The Centers of Disease Control and Prevention (CDC) recently updated guidance on what many people already know to be a (literal) pain: IUDs.
The August 8 recommendations notably suggest medication use for intrauterine device (IUD) placement, noting that misoprostol, which was approved to treat stomach ulcers and can be used to soften the cervix for easier IUD placement, should not be used routinely but only in select circumstances, and that lidocaine, a local anesthetic, may help reduce pain.
With these updated guidelines, the CDC addressed what has been a longstanding issue among some patients who faced pain during the procedure.
The guidance also comes after the number of laws heavily restricting reproductive rights has increased following the US Supreme Court’s 2022 Dobbs ruling. As eight states are taking steps to reduce birth control access so far this year, the CDC wants to make the medications more accessible. That’s in addition to 14 states banning abortion and false claims swirling around that IUDs cause abortions, according to the Washington Post.
And IUD is a form of birth control that is inserted through the cervix and into the uterus. The device can stay in place for eight to 10 years, according to Yale Medicine, though it can be removed any time.
Monica Ruehli, a practicing ob-gyn and Blue Cross Blue Shield of Massachusetts’s clinical director of reproductive health and gender-affirming services, spoke with Healthcare Brew about how the CDC’s guidelines can help address pain during IUD placement.
IUDs are effective, safe, and have low complication rates, Ruehli said, adding that patients don’t need to worry about taking daily pills after the procedure. And depending on the type of the device, some patients also stop menstruating when they have an IUD.
“I’d argue that contraception is more important than ever,” Ruehli said.
Why can IUDs be painful?
There’s no sense sugarcoating it: IUDs can be (very) painful when inserted. Ruehli said that this is because the provider is “manipulating the cervix.”
“You put a little device on to hold the cervix in place, and then you have to open up the cervix a little bit to pass the IUD through it, so that can irritate the nerves and that can cause pain,” she said.
Despite this experience of pain being relatively well known, Ruehli said there aren’t a lot of clear guidelines for pain management during or after the procedure. The CDC’s updated guidance, she said, is an attempt to address that.
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“At the moment, it’s left to each provider to make a decision on what they’re going to offer for pain management,” Ruehli said, adding that she has had some patients who reported no pain and others that have trouble getting through the procedure.
What are the takeaways from the CDC’s guidance?
By addressing IUD pain, Ruehli said the CDC will encourage more clinicians to talk with patients about it. In fact, as part of its guidance, the CDC said that “all patients should be counseled on potential pain during placement as well as the risks, benefits, and alternatives of different options for pain management.”
Patients have several options when it comes to pain management, Ruehli said, including oral pain medication, muscle relaxants, intramuscular injection of pain medication. Now, she added, the CDC is recommending lidocaine, which is a topical anesthesia that can be used as a gel on the cervix or an injection around the cervix.
Ruehli has also treated patients who required sedation for IUD placement, which she said is an added step, but can help as well.
“[The CDC] just said, ‘Take a patient-centered approach when it comes to making decisions [about] reproductive health or contraceptives,” Ruehli said.
“I like to think most ob-gyns do that anyway, but just the fact that [the CDC is] mentioning pain, and they’re bringing pain to the forefront, and making it a point of discussion, I think, is very beneficial to patients,” she added.
What’s next for IUDs?
The new guidelines from the CDC are just one small step toward helping patients have more positive experiences with IUD placement.
Until recently, providers recommended over-the-counter pain medications, but Ruehli said clinicians have since learned that it “doesn’t probably help all that much.”
Ultimately, she said, more research is needed to learn more about IUD placement and pain to build out the best possible care plans.
“It makes sense to do more research to try to figure out what would be optimal things you could offer your patients, so that there’s protocols that providers can look at and standardize what’s offered to somebody before they have a [gynecological] procedure,” Ruehli said. “This just highlights how important these discussions around women’s health and reproductive care are.”