Doctors are being urged to take patients’ pain more seriously during routine gynecological procedures — including when inserting intrauterine devices — under new recommendations by the nation’s leading OB-GYN organization.
The American College of Obstetricians and Gynecologists (ACOG) in mid-May recommended that patients be counseled about pain management and, when appropriate, offered interventions such as lidocaine spray, lidocaine-prilocaine cream or a paracervical block for IUD insertions. For procedures such as endometrial biopsies and colposcopies — exams where the cervix is viewed using a magnifying instrument — ACOG advised using nonsteroidal anti-inflammatory drugs, local anesthetics or medications like misoprostol.
The updated guidelines follow 2024 recommendations from the U.S. Centers for Disease Control and Prevention, which advised clinicians to counsel patients on gynecological pain and suggested that the local anesthetic lidocaine “might be useful” for pain management. The ACOG update also reflects years of research and growing concern about unmanaged pain — much of it shared by patients on social media.
One of the most common procedures addressed by the new recommendations is IUD insertion. The device, placed inside the uterus to prevent pregnancy, is inserted through a process that involves a speculum exam, cervix stabilization and passing the IUD through the cervical canal into the uterus with an inserter. According to a 2019 CDC survey, 10.4% of women aged 15-49 reported using long-acting reversible contraceptives, which include both IUDs and contraceptive implants, compared with 14% using the birth control pill.
“Any part of the IUD insertion process can be uncomfortable,” said Tracy Chen, an OB-GYN at Allegheny Health Network. “For some of my patients who have chronic pelvic pain, for example, they will require a different type of pain management than someone who has endometriosis or painful bladder syndrome.”
On TikTok, according to a 2022 study by Duke University researchers looking at IUD content on the platform, more videos had a negative tone toward IUDs (37.8%) than a positive one (19.4%), and 27.6% of users mentioned distrust of health care professionals. Of patient experience videos, 96.8% cited pain or side effects — most often during insertion and removal — with many blaming inadequate anesthesia and feeling dismissed by providers.
“It’s hard to make a broad recommendation about what kind of pain control people should receive when there's no clear evidence that says one method is different than the other,” said Chen. “Patients have done a great job in highlighting that perhaps we don't need a one-size-fits-all pain control plan for everyone, but that more individualized care is sufficient — and that they deserve that care, which they are completely correct about.”
Chen said that discussing different options, such as what each modality targets and when it is used, has led to a more comfortable experience for her patients.
The ACOG’s updated recommendations also highlight how systemic racism and bias about how pain is experienced has shaped pain management practices, and often negatively impacts marginalized communities.
“Our policy is that we offer these pain management modalities to everyone,” said Chen. “All of our physicians [at AHN] are trained on trauma-informed care and reproductive justice.”
Many patients choose IUDs over birth control pills for both practical and medical reasons. With four hormonal options and two FDA-approved non-hormonal IUDs — Miudella, approved in February, joined Paragard — they can be a safer alternative for individuals with high blood pressure, hormone sensitivity or inconsistent access to medication. But the barriers to IUD access for some, such as scheduling appointments, insurance approval and procedural pain, still remain high.
Among the most successful reversible forms of contraception — IUDs are 99% effective, per the Cleveland Clinic — intrauterine devices can be effective for three to 10 years, depending on which type is being used.
Although pain management research is growing, Chen said studies often have small sample sizes and conflicting outcomes. Some new techniques, such as vapor coolants or intranasal fentanyl, were explored, but no definitive solution has emerged.
“I’m happy that the hard-working doctors and scientists who’ve been working on this problem for so long are finally getting the recognition they deserve,” said Chen. “But I’m also sad, because we still don’t really have a great answer for patients yet.”
Ava Dzurenda (ava.dzurenda@gmail.com) is a science writer and exercise physiologist based in White Oak.
First Published: May 31, 2025, 8:00 a.m.
Updated: June 1, 2025, 2:03 a.m.
