IUD Insertion Pain: New Guidelines for Pain Management (Episode 591)

Full Transcript: Episode 591

Lisa Hendrickson-Jack:

This is the Fertility Friday Podcast, episode number 591.

IUD insertion pain. If you’ve been a longtime listener to this podcast, you have heard this topic come up time and time again. Maybe not so much in the recent year, but I previously used to regularly record Pill Reality Series episodes. And in those episodes, I would interview real women, part of the Fertility Friday community, who would share their personal experiences with hormonal birth control and other types of birth control, including the hormonal and non-hormonal IUDs. This phenomenon was something that I didn’t really know about so much until I started interviewing women. And even still when I do the FAMM practitioner series and our practitioners are sharing about their experiences using birth control or other methods, this theme of IUD insertion pain just kept coming up over and over and over again. And while 100% of the women that I’ve interviewed who have had an IUD placed did not necessarily have an issue with pain, it’s really high. I would say it’s something like 70 to 80%. And when they describe the pain, it is just excruciating, unbearable, and it varies, of course. Some women continue to have dull aching and discomfort for hours or even days after the procedure is done.

And this subject — I don’t know if it’s as controversial now — but there is some controversy around it because there are many medical practitioners who actually don’t believe that women have nerve endings in their cervix. And so, they don’t even think to offer any type of pain management to them. Well, in today’s episode, we are covering a brand new paper. It literally came out in July 2025. And the paper is essentially a consensus statement from the American College of Obstetrics and Gynecologists. Now, this isn’t the first statement by them about IUDs, but because it recently came out, I think it’s really important that we talk about it and go through this whole situation. I would say debacle. And so, obviously, this issue is coming up more and more. I think that would be what prompted them to say something about it. But essentially there is this issue with medical professionals not believing that women can feel anything in their cervix and definitely not taking proactive measures to ensure that women who are having their IUDs placed are comfortable — and even just acknowledging that. So I’m going to talk about what the paper discusses. I’m going to go through that.

Now the paper doesn’t only talk about IUD placements — that’s going to be our focus today. They do talk about other procedures that involve going in through the cervix and how they should be managed. But I mean, it’s just wild to me that this is 2025 and it’s like now they’ve got to do something about this, where women have been suffering and experiencing just these painful experiences of insertion for so long, and it really does, like many things related to women’s health, feel like it’s falling on deaf ears. So for any practitioners who are listening to this episode, it’s also really useful to get a hold of this paper. So you can head over to fertilityfriday.com/591. Of course, we will have the show notes there with the link to the paper so that you can have a look at it. But essentially this is important information for practitioners and women to know alike because this also means that ACOG has officially provided some direction and acknowledged this issue. And for anyone — if you’re having resistance from a health practitioner around providing some sort of pain management for this procedure — then you can ask for it. And now if you get any pushback, you could literally pull up the abstract or the full paper if it’s available and show them, look, the recommendations have changed here.

So I will start with one of the kind of statements that this committee made right off the bat. So according to them, quote, “There is an urgent need for healthcare professionals to have a better understanding of pain management options and to not underestimate the pain experienced by patients, and for patients to have more autonomy over pain control options during in-office procedures.” Well, duh. I still think it’s amazing that we have to have a committee declare this, but we will continue.

So they’re basically saying in more professional language — I’ll read another couple of quotes here from the paper. They say, “The way pain is understood and managed by healthcare professionals is also affected by systemic racism and bias of how pain is experienced. Specific populations such as adolescents and those with chronic pelvic pain, sexual violence or abuse, and other pain conditions may also have increased or decreased tolerance of pain and resistance to pain medications.” So they’re kind of saying: look, we have to actually take this seriously. You have to be aware of the fact that every patient isn’t the same. So for example, if you have a medical professional and most of his patients haven’t complained, right, they might be under the impression that there’s really no problem. But then how comfortable are your patients speaking up? How many women may be experiencing some discomfort, maybe not enough for them to kind of yell out and say something. And being in the doctor’s office is often intimidating, even with a doctor that you’ve known for your whole life, especially if their default is that this procedure is fine, it just takes a couple minutes. Even if you experience some discomfort, it’s not a big deal. Like how comfortable are your patients even to say anything if you have that disposition?

So they actually define pain in the paper, which again is necessary and useful. So they say pain is a highly subjective and personal experience for the individual patient. Again, duh. But they have to actually say that. They have to say that it’s not experienced in the same way by everybody. And there are all these factors that could increase how sensitive a person is to pain and what their pain tolerance is. Pain is defined as an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage.

