Pain Management of Intrauterine Device (IUD) Insertion

Intrauterine devices (IUD) are safe and highly effective treatment options for contraception and menses suppression. For most people the procedure is generally well tolerated with varying degrees of discomfort experienced. However, some people will experience significantly higher levels of pain during insertion. Healthcare providers can offer options to help reduce pain experienced 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 fear or anticipated pain and discuss ways to mitigate adverse events, such as ensuring to eat and drink prior to the procedure. Ask if there is a history of adverse events with procedures, pain with speculum exam, or vulvodynia. Fear of the procedure or anticipated pain with insertion can increase pain perception and may be barriers to choosing an IUD as an option for contraception or menses suppression.^{Footnote 1 Footnote 2}

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

Conflicting Literature

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) – There is conflicting evidence in the literature regarding NSAID efficacy in reducing pain for IUD insertion. Some studies suggest NSAIDs may provide a placebo effect. Despite the conflicting evidence, NSAIDs (oral ibuprofen 800 mg or naproxen 500 mg) are often offered either before or after IUD insertion.^{Footnote 4}

Paracervical/Intracervical Block – There is conflicting evidence regarding the benefits of paracervical block for IUD insertion and it remains an unpopular option ^{Footnote 4  Footnote 5 Footnote 6} . Additionally, it is not recommended to perform a paracervical/intracervical block without prior dedicated training. Consider referral to a gynaecologist if this a preferred option.
Use: Intracervical block: Inject 1-2 ml of 2% lidocaine infiltrating the cervix at the anterior lip to ease pain associated with tenaculum placement. 

Not Supported by Literature 

Timing of IUD insertion – There is limited evidence that timing of the IUD insertion, such as during menses, reduces pain or improves outcomes. IUDs may be inserted at any time during the menstrual cycle if pregnancy can be reasonably excluded.^{Footnote 5}

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. It is currently not recommended by the Society of Obstetricians and Gynaecologists of Canada^{Footnote 6} . However, many healthcare providers continue to report using it on an as needed basis or after a previous failed attempt.
Use: 400mcg (200mcg X 2 tablets) inserted into the vagina, either 4 hours prior to or the night before the procedure.

Other medications – There is currently no literature available on the efficacy of anxiolytics for pain management. However, some persons may benefit from pre-procedural oral anxiolytics to reduce anxiety related to insertion.

Other Considerations

Sexually transmitted infection counseling and screening – Screening for gonorrhea and chlamydia is recommended for all persons presenting for IUD insertion regardless of risk factors. If there is no suggestion that an acute pelvic infection is present, screening should not delay IUD insertion^{Footnote 1} . If a person tests positive, they should be treated and the IUD can remain in situ^{Footnote 6} .

Antibiotics – Antibiotic prophylaxis for the placement of an IUD is not recommended, even for persons with valvular heart disease^{Footnote 1} .

Bacterial Vaginosis (BV) – Routine screening or routine antibiotic prophylaxis for BV is not recommended. Screening can be considered in those who are symptomatic or persons 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 6}

Referral – For persons 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.