Docs Should Counsel Patients About IUD Pain, CDC Says

As part of an update to the CDC’s practice recommendations on contraception, physicians are being encouraged to counsel patients on pain associated with intrauterine device (IUD) insertion.

The 2024 guidance on contraceptive use includes the Medical Eligibility Criteria, which details what contraception is safe for people with various medical conditions, and the Selected Practice Recommendations, which focuses on a group of common, and often complex, issues with initiation and use of specific contraceptive methods. Both were published in the Morbidity and Mortality Weekly Report.

To determine which updates to include in the practice recommendations, which were last updated in 2016, CDC researchers conducted a thorough review of scientific evidence and held listening sessions with patient advocacy organizations and patients representing themselves.

“The goal of the listening sessions was to gather insights about participants’ experiences, values, preferences, and information needs related to contraceptive method use and decision making,” said Antoinette Nguyen, MD, of the division of reproductive health at CDC’s National Center for Chronic Disease Prevention and Health Promotion, who was an author on both updates.

The updated recommendations “can support providers in improving access by using evidence-based eligibility criteria and practice recommendations,” she told MedPage Today.

Patients have taken to posting their IUD insertion experiences on TikTok in recent years, with some even filming their pained facial expressions during the procedure. Research in Obstetrics & Gynecology has shown that most videos tagged #IUD have a negative tone and focus on pain and side effects. Another study in Contraception found that doctors underestimated patient pain during IUD insertion.

“Before IUD placement, all patients should be counseled on potential pain during placement as well as the risks, benefits, and alternatives of different options for pain management,” the researchers wrote in the practice recommendations. “A person-centered plan for IUD placement and pain management should be made based on patient preference.”

They noted that lidocaine, either used as a paracervical block or topically, “might be useful for reducing patient pain.” The researchers still do not recommend misoprostol, except for select circumstances, such as if a patient had a recently failed placement, in which case vaginal misoprostol 400 µg may be used.

The practice recommendations also had updates about counseling patients on bleeding irregularities during implant use. Changes in bleeding patterns, including amenorrhea, are generally not harmful, though heavy bleeding is not common.

Guidance on testosterone use and the risk for pregnancy are new additions to the guidance, and address trans, nonbinary, and gender-diverse people with uteruses who may need additional contraception even if they are taking testosterone, since the hormone may not prevent pregnancy. The researchers recommended offering “contraceptive counseling and services to those who are at risk for and do not desire pregnancy.”

They also highlighted the recommendation that self-administration of the subcutaneous depot medroxyprogesterone acetate be made available as an additional approach to deliver injectable contraception, which was originally added to the practice recommendations in 2021.

In terms of the medical eligibility criteria, there were several updates to recommendations for patients with certain characteristics or medical conditions, including breastfeeding, postpartum, post-abortion, obesity, surgery, history of deep venous thrombosis or pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, cirrhosis, liver tumor, sickle cell disease, and solid organ transplantation, as well as for those at high risk for HIV infection and those taking HIV antiretrovirals.

There was also new guidance for patients with chronic kidney disease, particularly those with nephrotic syndrome and those receiving hemodialysis or peritoneal dialysis. Patients with these conditions face increased risks for adverse health events as a result of pregnancy.

One other major change to the medical eligibility criteria was the inclusion of new contraceptive methods and doses, such as combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulators.

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