IUD insertion has been performed without adequate pain management for decades, and the reasons are a tangle of clinical inertia, underwhelming trial results for the most convenient medications, provider underestimation of pain, and gaps in training. The situation is not that effective options don’t exist; it’s that the options that do work require more time, skill, or equipment than many clinics have been set up to provide. That mismatch between what’s available and what’s routinely offered is finally getting serious attention, driven in part by patients who have been vocal about how painful the procedure can be.
Providers and Patients See the Pain Differently
One of the foundational problems is that many clinicians have historically underestimated how much IUD insertion hurts. A study that compared patient-reported pain to provider assessments found that patients rated their maximum pain at an average of about 65 on a 100-point scale, while their providers estimated roughly 35 for the same insertions. Agreement between patients and providers on even which step of the procedure hurt most was weak.1PubMed. Accuracy of providers’ assessment of pain during intrauterine device insertion A separate study confirmed the pattern, finding that providers consistently scored pain lower than patients did, with only slight statistical agreement between the two perspectives.2PubMed. Patients’ experiences and providers’ observations on pain during intrauterine device insertion
When providers believe the pain is mild or fleeting, there’s less motivation to add steps, medications, or time to the appointment. Survey research on physicians who place IUDs has found that some believe the pain is minimal or short-lived, while others who want to offer analgesia face logistical barriers that discourage them from doing so.3PubMed. Barriers and facilitators for providing pain control during intrauterine device insertion: a multi-center physician survey The perception gap is not about individual callousness. It reflects a clinical culture that, for a long time, treated IUD insertion as a quick office procedure rather than a pain-significant one.
Where the Pain Actually Comes From
IUD insertion is not one moment of discomfort; it’s a sequence of steps, each potentially painful in its own right. The cervix is grasped with a tenaculum (a clamp-like instrument), a sound is passed through the cervical canal to measure the uterus, and then the device itself is pushed through and deployed. Different nerve pathways are involved at different stages. The cervix is innervated by parasympathetic nerves from the lower spinal cord, while the uterine body receives sympathetic fibers from higher up.4Cochrane Library. Interventions for pain management on intrauterine device insertion This dual-nerve setup helps explain why a single painkiller aimed at one mechanism often fails to cover the whole procedure.
Research tracking pain at each step has found that uterine sounding, the measurement step, tends to be the most painful moment during the procedure.5PubMed Central. Comparison of Intrauterine Device Insertion-Related Pain and Ease of Procedure at Different Times During Menstruation Other studies have found that the peak arrives at the moment of device deployment itself.6PubMed. 10% lidocaine spray for pain control during intrauterine device insertion: a randomised, double-blind, placebo-controlled trial The inconsistency across studies probably reflects real variability among patients, devices, and providers’ techniques. What matters for the pain-management question is that the painful stimulus is brief but intense, happening over seconds to a minute, and comes from tissue that is not easy to numb topically.
On top of the direct pain, some patients experience vasovagal reactions, where the body responds to the cervical manipulation with a drop in heart rate and blood pressure, sometimes leading to fainting. An analysis of international IUD insertion data found that people who had never given birth vaginally and those who experienced moderate to severe pain were at the highest risk for these reactions.7PubMed. Syncope and other vasovagal reactions at interval insertion of Lippes Loop D–who is most vulnerable? Preventing pain, in other words, isn’t just about comfort. It could reduce the rate of these more alarming events.
Why Over-the-Counter Painkillers Haven’t Solved It
The most common recommendation patients receive is to take ibuprofen before their appointment. It’s simple, cheap, and requires no extra clinic resources. The problem is that the evidence for it is weak. A randomized trial specifically testing prophylactic ibuprofen found that it did not improve pain scores during IUD insertion.8PubMed. Prophylactic ibuprofen does not improve pain with IUD insertion: a randomized trial A systematic review of NSAIDs more broadly found limited evidence that they provide meaningful pain relief for most people during the procedure, though a handful of individual studies did show statistically significant reductions.9PubMed. Efficacy of NSAIDs in reducing pain during intrauterine device Insertion: A systematic review
Some specific regimens look more promising than the standard single dose. Naproxen sodium taken before the procedure reduced pain after insertion, though it did nothing during the cervical grasping or the insertion itself.10PubMed Central. Pain Management During Intrauterine Device Insertion in Nulliparous Women: A Scoping Review A trial of multidose ibuprofen, taken over a longer lead-up period rather than a single dose an hour before, did find a meaningful reduction in insertion pain compared to placebo.11American Journal of Obstetrics and Gynecology. Multidose Ibuprofen Prior to Intrauterine device insertion (MIPI): a triple blinded randomized controlled trial This suggests timing and dosing matter more than most standard advice accounts for, but the single-dose approach that most patients use remains the norm.
