The US Centres for Disease Control and Prevention (CDC) has updated guidelines on intrauterine contraceptive devices(IUD) insertions to include pain management.
In the first update since 2016, the agency suggests that lidocaine “might be useful for reducing patient pain” when injected as a local anaesthetic or applied topically as a numbing gel, cream or spray: it also recommends doctors warn patients about potential pain, and personalise IUD placement and pain management plans for each individual.
The patient-centred language in the update is a large shift from the 2016 guidelines, which were less specific and less detailed, said Dr Tessa Madden, professor of obstetrics, gynaecology and reproductive sciences at the Yale School of Medicine.
Madden’s research on the use of lidocaine was referenced in the updated guidelines. However, she noted, her research is nearly 12-years-old, highlighting the longstanding challenge in improving pain management during the procedure.
CNN reports that in a 2019 survey of about 1 000 family planning providers, less than 5% reported using a lidocaine injection during IUD insertion.
Instead, they more frequently suggested ibuprofen, which research has shown does not reduce insertion pain.
“Suggesting that women take ibuprofen is the bare minimum, and it’s not enough,” said gynaecology nurse practitioner Stephanie Edwards-Latchu, whose campus health clinic at University of North Carolina Chapel Hill offers lidocaine gel and injections, heating pads, Valium and the option to bring a supporting person.
The clinic is also experimenting with umbilical vibration devices that might reduce discomfort during the procedure.
The procedure to insert an IUD takes about 15 minutes or less. A healthcare provider performs a pelvic exam and then uses a speculum to widen the vagina, through which they place the device within the uterus.
“Any one of those steps can be uncomfortable for women, from the pelvic examination to the IUD insertion, although it’s typically the insertion that’s the most uncomfortable, when they experience the highest level of pain,” said Dr Beverly Gray, an associate professor of obstetrics and gynaecology at Duke University and an obstetrician and gynaecologist at Duke Health.
Cramping and other uncomfortable or painful sensations can occur during and after insertion, as the procedure involves using pointed forceps – a tenaculum – to stabilise the cervix and passing the intrauterine device through the narrow cervical canal.
“Patients have clearly spoken out about their traumatic or painful experiences,” Gray added. “These guidelines highlight the importance of discussing pain management and being frank about the spectrum of experiences that they might have.”
Female pain has long been under-recognised and under-treated.
“Women have been saying for decades, ‘my pain is not being taken seriously’,” Edwards-Latchu said. “It feels like screaming into the void.”
A 2021 study found that pain in female patients is consistently underestimated due to gender stereotypes, and women are judged to benefit less from pain medicine than men, despite equal likelihood of seeking care.
“In medicine, we historically have not done a very good job of taking women’s pain, in particular, seriously,” added Madden.
Edwards-Latchu described a female patient whose appendix ruptured after her abdominal pain was dismissed as menstrual cramps, pointing to a broader issue of women’s pain being mismanaged. Research echoes this, showing that women in emergency rooms with similar abdominal pain scores to men waited longer and were less likely to receive pain relief.
This issue also extends to IUD insertion, where studies have shown patients report significantly higher pain levels than providers perceive.
There is no guaranteed way to predict a woman’s response to an IUD insertion, according to Madden, who said that some of her patients have high levels of pain while others experience “very little”.
However, increased pain during the procedure is more likely if the patient hasn’t had a vaginal birth, has a history of painful periods, or has experienced trauma.
Some research also suggests that anxiety is associated with worse pain across various medical procedures.
“It’s sometimes hard to predict who will have an easy experience with insertion and who will have a more challenging experience,” Gray added. “Understanding that is important.”
A 2014 study of 109 IUD recipients found that 78% reported pain ranging from moderate to severe upon insertion. That range is clear on TikTok, where numerous women have shared live videos from the exam table as their IUDs were inserted.
“IUD insertion is the worst pain imaginable,” wrote one user who showed herself writhing in pain.
“This was the most excruciating pain I’ve ever experienced,” another shared. In both videos, the healthcare providers inserting the IUDs could be heard telling their patients to expect pressure or a “pinch”.
Social media shows part of the picture
“It’s heartbreaking,” Edwards-Latchu said of the videos on her social media feed. “The first thing that I think is, ‘I doubt they were given anything for their pain’, and that is upsetting.”
The videos bring awareness to the potential pain, she said, adding that it’s important “to know about the negative experiences so that something changes”.
However, Madden said the videos could also dissuade viewers from considering a contraceptive option as a viable option.
“Patients come into the office talking about videos that they’ve seen on TikTok or Instagram, which is where a lot of times patients get their information from,” she said. “Seeing a video like that could be a significant deterrent.”
Intrauterine devices have had a tumultuous history. Notably, the Dalkon Shield in the 1970s caused cases of severe infection and other complications, casting a long shadow over the safety of IUDs. However, modern IUDs have been proven to be safe and effective, and are used by more than 10% of women aged 15 to 49, shows CDC data from 2017-2019.
They can last for up to 10 years or more and are 20 times better at preventing unintended pregnancies than birth control pills and other short-term contraceptive methods, according to a 2012 study.
“An IUD is a highly effective method with which many women are very satisfied,” Madden added. “But for some of the, the concern about pain with insertion is the reason they’re not using it.
“If patients feel we’re addressing their concerns about the pain, and taking those seriously, then that might increase their willingness to use the method.”
The Journal of Pain article – Gender Biases in Estimation of Others’ Pain (Open access)
NEJM article – Effectiveness of Long-Acting Reversible Contraception (Open access)
See more from MedicalBrief archives:
IUDs may cut cervical cancer risk by a third — US systematic review
Social media fuels birth control backlash
New WHO guidance on hormonal contraception for women at high HIV risk