I think this is just indicative of where we’re at, where they have to tell the professionals that pain is real and that people experience it differently — because they know, they know that this is an issue that has been going on for some time, and they know that many health professionals don’t really believe that women experience pain. And who knows, it could just be that it’s easier for them to just go ahead and do the procedure real quick. And actually having to go through a process of assessment and strategizing around pain management options for a “simple procedure” might just take too long.

So it says right here, like black and white: pain management may be perceived by healthcare professionals as unnecessary, and in turn may not be discussed with or offered to patients. Notably, despite patients reporting a higher level of pain than clinicians expect, patients still report a high level of satisfaction with office procedures. So they’re also kind of saying — based on the surveys that they’re quoting here — that patients aren’t being offered pain management. Again, they know. They know what’s going on. They know it’s happening. And enough women are complaining that this body of medical professionals, this committee, is calling it out.

So they also define certain groups of women that may be experiencing more pain or may be more susceptible to pain. They identify patients with a history of period pain, specifically women who have never had children — they are calling them out and saying, okay, they may experience more pain. And so from a practical standpoint, if you’ve never had a child vaginally, then the cervix is tighter, it’s smaller. Even from the fertility awareness perspective, there are specific instructions that we share with our practitioners when we teach about cervical position checking. And you can feel — when you feel and palpate the cervix once a day to identify the fertile window — you can feel how open the cervix is. And so before you’ve had children, the cervix feels like the end of your nose. So if you were to just take a moment right now and touch the end of your nose and just kind of palpate it — typically that is how the cervix feels when you touch it before you’ve had children. And then during the fertile window, if you were to put your lips together and touch your lips, you can’t stick your finger in it, but you can feel a bit of an indent. And that is how the cervix feels before you’ve had children. After you’ve had children, after a baby has gone through the vaginal canal, obviously the cervix had to open to allow the baby to come out. The cervix is never again as closed as it will be. So it’s always slightly dilated. And so when you touch the cervix after you’ve had children outside of the fertile window, it will feel firm, but you will feel a bit of an opening. And then once you’re in the fertile window, it will feel a lot softer and the opening will be more pronounced.

So from the fertility awareness standpoint, we know that the cervix of a woman who’s never had children — there’s just very little opening there, there’s little give — compared to a woman who’s had children. But again, they have to identify this specifically. So they also go on to call out specific populations that may have increased or decreased tolerance of pain, resistance to pain medications — people for whom even pain medications don’t really have the same effect. So they’re talking about individual differences here. And then of course the women who have a history of pelvic pain or abuse may be more sensitive to pain in those areas. Throughout the study, they also call out that certain medical health professionals may be less likely to offer women pain medication or pain relief if they are Black or non-white.

So what they did essentially to determine their recommendations: the purpose of this consensus statement is to offer evidence-based recommendations for how to support pain management effectively for a list of different procedures that involve essentially inserting things into the cervix or through the cervix. And so they looked at a variety of studies over 24 years. Their search period was from the year 2000 to 2024. And they looked at studies that specifically measured interventions — a variety of different pain management interventions and how effective they were. So they went through, okay, what about this? What about that? What were the results of this study when they used this type of pain management? What were the results of the study when they used this other type of pain management? They looked at it in a methodical, evidence-based, scientific way to determine what is actually working, what is not working, what is more effective, what is less effective.

So interestingly, the takeaway from all of this is that they did come to the conclusion that pain is actually real. Women actually do experience pain during these gynecological procedures. They have concluded that it is definitely — like as a fact — underestimated by many health professionals. And there’s a problem. There’s a need for professionals to kind of come together and sort this out. And at the end of the day, this really validates the concerns that so many women have, that their problems, their concerns, their complaints are falling on deaf ears. So if you’ve ever felt a little gaslighted when you’re going into a medical office and you’re talking about pain — whether it’s related to the insertion of something into your cervix, or whether it’s just related to pelvic pain, period-related pain — and you’re not being taken seriously, this is a real phenomenon.

So when we look at the results — they assessed all these different papers over the course of 24 years. The results showed that every woman doesn’t experience this the same way. Obviously, every woman does not experience intense pain with insertion. And they say, “There are no reliable predictive factors that healthcare professionals can use to gauge an individual’s potential for pain.” And what they also say is: every patient who has an IUD placed should receive thorough counseling about the potential for pain associated with this procedure and should be provided with options to mitigate potential pain. So I mean, again, duh. This is something that I’ve been saying for years. Of everyone I’ve talked to over the years, it’s very, very few that have ever been offered pain meds. And if anything, the only thing they’re told is to take an ibuprofen or something a couple hours before. But as we’ll discuss, that was one of the strategies that was not effective — because it’s not a generalized pain that they’re having. It’s a very local, specific pain. So how does taking ibuprofen help you when they stick it in?