The underlying issue is that NSAIDs reduce prostaglandin-mediated inflammation and cramping, but much of the acute pain during insertion comes from mechanical stretch and nerve activation in the cervix and uterus. An anti-inflammatory taken orally needs time to reach meaningful tissue levels and primarily targets the post-procedure cramping rather than the sharp pain of the instrument passing through the cervical canal. That’s why these drugs can help with the aching afterward but consistently fail to touch the worst moment.
Misoprostol Was Supposed to Help. It Didn’t.
For years, some providers prescribed misoprostol before IUD insertion with the idea that softening and dilating the cervix would make the procedure less painful. A Cochrane review of randomized trials found that misoprostol made little to no difference in pain during tenaculum placement, during IUD insertion itself, or after placement. It also didn’t meaningfully reduce the need for mechanical cervical dilation or improve providers’ ease of insertion. What it did do was roughly double the rate of pre-procedure abdominal cramping and increase diarrhea.12PubMed Central. Misoprostol for intrauterine device placement A separate meta-analysis reached the same conclusion on pain but noted higher patient satisfaction scores in some studies, possibly because the ritual of taking a preparatory medication gave patients a sense that their pain was being taken seriously, even though the drug itself wasn’t doing much.13Middle East Fertility Society Journal. The value of misoprostol administration before intrauterine contraceptive device insertion: a systematic review and meta-analysis
The one exception worth noting is in patients who have had a recent failed insertion attempt. In that subgroup, misoprostol probably increases the chances of successful placement on the next try.14Cochrane Database of Systematic Reviews. Misoprostol for intrauterine device placement For everyone else, it’s a drug that adds side effects without reducing pain.
What Actually Works Better
The interventions with stronger evidence tend to require more from the clinic. Paracervical blocks, where a local anesthetic is injected into the tissue around the cervix, have shown real benefit. A randomized trial in people who had never given birth found that those who received the block reported substantially lower pain during insertion, sounding, and five minutes after placement compared to those who received no block. The catch is that the injection itself is painful, so there’s a trade-off in the moment.15PubMed Central. Paracervical Block for Intrauterine Device Placement Among Nulliparous Women: A Randomized Controlled Trial Still, the net effect is less total pain, and patients consistently prefer it. The real barrier is that many providers haven’t been trained to do it.
Topical lidocaine tells a more complicated story. A randomized trial of a novel topical lidocaine formulation applied before insertion showed about a 36% reduction in maximum pain compared to placebo, with roughly three out of four patients experiencing less pain than they would have without it.16PubMed. Novel topical formulation of lidocaine provides significant pain relief for intrauterine device insertion: pharmacokinetic evaluation and randomized placebo-controlled trial But not all lidocaine formulations perform the same way. One trial of 10% lidocaine spray found it reduced pain during tenaculum use and sounding but not at the peak moment of device deployment.6PubMed. 10% lidocaine spray for pain control during intrauterine device insertion: a randomised, double-blind, placebo-controlled trial Another study of lidocaine spray found that it reduced pain from both the tenaculum and the insertion itself, and performed better than lidocaine injection.17PubMed. Lidocaine for pain control during intrauterine device insertion And yet another trial of lidocaine spray found absolutely no benefit over placebo, with about 27% of patients in both groups reporting severe pain.18PubMed Central. The role of lidocaine spray in reducing pain during intrauterine device insertion
The inconsistency across lidocaine studies likely comes down to formulation, application technique, and wait time before the procedure starts. Simply spraying a generic lidocaine product on the cervix and immediately proceeding may not give the anesthetic enough time to penetrate the tissue. The formulations that seem to work better are designed for better mucosal absorption or are applied with longer wait periods. This variability in technique and product is part of why “just use lidocaine” never became a universal standard, even though the underlying principle is sound.
Training Gaps and Clinic Logistics
Even when effective options exist, the system often isn’t built to deliver them. Paracervical blocks require specific training, supplies, and extra procedure time. OB-GYN residencies typically teach the technique because it’s used for multiple procedures, but family medicine physicians, pediatricians, and nurse practitioners who also place IUDs may have little exposure to it. Research into specialty-related variation in paracervical block use found that differences in training almost certainly drive the gap, and that non-OB-GYN clinicians who want to offer the block often lack accessible training opportunities.19PubMed Central. Use of Paracervical Blocks for Patients Who Undergo Intrauterine Device Insertion
There are also practical constraints. A paracervical block adds five to ten minutes to an appointment that’s often scheduled for fifteen. It requires drawing up medication, applying it with a specific technique, and waiting for it to take effect. For a busy clinic seeing patients back to back, that’s a meaningful disruption. When the alternative is a procedure that’s over in under a minute, and the provider believes the pain is brief and manageable, the path of least resistance is to skip the block. This isn’t a conspiracy; it’s the predictable outcome of a healthcare system that rewards efficiency and underinvests in patient comfort for procedures categorized as “minor.”
