The CDC’s IUD Guidelines Finally Include Pain Management

Intrauterine devices, or IUDs, are an extremely effective and convenient form of birth control for many people-but it can also very painful to get one inserted. For the first time, the Centers for Disease Control and Prevention's new contraceptive recommendations include a section on how and why providers should help you with pain relief.

Before we get into the new recommendations and what they say, it's important to keep in mind that that not everybody feels severe pain with insertion-the estimate is actually 10% of people who have given birth, and 50% of those who have not, according to Rachel Flink, the OB-GYN I spoke with for my article on what to expect when you get an IUD. (She also gave me a great rundown of pain management options and their pros and cons, which I included in the article.)

I'm making sure to point this out because I've met people who are terrified at the thought of getting an IUD, because they think that severe pain is guaranteed and that doctors are lying if they say otherwise. In reality, there's a whole spectrum of possible experiences, and both you and your provider should be informed and prepared for anything along that spectrum.

Your provider should discuss pain management with you

The biggest thing in the CDC recommendations is not just the pain management options they discuss, but the guideline that says there is a place for this discussion and that it is important!

You've always been able to ask about pain management, but providers are now expected to know that they need to discuss this with their patients. The CDC says:

Before IUD placement, 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.

Person-centered" means that the plan should take into account what you want and need, not just what the provider is used to doing or thinks will be easiest. (This has sometimes been called patient-centered" care, but person-centered" is meant to convey that you and your provider understand that they are treating a whole person, with concerns outside of just their health, and you're not only a patient who exists in a medical context.)

The guidelines also say: When considering patient pain, it is important to recognize that the experience of pain is individualized and might be influenced by previous experiences including trauma and mental health conditions, such as depression or anxiety." (Dr. Flink told me that anti-anxiety medications during insertion are helpful for some of her patients, and that she'll discuss them alongside options for physical pain relief.)

Lidocaine paracervical blocks may relieve pain

There's good news and bad news about the recommended pain medications. The good news is that there are recommendations. The bad news is that none of them are guaranteed to work for everyone, and it's not clear if they work very well at all.

The CDC says that a paracervical block (done by injection, similar to the numbing injections used for dental work) might" reduce pain with insertion. Three studies showed that the injections worked to reduce pain, while three others found they did not. The CDC rates the certainty of evidence as low" for pain and for satisfaction with the procedure.

Dr. Flink told me that while some of her patients appreciate this option, it's often impossible to numb all of the nerves in the cervix, and the injection itself can be painful-so in many cases, patients decide it's not worth it. Still, it's worth discussing with your provider if this sounds like something you would like to try.

Topical lidocaine may also help

Lidocaine, the same numbing medication, can also be applied to the cervix as a cream, spray, or gel. Again, evidence is mixed, with six trials finding that it helped, and seven finding that it did not.

The certainty of evidence was judged to be a bit better here-moderate for reducing pain, and high for improving placement success (meaning that the provider was able to get the IUD inserted properly).

Other methods aren't well supported by the evidence (yet?)

For the other pain management methods that the CDC group studied, there wasn't enough evidence to say whether they work. These included analgesics like ibuprofen, and smooth-muscle-relaxing medications.

The CDC also came out with a recommendation against misoprostol, which is sometimes used to soften and open the cervix before inserting an IUD. Moderate certainty evidence says that it doesn't help with pain, and low certainty evidence says that it may increase the risk of adverse events like cramping and vomiting.

What this means for you

The publication of the guidelines won't change anything overnight at your local OB-GYN office, but it's a good sign that discussions about pain management with IUD placement are happening more openly.

The new guidelines also don't necessarily take any options off the table. Even misoprostol, which the CDC now says not to use for routine insertions, might be useful in selected circumstances (e.g., in patients with a recent failed placement)," they write.

Don't be afraid to ask about pain management before your appointment; as we discussed before, some medications and procedures require that you and your provider plan ahead. And definitely don't accept a dismissive reply about how taking a few Advil should be enough; it is for some people, but it's not for others, and you deserve to have your provider take your concerns seriously.