So the specific recommendations for pain management with IUD placement: one of the things they defined as most effective was the use of local anesthetic agents, specifically lidocaine. They would essentially inject a numbing agent into the tissues around the cervix at several points — kind of like when you go to the dentist and they put numbing there before they do it. That blocks the nerve pathways around the cervix, reducing the cervical pain and cramping. Based on their research, that was the most effective pharmacologic method for reducing pain during IUD insertion. It only takes a few minutes to administer. So we went from “they don’t have any nerve endings down there” to — actually, the research shows that the most effective way to consistently manage this is to numb the area. Again, duh.

So one of the things that has also been used for the procedure is what they call cervical ripening agents — agents associated with softening the cervix and potentially opening it a bit. But what the research shows is that this method actually increases pain and adverse effects. The adverse effects of misoprostol — the most commonly used cervical ripening agent — include abdominal pain, diarrhea, low-grade fever, and increased risk of IUD expulsion. And getting back to the ibuprofen strategy: the evidence does not support pre-procedural administration of NSAIDs as an effective intervention for reducing pain at the time of IUD insertion. They’re not causing harm, but they’re saying it doesn’t work. It doesn’t actually provide relief for the actual moment of insertion. So here we have it: the actual research is saying that if we want to consistently and effectively control pain, we actually need to numb the area.

So I have something to say outside of all of this, just as a practical thing, because I’ve had many women who’ve had this procedure tell me that doctors would recommend to come during their period because the idea is that the cervix is open a little bit — because it has to be open a little bit to let out the bleeding. But again, going back to the fertility awareness perspective: for any woman who’s checked her cervix throughout her cycle, when is the time in the cycle when the cervix is softest and most open, even more so than on the period? Obviously, it would be during the fertile window. So I mean, I’m not saying that that’s going to get rid of the pain altogether, for sure. But you can feel how hard and firm the cervix is outside of the window. And if you’ve never had a child before, you can’t even feel an opening. So if there was a practical time to go and get the IUD placed — even with the administration of pain medication — I would think it would be during the fertile window when you can actually feel how much softer the cervix is and you can actually feel the indent of the opening.

And one of the questions that I have — that I have not seen research about — is: for women experiencing extreme pain, really severe cramping that lasts all day or even a few days after insertion, is there a possibility that that is damaging the cervical cells? This IUD is going right into the cervical canal. And when you have that base of fertility awareness knowledge and anatomy, you understand that the cervical canal is where we have our cervical crypts — these delicate cells that produce cervical fluid. Anecdotally, I have seen women who have had IUDs placed and removed have limited mucus post-removal, at least for a time. Is it possible that if women are experiencing such extreme pain with insertion, there’s some tissue damage? I think it’s possible. And to what extent, we have no idea, because they haven’t studied it.

So huge, huge — I don’t even know what to say. Huge progress here, or just a wake-up call. So I hope that this is something that’s presented at medical conferences to shift the practices of current doctors. But if you’re familiar with the research on how long it takes research to actually get into medical offices — the estimate is anything from 18 to 20 years plus. So on average, it takes about 20 years for new research to actually trickle into your medical doctor’s office. So just to wrap this all up: pain is real and obviously underestimated — systemically underestimated. If you yourself need to have a procedure, it is worthwhile to make sure that you advocate for yourself. In terms of advocacy for pain management, it means you have to be vocal about it. And if you’re speaking to a provider who is not open to it, or is convinced that it’s fine and it’s a simple procedure — if that’s the pushback that you’re getting, then you may need to find another provider.

The common strategy of giving somebody ibuprofen or Tylenol or whatever — that doesn’t work. Collectively, the consensus was that that is not an effective strategy. What they did conclude is that the local anesthetic, the lidocaine, is what works. Overwhelmingly, that strategy of actually injecting anesthetic to the area was consistently the most effective strategy for reducing pain for the IUD insertion as well as all of these other procedures. The cervical ripening agents do not work and actually make it worse based on the research. The takeaway from all of that is: medical providers, stop thinking that you know if someone’s going to experience pain or not. Just give them the pain options.

And I would say if you’re a women’s health practitioner listening, it’s important to be able to help your clients to advocate for themselves and to share information like this with them so that they are more empowered. At least if you’re in the ring and you have to fight, it’s better to fight with data — because then it’s harder for you to be ignored. There’s an ACOG statement that came out in July 2025, and it specifically states that providers should be providing different pain options for their patients. And what they came to was that the local anesthetic was more effective than the other options — from a study of these interventions over the course of nearly 25 years.

If you found this information to be compelling and you can think of someone who needs to hear it, then I highly recommend sharing this with your friends and colleagues. This is important information — we need to get it out there. So fertilityfriday.com/591 if you want to share this information. And of course, as always — until next time, be well and happy charting.