to help you counsel patients and manage their pain during IUD insertion in your practice.
Premedication with NSAIDs
Evidence is conflicting regarding non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, and ketorolac, as premedication before IUD insertion. Because differing studies have used different medications, doses, and routes of administration, it’s difficult to reach a consensus. However, offering patients the option to take an NSAID before IUD insertion can provide a sense of autonomy and comfort. Furthermore, because NSAIDs are proven to be effective at treating pain from uterine contractions or cramps, taking them before the procedure may be helpful in reducing pain after the procedure as well.
There are also conflicting studies on paracervical blocks at the time of IUD insertion, although research suggests a lidocaine injection in the cervix does reduce pain before tenaculum placement. In one study, when compared with a sham block, a 10ml 1% lidocaine block was shown to reduce pain during IUD insertion for individuals aged 14-22 years old. However, lidocaine injections themselves can be uncomfortable and may make the procedure longer. That means it’s worth offering this option as part of an informed decision-making process, and in particular for those who you anticipate may require more uterine manipulation or dilation for IUD insertion.
Misoprostol, a medication used to soften or “ripen” the cervix, has not been shown to widely increase the ease of IUD insertion or reduce pain and is not recommended as standard practice. Additionally, the side effects of misoprostol can be uncomfortable, including cramping, bleeding, and gastrointestinal discomfort. However, for patients who have already experienced one failed attempt at IUD insertion, premedication with misoprostol is shown to increase the likelihood of successful placement. For patients choosing to try IUD insertion again, use misoprostol 400mcg, placed vaginally, four to 10 hours before the procedure.
Using an Allis clamp for cervical stabilization
Using a single-tooth tenaculum to stabilize the cervix and reduce the risk of uterine perforation can be uncomfortable and may cause additional bleeding from the cervix. Tenaculum site bleeding that requires extra monitoring or treatment (e.g., with silver nitrate) prolongs the procedure, potentially worsening patient discomfort and increasing anxiety. Studies have compared the single-tooth tenaculum to the Allis clamp, which is theoretically less traumatic, for cervical stabilization during IUD insertion. While the Allis clamp did not decrease patients’ pain in one study, another study found that it did lead to decreased bleeding at the time of IUD insertion, without diminishing insertion success.
Future innovation: suction cervical stabilizer
Swiss scientists have designed a cervical stabilizer that attaches to the cervix using suction, creating an opportunity for safe, less traumatic trans-cervical procedures—including IUD insertion. While this device is not yet on the market, initial evidence suggests that the cervical stabilizer leads to significantly decreased pain during IUD insertion, particularly for nulliparous patients, when compared to the single-tooth tenaculum. Hopefully, this technology will become more widely available in the future.
When IUD insertion is particularly challenging, whether due to anxiety, prior trauma, scarring, or difficulty with positioning, sedation may be a reasonable option. Sedation allows for increased comfort and relaxation and can make it easier for the procedure to be completed safely and efficiently. It is important to note that it may be challenging to stock and administer the appropriate medications, and the cost of the procedure will likely increase, making IUD insertion under sedation prohibitive in some health centers and for some patients who could benefit from it. However, it should be considered and offered, when possible, for patients who desire it.