Pain or Anxiety Medication Prescription With IUD Insertion Procedures Are Proportionately Low, Studies Find

Following the CDC’s updated practice recommendations for intrauterine device (IUD) insertion procedures¹, an Epic Research study² determined that the proportion of pain or anxiety medications prescribed alongside the procedure is proportionately low. Although the study was initiated prior to the updated guidelines, the findings still demonstrate a need for change to address the pain and discomfort patients experience both during and after insertion.

Image credit: New Africa | stock.adobe.com

An IUD is a small, flexible device that is inserted into the uterus to prevent pregnancy. These can be either hormonal or non-hormonal, and there are currently 5 FDA-approved IUDs in the US: the copper T 380A (ParaGard; Teva); and hormonal levonorgestrel-releasing systems, such as Mirena (Bayer), Kyleena (Bayer), Liletta (Allergan), and Skyla (Bayer).¹ Although IUDs have become a more popular method of birth control in women in recent years, many patients report significant pain or cramping during IUD insertion procedures.²

In August 2024, the CDC updated their practice recommendations for IUD insertions to address women’s concerns about symptoms during and after the procedure. Women nationwide reported experiencing extreme pain, vomiting, significant bleeding, or blackout because of the procedure. Alongside health care professionals, women used social media platforms—such as TikTok, Instagram, and X (formerly known as Twitter)—to raise awareness and suggest methods that can improve the quality of care for patients receiving IUDs. In response, the CDC incorporated new evidence and feedback to enhance patients’ comfort and safety.¹

To further understand pain and anxiety management that is associated with IUD placements, the Epic Research study investigators evaluated 2.4 million outpatient IUD placement procedures between the first quarter of 2017 and the third quarter of 2024. The authors assessed the rate of pain or anxiety medications administered—such as any pain medications, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, anesthesia, among others—on the same day prior to the IUD insertions. The authors noted that these rates did not include OTC or prescribed medications that patients were taking prior to their procedure.²

The results showed that only 536 per 10,000 IUD placements (5.36%) were accompanied by either a pain or anxiety medication administration documented on the same day. The investigators observed that the most commonly documented medications were NSAIDs and opioids, which were administered at 321 and 318 per 10,000 IUD placements, respectively. Other less common medications included the following (per 10,000): benzodiazepines (n = 242); local anesthetic (n = 242); acetaminophen (n = 147); parenteral ketamine (n = 24); and topical anesthetic (n = 8).¹

Despite these findings appearing relatively low, the authors noted that pain medication administrations alongside IUD insertions increased throughout the study’s duration. The rate of pain medication administrations of any type had increased approximately 170% in the first quarter of 2017 to the third quarter of 2024, increasing from 343 to 927 per 10,000 insertions, according to the investigators.²

Further, another study published in PLoS One evaluated IUD insertion procedures within the Veterans Health Administration to assess the pharmaceutical pain medication types and proportions prescribed as well as any notable trends.³ The authors included procedures which were performed and documented from January 1, 2018, to October 13, 2023. Descriptive statistics described patient and facility characteristics whereas linear regression assessed annual trends.³

The authors of this study found that only 11.4% of 28,717 IUD procedures had any form of prescribed pain medication. Similar to the Epic Research study², NSAIDs were the most frequently prescribed pain medication category (8.3%). Additionally, ibuprofen was the most common overall prescribed pain medication (6.1%). Further, the average annual increase rate over the assessment period was about 0.52% (p = .038) for prescribed pain medication, increasing from 10.3% to 13.3% in 2023.³

Although there were increases in both studies, the overall proportion of prescribed pain medication continues to be disproportionality low relative to the pain experienced during IUD insertion. Additionally, when pain interventions were initiated, they disproportionally utilized medication that have been shown to be ineffective.^2,3 Given these findings, outcries from women to change the protocols or guidelines for procedures is unsurprising. Approximately 50% to 80% of women receiving IUDs report experiencing moderate to severe pain or cramping during insertion. Advancements have been made to the IUDs themselves, but not necessarily the insertion procedure.¹

The updated CDC guidelines advise that patient-centered language is essential prior to and during insertion, placing and emphasis on the use of topical lidocaine or paracervical blocks in combination with comprehensive procedure and pain counseling. Additionally, the CDC provided guidance to manage bleeding irregularities that may occur both during and after the procedure. These updates help improve practices by placing the patient at the center of care, which is essential in improving practices within gynecology and women’s health while making patients feel more comfortable.¹

REFERENCES

1. Gerlach, A. CDC Recommends Use of Lidocaine for IUD Insertion in Updated Guidelines. Pharmacy Times. August 16, 2024. January 23, 2025. https://www.pharmacytimes.com/view/cdc-recommends-use-of-lidocaine-for-iud-insertion-in-updated-guidelines

2. Bartelt K, Stamp T, Wong K, Higgs E. Pain and Anxiety Medications Are Uncommon for Patients Who Have an Intrauterine Device Placed, Though Rates Increasing. Epic Research. Accessed January 23, 2025. https://epicresearch.org/articles/pain-and-anxiety-medications-are-uncommon-for-patients-who-have-an-intrauterine-device-placed-though-rates-increasing

3. Ware AD, Blumke TL, Hoover PJ, et al. National assessment on the frequency of pain medication prescribed for intrauterine device insertion procedures within the Veterans Affairs Health Care System. PLoS One. 2025;20(1):e0308427. doi:10.1371/journal.pone.0308427