Pain and Anxiety Management with IUD Placement: What’s In, What’s Out

IUD insertions have long been known to cause pain, with some patients describing the experience as extremely uncomfortable or even traumatic. Until recently, pain management for this procedure didn’t receive much attention, but that’s starting to change.

In response to patient advocacy, social media movements, and new federal recommendations, healthcare providers are rethinking pain and anxiety management during IUD placement. Let’s take a closer look at the evidence-based options now available for pain management—and what’s no longer recommended.

The Problem: Pain and Anxiety with IUD Placement

Social media is rife with stories of people sharing their painful IUD experiences, with some saying the pain was worse than childbirth. Many of these posts go viral, receiving thousands of comments and shares, reflecting how widespread the discomfort is.

For example, some social media users have said:

• “Mine was excruciatingly painful, and I have had a baby.”
• “I have a high pain tolerance and screamed—it was the worst pain I’ve ever felt.”
• “The IUD was worse than my labor.”

Beyond personal stories, there’s also a significant gap in pain perception between patients and providers. Studies have found that patients often report much higher levels of pain than providers anticipate, particularly during specific parts of the procedure like tenaculum placement and uterine sounding. This gap in perception highlights the importance of addressing pain management proactively and ensuring patient concerns are taken seriously.

With such feedback making waves online, the CDC released updated guidance in August 2024 recommending that clinicians routinely address pain management options for IUD placements—a much-needed shift.

What’s In and What’s Out: Updated Pain and Anxiety Management Recommendations

What’s In:

• NSAIDs (Naproxen): Consider using naproxen sodium (220 mg) the night before or naproxen (550 mg) an hour before the procedure. It's shown some effectiveness in reducing pain, unlike ibuprofen, which is not supported by evidence for this procedure.
• Lidocaine Gel (4%) or Lidocaine 2.5%/Prilocaine 2.5% (EMLA cream): Applying 10 minutes before the procedure has demonstrated modest pain reduction. Topical anesthetics are particularly helpful in managing discomfort, especially for patients who are more sensitive to the procedure. They can be applied via swab or tampon. 
• Paracervical Block: A more invasive but effective option for reducing pain with tenaculum and IUD placement. With proper training, this option can be easily used in most clinical settings.
• Tramadol:  A 50 mg dose one hour before the procedure is an option for patients who need stronger pain management.
• Benzodiazepines: Diazepam (5-10 mg, 30 minutes before the procedure) can help reduce anxiety and enhance patient comfort, especially for those with significant anxiety or trauma associated with medical procedures.
• Lavender: Inhaled lavender has been shown to reduce anxiety and improve patient satisfaction, although it doesn’t reduce the pain itself.
• Ultrasound Guidance: This technique has been shown to reduce pain and procedural time while improving accuracy and patient satisfaction. It’s particularly useful for complicated cases or for patients who might benefit from a more precise approach.

What’s Out:

• Ibuprofen: No longer considered effective for IUD placement pain management. Studies have shown no significant pain reduction at any dose.
• Misoprostol: Previously used to soften the cervix, misoprostol is no longer recommended for routine IUD placements as it does not improve pain or ease of insertion and can cause increased cramping and discomfort. It is recommended after a failed insertion attempt. 
• Cold Compresses: No longer supported by evidence as a viable option for pain management. Warm compresses have not been studied.
• Timing with Menstruation: Performing IUD placement during menstruation has not been shown to reduce pain, and it may actually increase the risk of IUD expulsion.

The Takeaway

In gynecological care, patient-centered pain management for IUD insertions is finally getting the attention it deserves. Providers now have a range of tools to reduce both pain and anxiety. With options like naproxen, topical anesthetics, and paracervical blocks, along with considerations for tramadol or benzodiazepines, patients can feel more empowered to choose the best option(s) for them.

And for those who’ve endured significant pain in the past, progress is happening. It’s time we start listening more closely to patients’ experiences, validating their concerns, and offering effective solutions that make a real difference in their healthcare journey. 

We now have the tools to make IUD placement a more comfortable, less anxiety-provoking procedure. Let’s use them. For more, check out our Primary Care RAP episode, "IU-Doing this Right? Pain and Anxiety Management for IUD Placement."