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This bulletin is being sent by the Health Care Authority (HCA) in partnership with the Reproductive Health Access Project (RHAP).
Written by Meera Nagarsheth, MD
Intrauterine devices (IUDs) are a safe and effective form of contraception and have numerous non-contraceptive benefits. However, pain and discomfort during IUD placement are commonly reported.1 The CDC’s 2024 US Selected Practice Recommendations (SPR) for Contraceptive Use recommends counseling patients on pain management options prior to IUD placement.2 Both actual and anticipated pain during insertion often arise from a confluence of patient-related, trauma-related, psychological, and socio-structural factors. Clinicians should be aware of the history of white supremacy, patriarchy, sexism, ableism, medical discrimination, and racism, specifically related to the history of the IUD, which served as a tool for both population control and reproductive coercion.3 Patient-centered contraception counseling, trauma-informed care, and reproductive justice are helpful frameworks to approach an individualized discussion of pain control prior to IUD placement.4,5 The following describes different pharmacologic and non-pharmacologic options clinicians can offer patients to manage pain and discomfort during IUD insertion.
Pharmacologic options
Oral medications
NSAIDs
The effectiveness of NSAIDs prior to IUD placement in reducing pain during and after the procedure has been mixed.6,7 Studies that have demonstrated a reduction in pain recommend:8,9,10
- Oral naproxen 550 mg taken 60 to 120 minutes prior to placement, or
- Oral ketorolac 20 mg taken 40 to 60 minutes prior to placement
Ibuprofen has not been shown to be effective in reducing pain during IUD insertion.11,12,13
Opioids and anxiolytics
Utilizing opioids and benzodiazepines prior to IUD placement requires planning:
- Review the consent with the patient prior to taking the medication
- Ensure the patient has a ride home after the procedure
- Combined sedation with opioid and benzodiazepine medications, given orally or IV, requires adequate monitoring.
Opioids
One study demonstrated that oral tramadol 50 mg taken 60 minutes prior to placement, decreased pain.9
Anxiolytics
Pain and anxiety can often be interconnected, so the use of oral anxiolytics may be beneficial during IUD placement. Consider the following:8
- Oral midazolam 10 mg taken 30 to 60 minutes prior to placement, or
- Sublingual lorazepam 1 to 2 mg taken 20 to 30 minutes prior to placement, or
- Oral diazepam 5 to 10 mg taken 60 to 90 minutes prior to placement.
Misoprostol
Misoprostol is not recommended to facilitate routine IUD placement or for pain control during the procedure. It can be considered in circumstances such as a recent failed insertion, history of cervical stenosis, or prior cervical surgery.2,7
Other medications
There is insufficient evidence to demonstrate that acetaminophen or smooth muscle relaxants are effective in reducing pain related to IUD placement.2
Evidence regarding the effectiveness of nitrous oxide in reducing pain related to IUD placement has been mixed.6,8
Topical medications
Topical lidocaine may be effective in reducing pain.2,14 Topical lidocaine formulations include cream (Lidocaine-Prilocaine or EMLA; self-administered or administered by a clinician), 2% gel (can be self-administered), 10% spray, and solution (1% or 2% in a paracervical block).8
Paracervical block
Experts advise paracervical blocks for nulliparous patients, those at increased risk for and who have increased concern for pain, and for more complicated IUD placements.8 An intracervical block may also be considered as an alternative to a paracervical block.8,14
Other options
Moderate sedation with IV Fentanyl or Midazolam (typically at doses of Fentanyl 100 mcg and Midazolam 2 mg), which is routinely utilized for surgical abortion procedures, can also be considered depending on patient preference, history, and their experience with placement. IUD insertion under general anesthesia can also be discussed. Offer patients a list of referral options that specify cost, insurance coverage, and scheduling options.
Non-pharmacologic options
Clinicians should always provide trauma-informed care by considering screening for trauma prior to the visit for the insertion and by taking universal precautions, including limiting touch and exposure to only what is necessary, and in the language and overall approach during insertion. Clinicians should also center reproductive justice through prioritizing patient autonomy and control during the procedure. This can be done by offering guided self-placement of the speculum, self-application of topical lidocaine, and being willing to stop or pause the procedure at any time if the patient says they need a break or cannot tolerate the pain or discomfort.
There are a number of non-pharmacologic approaches to pain control that can support the patient during IUD placement, including verbal distraction (“verbicaine”), music, visual distraction, aromatherapy, and a support person.15 Non-pharmacologic options should be offered to all patients, as they are low-risk interventions that are easy to implement.
Conclusion
There are several oral pharmacologic options (NSAIDs, opioids, benzodiazepines), topical pharmacologic options (Lidocaine cream, spray, gel, or a paracervical/intracervical block), and non-pharmacologic options that can be discussed with a patient to create a personalized pain management plan for IUD placement.
- Consider offering a call or visit prior to the appointment for IUD placement.
- Some patients may prefer same-day pain control options to ensure a quick start and rapid initiation.
- Referrals to outside clinicians may be necessary for adequate pain control.
A comprehensive discussion of pain management that centers the patient’s autonomy, prior experiences, and concerns prior to IUD placement and utilizes shared decision-making and trauma-informed care principles is essential to advancing reproductive justice and health equity in the provision of reproductive health care.
References
See RHAP's original post for sources
For more information, review the 2025 ACOG Clinical Consensus on Pain Management for In-Office Uterine and Cervical Procedures.
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