The CDC (Centers for Disease Control and Prevention) has issued new guidelines about the IUD (Intra Uterine Device) for better pain management during the IUD insertion procedure.

IUD (Intra Uterine Device):

An IUD (Intra Uterine Device) is a birth control device that is inserted in the uterus to prevent pregnancy. IUDs are of 2 types. They are copper and hormonal IUDs. They are T-shaped. The difference between the IUDs is that in the copper IUD, the stem part of the T has copper wire, whereas in the hormonal IUD, the progestin hormone levonorgestrel is around the stem of the T. The IUD brands approved by the FDA are Paragard, Mirena, Liletta, Kyleena, and Skyla.¹

In the year 2021, there was a huge resentment regarding the pain associated with IUD insertion. Many women resorted to social media to share their experiences and feelings they endured due to pain during the IUD insertion procedure. About this matter, a study titled “Pain experiences during intrauterine device procedures: a thematic analysis of tweets” was carried out to analyze the tweets to gain insight into the public's perspectives and experiences.²

For the study, about 1431 tweets that had descriptions of the pain experiences linked with an IUD or coil were included. After thorough analysis, it was found that

1. The women reported that they were not informed of the pain intensity and relief options.

2. Some shared the varied levels of pain they had to go through.

3. Some of them shared about the impact it had on their mental well-being.

4. Some described IUD procedures as painful experiences.

5. Some shared that they were not previously counseled about the pain intensity.

6. Some reported that they were not given any relief options before insertion.

7. Some felt a sense of community by sharing their painful experiences and extracted validation by sharing their experiences.

8. Through this community, some shared lived experiences to provide information and guidance to others.

9. Some also viewed this as a stage for collective action to generate evidence and improve pain management options.

The conclusion that can be drawn from the study is that it has shown many perspectives and experiences of women during the IUD insertion procedure, and there is a need to look into this matter and focus on the development and implementation of strategies to reduce IUD pain.

Taking this matter into account, the CDC’s 2024 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR), which provide recommendations on the use of contraceptives, side effects associated with them, and removing barriers involved in accessing contraception, has updated guidelines to manage IUD pain during January 25–27, 2023, after reviewing scientific evidence and holding a meeting with experts from Atlanta, Georgia.³

The new guidelines by CDC have updated recommendations for provisions of medications for IUD placement, bleeding irregularities during implant use, testosterone use and risk for pregnancy, and self-administration of injectable contraception. 

Provisions of medications for IUD placement:

The updated recommendations suggest that:

1. Misoprostol should be restricted only in selective circumstances and should not be regularly used.

2. For decreasing the pain in patients during IUD placement, lidocaine (topical or paracervical block) should be used.

Evidence Summary:

• Patients should be counseled and informed about the risk-benefit ratio, side effects, pain associated with it, how to manage pain, and alternative methods of managing pain.

• A personalized plan should be prepared based on the patient's condition for placing an IUD and managing the pain.

• The barriers involved when using an IUD are that the patients are concerned about the pain that can occur when placing the IUD; patient concern about pain is dependent upon the individual experience, and factors like previous experience of trauma or anxiety can also play an important role.

Misoprostol:

Misoprostol was administered via oral, buccal, sublingual, and vaginal routes at a <400µg dose in 3 randomized control trials and at a 400µg dose in 11 randomized control trials for examination. Misoprostol was administered 1–8 hours before IUD placement.

• From the evidence, it was found that misoprostol does not reduce pain, adverse effects, or the need for adjunctive placement measures and does not ease the placement of the IUD.

• The evidence also showed that misoprostol is known to increase patient pain and cause abdominal pain, cramping, and diarrhea.

Lidocaine:

1. Topical gel, cream, or spray of lidocaine: 15 mins before the IUD placement; 2% lidocaine gel in 5 trials; 10% lidocaine topical spray (cervical) in 3 trials; lidocaine-prilocaine cream (cervical) in 3 trials; 10% lidocaine topical spray (intracervical) in 1 trial; lidocaine topical cream (intracervical) in 1 trial; and 2% lidocaine topical gel (cervical) plus oral diclofenac in 1 trial was applied for examination.

• From the evidence, it was shown that lidocaine reduces pain.

• The evidence also showed that lidocaine does not reduce adverse effects or the need for adjunctive placement measures.

2. Paracervical block of lidocaine: 5 minutes before IUD placement, 1% lidocaine paracervical block in 4 trials, and 2% lidocaine paracervical block in 2 trials were administered for examination.

• When randomized control trials were carried out, the results of the paracervical block of lidocaine were the same as the topical gel, cream, or spray of lidocaine.

REFERENCES:

1. Professional, C. C. M. (2024b, May 1). Intrauterine device (IUD). Cleveland Clinic. https://my.clevelandclinic.org/health/treatments/24441-intrauterine-device-iud

2. Taghinejadi, N., Van Der Westhuizen, H., Ayomoh, F. I., Ahmed, W., Greenhalgh, T., & Boylan, A. (2024). Pain experiences during intrauterine device procedures: a thematic analysis of tweets. BMJ Sexual & Reproductive Health, bmjsrh-202011. https://doi.org/10.1136/bmjsrh-2023-202011

3. Curtis, K. M., Nguyen, A. T., Tepper, N. K., Zapata, L. B., Snyder, E. M., Hatfield-Timajchy, K., Kortsmit, K., Cohen, M. A., Whiteman, M. K., Baker, C., Dethier, D., Garbarino, S., Gold, H., Halper, E., Kapp, N., Krishna, G., Meurice, M., Ramer, S., Rodenhizer, J., . . . Wright, S. (2024). U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recommendations and Reports, 73(3), 1–77. https://doi.org/10.15585/mmwr.rr7303a1

By Dr. Siddiqua Parveen