Updated CDC guidance recommends pain management options for IUD insertion
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Key takeaways:
- Updated CDC recommendations state lidocaine for IUD insertion “might be useful” for reducing patient pain.
- The guidance now states misoprostol is not recommended for routine use for IUD placement.
The CDC recently issued updated guidance regarding the provision of medications for IUD placement, stating that lidocaine “might be useful” for reducing patient pain and that misoprostol is no longer recommended for routine use.
The updated 2024 U.S. Selected Practice Recommendations for Contraceptive Use replaces guidance issued in 2016 and is based on new evidence and input from experts. The document, which recommends counseling patients on pain management options, comes after a surge in social media posts from patients describing pain during their IUD placement, sometimes documenting the procedure on forums such as TikTok.
Over-the-counter anti-inflammatory medications are typically the only options recommended to help manage IUD pain, though research suggests they are largely ineffective.
“This is part of a long overdue trend toward actually centering the voices of patients in medical care,” Katharine O’Connell White, MD, MPH, chief of the department of obstetrics and gynecology at Boston Medical Center and professor and chair of OB/GYN at Boston University Chobanian & Avedisian School of Medicine, told Healio. “It does not mean clinician voices do not matter. This is the essence of shared decision-making. Clinicians are the experts on the evidence. Patients are the experts in their lives, what their values and needs are.”
Healio spoke with White about the specifics of the updated CDC recommendations, why there has been debate regarding pain management options and what the guidance means for patients.
Healio: There is a lot of misinformation on social media regarding IUD insertion. What have you heard from patients?
White: Patients do not always share the fact that they are getting their information from friends and social media. Patients, for years, have voiced to me their concerns, their worries — in some cases, their absolute terror — about getting an IUD inserted because of what they have heard about the pain. There are many patients who think they would like an IUD, but the process sounds so scary to them that they cannot overcome that barrier.
Healio: You were part of an advisory committee that led to the updated guidance. Can you walk us through the new recommendations?
White: CDC periodically puts out two guidance documents about contraceptive care. The first is intended for providers to help them with medical decision-making about which methods of birth control are safest for people with various medical conditions. The second includes evidence-based practice recommendations.
One of the new statements says lidocaine for IUD placement “may be useful” for pain management. On the surface, that does not look like a big change, but this actually represents a sea change. The guidance states that all patients should be counseled about potential pain during IUD placement as well as the risks, benefits and alternatives of doing something to try to reduce or prevent that pain. The updated guidance also refers to a person-centered plan for placement and pain management to be made based on the patient’s preference. This is revolutionary.
The guidance also includes an expert-level summary of the evidence for pain management options. That makes this helpful not only for any patient considering getting an IUD, but to the providers who really do want to do right by their patient, by pulling all of the evidence into one place. It says, here is what we know, and here is what we don’t.
The sobering part of this story is that CDC also uncovered how little conclusive evidence there is. That is why there have not been phenomenal recommendations to date about what people should do because we still do not know.
Healio: In addition to counseling patients about lidocaine for IUD placement, what other recommendations are new?
White: The medication called out as something that should not be used during an IUD placement is misoprostol. Misoprostol can help the cervix dilate for labor, pregnancy loss or abortion care, so it made sense that it may also open up your cervix for an IUD insertion. It was grounded in good theory, but what has been found is misoprostol increases side effects without actually making the procedure any easier. We do still have it in reserve, and if a provider has difficulty with an IUD insertion and a patient is willing to have a second try, misoprostol could help. But it should not be first-line for anyone.
So, we are essentially talking about one recommended drug, lidocaine. It can be given in many forms, but it is not like the CDC said here is a cornucopia of pain options for women. That is not what came out of this.
Healio: Why was this update needed and what does this mean for patients going forward?
White: This is part of a long overdue trend toward actually centering the voices of patients in medical care. It does not mean the clinician voices do not matter. This is the essence of shared decision-making. Clinicians are the experts on the evidence. Patients are the experts in their lives, what their values and needs are. We are finally getting to the point that for decisions that have no medical “right” answer, both of these experts need to be in the room and treated as such. Sometimes in medicine there is one correct answer. But when it comes to what form of birth control to use, when to obtain it and how long to keep it? There is no “right” answer to that. What is right is equally determined by what the patient wants as much as by what the medical determination is.
Healio: Why did it take so long for an update like this?
White: One of the reasons this took so long is because many people have minimal to no pain with an IUD insertion. They just don’t make a TikTok about it. That is what clouded the picture for clinicians and researchers through the years — pain is variable.
Yet, people may still have anxiety and fear about pain, even if they end up not having pain. We must be careful. Talking about anxiety is a double-edged sword. While there are some patients who do have anxiety and may benefit from an antianxiety medication, I do not want this to turn into, “Oh, she is just anxious.” Pain and anxiety, while related, are two separate things. We do not want to turn more people off on this form of birth control, which is incredibly important.
Healio: Is there anything else you would like to highlight about the updated recommendations?
White: When CDC talks about patient-centered care, they talk about the array of medications available, including oral medications, lidocaine and sedation. Studies suggest oral medications do not work. There are mixed data for oral medications and for treating anxiety.
The guidance does not go into detail about sedation during IUD placement because there are few studies on sedation. It should be available to everyone for this procedure, but in the U.S. in 2024, it is not because it is not always covered by insurance and people do not always go to providers who have access to sedation in their clinical practice. It is important that patients are aware that sedation is an option. The sad truth remains that even contraception does not have universal coverage, let alone something that is still going to be considered an add-on as opposed to essential for some patients.
All of this is why it is important for clinicians to counsel patients about the availability of postpartum IUD access. The cervix is already open and the uterus is large, making this an opportune time. That is outside the scope of these recommendations, but it is a good conversation to have with someone while pregnant.
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Katharine O’Connell White, MD, MPH, can be reached at katharine.white@bmc.org.