CDC Issues New Pain Management Guidelines for IUD Insertion: Doctors Respond

 Women everywhere are celebrating what’s considered a major step forward in feminine  health care. The Centers for Disease Control and Prevention (CDC) recently issued new guidelines for pain management treatment and counseling regarding intrauterine device (IUD) insertion. While doctors specializing in women’s health view this as progress, many also say there is still a good deal of room for improvement. Here, Ob-Gynss share their thoughts on the new protocol as well as their suggested approaches to women’s pain management. 

What is an IUD?

As one of the most effective forms of preventing pregnancy available today, IUDs are a preferred family planning tool, with rates of failure similar to various forms of sterilization, according to the National Library of Medicine. The benefits of IUDs include efficacy, ease of use and reversibility. 

There are two types of IUDs currently available In the US, including the copper-containing IUD and levonorgestrel-containing (hormonal) IUD. The two have similar rates of preventing pregnancy, with failure rates of 0.08 percent and 0.02 percent, respectively. This makes these devices more than 99 percent effective in preventing pregnancy. 

The hormonal IUD is effective at providing reliable contraception, but higher doses are also approved for the treatment of heavy bleeding and endometrial protection during hormone replacement therapy (HRT). 

The copper IUD works by preventing sperm motility and viability within the uterine cavity. Hormonal IUDs cause progesterone to act on the innermost uterus lining to suppress growth. Additionally, the levonorgestrel thickens the consistency of the cervical mucus, which prevents pregnancy by inhibiting the motility of the sperm. 

IUD removal occurs after the IUD has been in for the approved amount of time, but if you’d like further contraception, a new IUD can be inserted on the same day. The 13.5 mg IUD is approved for use for up to three years, while the 19.5 mg and 52 mg IUDs are approved for up to five years. The copper IUD is approved for contraception for up to 10 years.

The pain commonly associated with IUD insertion has become something of a phenomenon, with countless women sharing their experiences — some quite severe — on social media. While most women have reported mild to moderate cramping and pain that resolves relatively quickly, some women have reported fainting, crying and even vomiting during the insertion process. 

New CDC guidelines for IUD insertion 

CDC guidelines for IUD insertion recently saw the addition of a new recommendation encouraging doctors to counsel patients on pain management beforehand. The updated guidelines also expand options for pain management for the first time since 2016. At that time, lidocaine injections into the cervix were recommended as a local anesthetic pain relief option. Now, suggested options include both injectable and topical lidocaine in the form of gels or sprays. 

Why is IUD insertion so painful?

“IUD insertions can be uncomfortable or painful because of the inherent nature of the procedure in which an IUD is placed through the vagina, through the cervix, and into the uterus,” explains Allison Salk, MD, obstetrician and gynecologist, Rush University System for Health. “The IUD is inserted without making any cuts or incisions, but instead by using holes that already exist in the patient body (the vagina and cervix) to place the IUD in the correct position in the uterus.” 

Pain or discomfort, Dr. Salk says, may occur because of speculum placement in the vagina, pain at the cervix when instruments are placed and cramping of the uterus from both measuring the size of the uterus and placing the IUD inside. 

While the process itself can be painful, the anxiety associated with the anticipation of insertion can make it even more difficult for the patient, adds Michael Tahery MD, a board-certified Ob-Gyn and urogynecologist. 

Pain with IUD insertion can also be worse for women who have not given birth and had their cervix stretched from a vaginal delivery, notes Karyn Eilber, MD, urogynecologist and co-author of A Woman's Guide to Her Pelvic Floor: What the F*@# is Going On Down There.

How to make IUD insertion less painful

There are several things that can help patients throughout the IUD insertion process, says Dr. Salk. As the new guidelines suggest, it is crucial for doctors to discuss the procedure with patients so that they are informed and aware of what they will be experiencing. 

“We often use diagrams and explain to patients how the device is placed and when they may experience pain,” she says. “I ask my patients if they prefer to hear me explain every step as I place the IUD, or if they would rather be distracted by music, watching a video or having a conversation.” 

These kinds of non-pharmacologic measures act as a helpful supplemental way of managing pain from the procedure, Dr. Salk notes. Additionally examples include stress balls, aromatherapy, asking a friend, family or staff member to hold your hand. 

There are measures you can take to mitigate pain before the procedure, such as asking for a cervical block ahead of insertion. A cervical block is only one injection usually, unless the block didn’t work, Dr. Eliber explains. If the block didn't work, then the physician might reinject, when the procedure starts if the patient is still really uncomfortable and experiencing pain or severe discomfort. The Lidocaine injection is also just one injection, but in two different places of the cervix. 

“Another alternative is taking a sedative and a pain pill before,” Dr. Eilber adds. “Just make sure you make sure to get a ride from someone else if you take these medications.” 

Doctors agree that one of the best things you can do for post-procedure cramping (which occurs because the uterus is recovering) when you get home is apply heat, whether from a heating pad or hot shower. Over the counter pain relief like Tylenol can also be taken afterwards, and it is safe to take ibuprofen at the same time.

IUD for menopause and perimenopause

While IUDs are a known effective contraception method, birth control is not their only use. In fact, doctors say the devices may be recommended for women approaching, during and even after menopause. 

“The hormonal IUD can be used to decrease menstrual bleeding which can be life-changing for patients with irregular periods, heavy periods and uterine fibroids,” says Dr. Salk. “Decreased bleeding can lead to improvement in iron deficiency anemia as well as improved quality of life. For postmenopausal women, hormonal IUDs can also decrease the risk of endometrial cancer as well as treat some cases of endometrial hyperplasia as the hormonal IUD thins the lining of the uterus.” 

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This content is not a substitute for professional medical advice or diagnosis. Always consult your physician before pursuing any treatment plan.