After social media outcry, CDC tells doctors to better manage IUD pain
Amid a nationwide outcry from women who say they experienced severe pain when getting an intrauterine device, new federal health guidelines published Thursday are urging health-care providers to address the problem.
The recommendations, from the Centers for Disease Control and Prevention (CDC), advise clinicians to counsel patients about the potential for pain during IUD placement and give them options to help manage it before undergoing the procedure.
“I think it’s excellent guidance,” said Eve Espey, chair of the American College of Obstetricians and Gynecologists’ Contraceptive Equity Expert Work Group and the OB/GYN department at the University of New Mexico. “It’s helping ensure we listen to our patients’ needs and preferences for outpatient procedures that may be painful.”
The issue has gained prominence in recent years as IUDs have become an increasingly popular contraceptive option for younger women and teens, who have taken their concerns about the sometimes painful procedure to social media. (Because younger patients typically have not given birth, IUD placement can be more painful for this age group.)
Earlier this year, The Washington Post reported that numerous women were using their smartphones to document their screams, tears and distress during the IUD insertion process. In social media posts, patients who have experienced IUD pain have described the procedure in graphic terms, including as an “explosion of cramps,” a sensation of “pulling, pushing and slicing” or being “cut or ripped open inside.”
Many of these patients said they were not warned of the potential for pain or given adequate options to manage it.
Local anesthetics, sedation and other options are available for IUD placement, but many clinicians do not readily offer them. Research also shows that physicians and other providers underestimate pain during IUD insertions. In a study of 200 women, most of whom had given birth, the women reported an average maximum pain score of nearly 65 on a scale of 0 to 100. The providers, however, rated the women’s pain at about 35.
Physicians have said that determining the best pain control can be difficult because patient’s preferences and experiences vary, and there are not enough effective options or guidelines on when to use them.
Often, over-the-counter anti-inflammatory medications such as ibuprofen are the only options recommended to help manage IUD pain, despite the fact that research shows they are largely ineffective.
The CDC said health-care providers can use the recommendations, which were updated after a review of available scientific evidence in January 2023, “to support person-centered contraceptive counseling and remove unnecessary medical barriers to accessing and using contraception.”
In its previous recommendations in 2016, the CDC outlined medications “to ease IUD insertion,” suggesting the advice was aimed, at least in part, at helping the provider complete the procedure. The updated version uses more patient-centered language.
The new guidance states that before placing an IUD, “all patients should be counseled on potential pain during placement as well as the risks, benefits and alternatives of different options for pain management. A person-centered plan for IUD placement and pain management should be made based on patient preference.”
The advice also broadens pain control options to include topical lidocaine, which may include a numbing gel or spray. The previous guidance mentioned only lidocaine injections given in the cervix called a paracervical block. Some studies show paracervical blocks can help with pain, while others have shown they do not. Although the CDC said lidocaine “might be useful for reducing patient pain,” the agency did not specifically advise clinicians to use it.
The new guidance also states that misoprostol, a medication that helps soften the cervix, is not recommended for routine IUD insertions but may be useful in certain circumstances such as in cases in which previous insertions have been unsuccessful.
Physicians say the new guidance emphasizes that there is no one-sized-fits-all approach to pain control.
“Shared decision-making is necessary to arrive at an individualized plan reflecting each patient’s unique context, values and preferences,” Monica Dragoman, system director of the complex family planning division at Mount Sinai Health System, said in an email.
Lauren Kus, a complex family planning fellow at Mount Sinai Hospital, added that while the recommendations can “optimize and individualize” pain management plans, “admittedly, none of these interventions are a magic bullet to eliminate IUD insertion pain, so continued research into additional effective strategies is critical.”
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