On August 8, 2024, the CDC updated its selected practice recommendations for contraception for the first time since 2016. This revision emphasized the importance of discussing pain management options with patients undergoing intrauterine device (IUD) placement. Although the steps involved in IUD insertion are widely recognized as painful, this update marked the first time the CDC recommended tailoring pain management strategies based on open conversations with patients.
Despite the well-known discomfort associated with IUD placement, clinical guidance from the American College of Obstetricians and Gynecologists (ACOG) has not identified a single method as definitively effective for pain relief. The analgesics studied include intracervical lidocaine gel, nonsteroidal anti-inflammatory drugs (NSAIDs), misoprostol, and nitroglycerin. While paracervical blocks show some promise, ACOG considers their use “controversial” due to mixed results from small studies.
Without a standard of care, it is reasonable for clinicians to hold differing opinions on the necessity and effectiveness of pain management during IUD procedures. However, this lack of consensus exemplifies the broader issue of dismissing women’s pain in medicine. For decades, women’s heart attacks went undiagnosed until clinicians stopped basing symptoms solely on male anatomy. Severe menstrual pain was often dismissed as “natural,” delaying diagnoses of conditions like endometriosis and uterine fibroids. The gender pain gap fosters distrust in medical professionals, particularly among those specializing in women’s health.
To gain trust and ensure continuity of care, physicians should initiate patient-centered discussions about factors influencing pain and patients’ desired levels of pain control. The CDC acknowledges in its updated recommendations that pain is a subjective, individual experience that can be exacerbated by a history of trauma or mental health conditions like depression and anxiety. For nulliparous women, a gynecological procedure may be an unfamiliar and intimidating experience, potentially causing fear and uncertainty. Even if clinicians believe they can infer patients’ comfort levels from body language, research has demonstrated that clinicians often underestimate patients’ pain levels during IUD placements. Patient interviews focusing on these factors can provide clinicians with valuable insights into individual pain tolerance and the need for additional pain control.
Conversations about pain control not only give patients a sense of autonomy in their care but also allow clinicians to demonstrate empathy and build trust. Positive relationships, in turn, may lead to improved health outcomes through routine screenings, such as Pap tests and STI screenings. Conversely, a negative experience with IUD placement due to poor patient-clinician communication may deter patients from seeking further reproductive health care. From an ethical standpoint, discussing pain management is a critical component of informed consent, empowering patients to choose options that align with their comfort levels with the guidance of their clinician.
With open conversations about pain and its management, we can demystify long-acting reversible contraception (LARCs) and women’s reproductive health care more broadly. Patients seeking effective, long-lasting, and low-maintenance birth control may currently avoid IUDs due to fear of pain. Furthermore, patients who have experienced painful IUD insertions often delay removal to avoid the anticipated pain. Even when clinicians’ offices offer various analgesia or anesthesia options, insurance may deny coverage, citing the lack of a “standard of care.” Without access to LARCs, individuals of childbearing age may resort to less effective contraceptive methods, increasing the risk of unintended pregnancies. Further research is needed to substantiate the efficacy of pain control measures, as women’s voices alone have had limited impact on how the medical community addresses women’s pain.
While we await a universally effective pain control method for gynecological procedures, clinicians should proactively address their patients’ concerns about pain. As a patient who underwent two IUD placements, I was shocked to learn that pain management options extended beyond the two ibuprofen my friend had suggested I take. Despite knowing the procedure would be painful and mentally preparing for it, my state of mind was only acknowledged when a medical assistant questioned why my blood pressure might be higher than normal that day.
By exploring and respecting patients’ concerns, clinicians can foster trust, improve health outcomes, and empower women in their health care decisions. Addressing pain in gynecological care is a small but vital step toward validating women’s experiences.
Madison Ziobro is a medical student.
