Pain Management of Intrauterine Device (IUD) Insertion

Intrauterine devices (IUD) are safe and highly effective treatment options for contraception and menses suppression. For most patients, the procedure is generally well tolerated with patients experiencing varying degrees of discomfort. However, some patients will experience significantly higher levels of pain during insertion. Providers can offer patients options to help reduce pain they experience with insertion which are outlined in this resource.

Literature Supports the Following Interventions

Counseling – Non-pharmacological approach to pain management includes preprocedural counseling and support during the procedure. Pain can often be underestimated by clinicians. Acknowledge any anxiety surrounding anticipated pain and discuss ways to mitigate adverse events, such as ensuring to eat and drink prior to the procedure. Ask patients if they have a history of adverse events with procedures, pain with speculum exam, or vulvodynia. Anxiety, fear of the procedure, or anticipated pain with insertion can increase pain perception and may be barriers for patients choosing an IUD for contraception or menses suppression.^{Footnote 1 Footnote 2}

Lidocaine-prilocaine cream (LPC) – LPC (2.5% lidocaine and 2.5% prilocaine or EMLA® cream) has been shown to reduce pain with placement of tenaculum and IUD insertion.^{Footnote 2 Footnote 3} 
Use: While the patient is in the lithotomy position, apply an antiseptic solution (e.g. provo-iodine) to the cervix and vagina. Then apply approximately 5 g of cream to the cervix including the external os. Allow 7 minutes for analgesia to take effect.

Conflicting Literature

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) – NSAIDs show limited efficacy for pain associated with IUD insertion. However, there is some evidence that oral NSAIDs can help with post-procedural pain. Despite the conflicting evidence, NSAIDs (e.g. naproxen 550 mg po) are often offered before or after IUD insertion.^{Footnote 2 Footnote 3 Footnote 4}  

Paracervical/Intracervical Block – There is conflicting evidence regarding the benefits of paracervical block for IUD insertion and it remains an unpopular option for patients and general practitioners.  ^{Footnote 2 Footnote 3}  It is not recommended to perform a paracervical/intracervical block without prior dedicated training. Consider referral to a gynaecologist if the patient prefers this option.
Low Dose Methoxyflurane (Penthrox®) - There is no data specific to methoxyflurane for IUD insertion but theoretically it could be helpful for pain control in this setting given the beneficial findings in other gynecological procedures. ^{Footnote 2 Footnote 5}

Use: See WDH Clinician Practice Support: Penthrox®

Not Supported by Literature 

Timing of IUD insertion – There is no evidence to support inserting IUDs only during menses. IUDs may be inserted at any time during the menstrual cycle if pregnancy can be reasonably excluded.^{Footnote 6}

Misoprostol – Despite a wide range of studies, evidence seems to suggest that pre-treatment with misoprostol does not decrease pain or improve ease of IUD insertion.  Misoprostol for this indication is not currently endorsed by the Society of Obstetricians and Gynaecologists of Canada and its use can be associated with uncomfortable side effects.^{Footnote 2}  However, a recent systematic review concluded that pre-procedure misoprostol may increase placement success in those patients with a recent failed IUD insertion attempt.^{Footnote 7} 
Use: Misoprostol (off-label use) 400 mcg vaginally or buccally 2-3 hours pre-procedure. 

Anxiolytics – There is currently no literature available on the efficacy of anxiolytics for pain management. However, some patients may benefit from pre-procedural oral anxiolytics to reduce anxiety related to insertion. ^{Footnote 3}

Use: Lorazepam (off-label use) 0.5-1 mg S/L 30 minutes pre-procedure.

Other Considerations

Sexually Transmitted and Blood Borne Infection (STBBI) Counseling and Screening  – At the time of IUD insertion, screening for gonorrhea and chlamydia is recommended for high-risk individuals and upon patient request. If there is no suggestion that an acute pelvic infection is present, waiting for STBBI screening results should not delay IUD insertion. If an individual tests positive, the individual and partner(s) should be treated while the IUD remains in situ. In the case of pelvic inflammatory disease, IUD removal is not necessary unless after 48-72 hours of appropriate antibiotic treatment there is no clinical improvement.^{Footnote 6 Footnote 8}

Antibiotics – Antibiotic prophylaxis for the placement of an IUD is not recommended, even for individuals with valvular heart disease.^{Footnote 8}

Bacterial Vaginosis (BV) – Routine screening for BV is not recommended for asymptomatic women. Screening can be considered in symptomatic patients or patients with a history of recurrent BV infections. There is no evidence indicating that presence of BV at time of insertion increases risk of clinical complications. ^{Footnote 8}

Referral – For patients with a history of trauma or inability to tolerate a speculum exam, consider referral to gynaecology to support other options for insertion, such as procedural sedation.

Deployments – We recommend inserting an IUD at least 6 weeks prior to a training exercise, operation or deployment to allow for a string check and to ensure there are no complications.