Lisa Bayer, MD, discusses pain management and patient-centered care during IUD placement

Updates to the Centers for Disease Control and Prevention (CDC) 2024 Selected Practice Recommendations for Contraceptive Use include new guidance on pain management during intrauterine device (IUD) placement. While the recommendations reaffirm that misoprostol is not advised for routine use, they now offer stronger support for the use of lidocaine—both topically and via paracervical block—as part of a multimodal approach to pain relief.

Lisa Bayer, MD, MPH, associate professor at Oregon Health & Science University, along with co-presenters Jenny Wu, MD; and Megan Cohen, MD, presented on these updates on pain management during IUD placement at the 2025 ACOG Annual Clinical and Scientific Meeting.

New CDC guidance highlights lidocaine use

According to Bayer, the CDC’s 2024 update incorporated patient feedback, expert guidance, and findings from systematic reviews. Thirteen new randomized controlled trials on topical lidocaine and four trials on paracervical blocks were evaluated.

“They still recommend against the use of misoprostol for routine use for IUD placement,” Bayer said. “They say that it can be helpful if it’s a more complex insertion, but they expand what their recommendation is for lidocaine and say that lidocaine, both paracervically and topically, may be beneficial for IUD placement.”

Understanding patient concerns and experiences

Bayer emphasized the importance of asking patients about prior experiences, including what they have seen or heard on platforms like TikTok or YouTube, and from peers. These factors may shape expectations or heighten anxiety around IUD placement.

“A lot of people see or hear things, and it might bring different levels of anxiety, and it’s really important to figure out what those anxieties are [and] address them directly,” she said.

She added that clinicians must be willing to acknowledge that “pain has been underscored and really under-addressed with office-based gynecologic procedures.” Understanding that each patient has unique pain thresholds and concerns is essential for appropriate counseling and care.

Risk factors and tailoring pain management

Pain perception during IUD placement is multifactorial. Bayer noted that biological, cultural, and psychological factors all contribute to patient experience. Risk factors for increased pain include younger age, lack of prior vaginal delivery, history of anxiety or sexual trauma, dysmenorrhea, and pain during pelvic exams or intercourse.

“If somebody has a history of having painful speculum exams, maybe using some topical lidocaine gel in the vagina can really make that speculum more comfortable,” Bayer explained.

Multimodal strategies and individualized care

Given the complexity of pain, Bayer recommended a multimodal approach. “Usually a multimodal approach is going to be necessary,” she said, emphasizing the role of trust between the patient and clinician.

“If they come in with skepticism [or] with medical mistrust, usually that’s going to be a worse experience for them,” she said. Building rapport and validating patient concerns helps create a more positive and effective clinical encounter.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen or oral ketorolac taken an hour before the procedure can help manage cramping. For patients with significant anxiety or prior negative experiences, Bayer advised considering separate appointments to explore sedation options or prescribe anxiolytics in advance.

Expanded options and comfort measures

The CDC update also includes guidance on topical medications. “2.5% lidocaine, prilocaine, or EMLA cream to the cervix has been helpful,” Bayer noted. Paracervical blocks are another option, although clinicians should be sensitive to patients with needle phobias.

In addition to medications, comfort measures may improve the patient experience. Bayer listed strategies such as allowing a support person in the room, using a heating pad, dimming lights, and playing music.

“There’s all these different comfort measures… just all these other little things do make a difference,” she said. “Every patient might want a different thing. So I think it really just goes back to asking the patient.”

Disclosures:

Advisory Committee/Board Member; Self; Bayer US LLC, CooperSurgical, Honorarium; Self; Organon.

Reference:

Bayer L, Wu J, Cohen M. Pain Management for IUD Placement: Examine the Evidence, Honor Autonomy, Reset Practices. Presentation. Presented at: 2025 American College of Obstetricians and Gynecologists (ACOG) Annual Clinical and Scientific Meeting. May 16-18, 2025. Minneapolis, Minnesota.