Who Hurts More and Why It Matters
Pain during IUD insertion is not evenly distributed. People who have never had a vaginal delivery consistently report significantly more pain. One study found that the mean pain score for those without a prior vaginal delivery was about 51 out of 100 compared to about 35 for those who had delivered vaginally, and after controlling for other variables, a vaginal delivery history was associated with roughly a 15-point reduction in pain.20PubMed. A prospective cohort study of pain with intrauterine device insertion among women with and without vaginal deliveries Another trial found that people who had never been pregnant at all reported the highest pain scores.21PubMed. Assessment of pain and ease of intrauterine device placement according to type of device, parity, and mode of delivery
Anxiety also plays a role. Patients who are more anxious before the procedure tend to report higher pain scores, and pre-procedure anxiety and the absence of a prior vaginal delivery can compound each other.22PubMed. Intrauterine contraception insertion pain: nursing interventions to improve patient experience The demographic picture is relevant because IUD use has been expanding among younger people who have never been pregnant, precisely the population that experiences the most pain and the most vasovagal reactions. A pain management approach calibrated to someone who has had multiple vaginal deliveries is not appropriate for a teenager getting their first IUD.
The Device Itself Makes a Difference
Not all IUDs are the same size, and the physical dimensions of the device affect how much insertion hurts. A trial comparing three different IUDs in adolescents found that the larger hormonal device (the 52-mg levonorgestrel IUD) produced significantly higher pain scores than either a smaller hormonal device or the standard copper IUD. The 52-mg device was also rated as harder to place by providers.23PubMed. Pain and ease of insertion of three different intrauterine devices in Brazilian adolescents: A participant-blinded randomized trial In that study, a history of painful periods and having had fewer pregnancies were also independently associated with higher pain scores, reinforcing that patient characteristics and device choice interact. Smaller-framed IUDs were developed partly to address this, and they do appear to reduce insertion pain in people with a smaller or less compliant cervical canal.
Social Media Changed the Conversation
For a long time, the pain of IUD insertion was something patients experienced and then didn’t talk about much publicly. Social media changed that. An analysis of TikTok videos tagged with #IUD found that about 80% of videos describing personal experiences with placement or removal had a negative tone, and nearly all of them highlighted pain. Roughly a quarter of those videos specifically expressed a desire for anesthesia during the procedure.24PubMed Central. TikTok, #IUD, and User Experience With Intrauterine Devices Reported on Social Media
This wave of public storytelling has had real effects. It put pressure on professional organizations, policymakers, and individual providers to take the pain question seriously rather than dismissing it as brief and tolerable. The CDC updated its Selected Practice Recommendations for Contraceptive Use in 2024, including guidance on pain management during IUD insertions.25medRxiv. Evaluating Changes in Pain Medication Administration During IUD Insertion, 2018-2025 Whether that guidance will translate into widespread changes in clinic practice is still playing out, but the shift in the professional conversation has been rapid.
Approaches Still Being Figured Out
Nitrous oxide, the same gas used for dental procedures, has been tested for IUD insertion with mixed results. A trial in adults who had never given birth found that nitrous oxide made no difference in maximum pain compared to oxygen alone.26PubMed. A randomized controlled trial of nitrous oxide for intrauterine device insertion in nulliparous women But a study specifically in adolescents found a large and significant reduction in reported pain, and patients who received nitrous oxide were more likely to say they’d recommend the procedure to others.27PubMed. Nitrous Oxide Use for Intrauterine System Placement in Adolescents The difference between these two results might reflect the higher baseline anxiety and pain sensitivity in younger patients, where a calming anxiolytic effect on top of mild analgesia makes more of a difference. Nitrous oxide is limited by the need for specialized equipment and training in its use, which most gynecology or family medicine clinics don’t have.
Transcutaneous electrical nerve stimulation, or TENS, where small electrical pulses are delivered through pads on the skin, is another approach that has shown early promise in a small case series. All patients in that report scored their pain lower than previously reported averages for IUD insertion.28PubMed Central. Use of Transcutaneous Electrical Nerve Stimulation (TENS) for Pain Management During Intrauterine Device Insertion: A Case Series TENS units are inexpensive and don’t require special training, which makes them appealing from a logistics standpoint, but the evidence base is still at the case-series level. Larger trials are needed before anyone can say with confidence how well this works.
The broader pattern across all these approaches is that the field has been testing interventions one at a time against placebo, and many of them show only modest effects in isolation. What’s increasingly clear is that the most effective strategy is probably multimodal: combining a topical or injectable local anesthetic with an oral analgesic taken in advance, good counseling to reduce anxiety, and choosing the smallest appropriate device. No single magic bullet exists, but layering several partially effective approaches may get closer to the pain control that patients have been asking for.