CDC Recommends Use of Lidocaine for IUD Insertion in Updated Guidelines

The CDC updated their practice recommendations for intrauterine device (IUD) insertion in response to nationwide outcry from women who experience extreme pain, vomiting, significant bleeding, or blackout during the procedure. Since the beginning of 2024, women and clinicians alike have taken to social media platforms, such as TikTok, Instagram, and Twitter, to call for methods that improve quality of care for patients. The updated guidelines aim to address these concerns by incorporating new evidence and feedback to enhance patient comfort and safety during IUD insertion procedures.

The 2024 updates utilize patient-centered language, placing an emphasis on use of topical lidocaine and paracervical blocks in and comprehensive procedure and pain counseling. Image Credit: © Halfpoint - stock.adobe.com

IUDs are a small, flexible device inserted into the uterus to prevent pregnancy that can be either hormonal or non-hormonal. Development of IUDs began in the 1960s with novel devices such as the Dalkon Shield (AH Robins Company) and progestasert (G.D. Searle & Company), which were both discontinued due to severe adverse effects (AE), such as pelvic inflammatory disease, sepsis, and infertility. This called for improved products with decreased risks, leading to the development of the copper T 380A (ParaGard; Teva) and the first hormonal levonorgestrel-releasing intrauterine system (Mirena; Bayer). Currently, there are 5 FDA approved IUDs in the US: the copper T 380A and hormonal levonorgestrel-releasing intrauterine systems including Mirena, Kyleena (Bayer), Liletta (Allergan), and Sklya (Bayer).^1,2

Since then, IUD efficacy and safety have greatly improved and there are various models and hormonal options available to suit every patient’s needs or goals. However, advancements in IUDs have been focused on the devices themselves, failing to acknowledge the severe pain associated with the insertion procedure. Studies investigating IUD insertion-related pain have found that 50% to 80% of participants describe the insertion pain as moderate to severe. As these long-term birth control options continue to grow in popularity, there is a need for better IUD insertion methods and pain management options.^3,4

In response to this pronounced discourse, the CDC updated their 2016 guidelines for IUD insertion in 2024. These updates utilize patient-centered language, placing an emphasis on use of topical lidocaine and paracervical blocks in combination with comprehensive procedure and pain counseling. In addition to medication recommendations for IUD placement, the CDC included guidance for managing bleeding irregularities during and after the procedure.⁵

The CDC also advised against routine use of cervical softeners such as misoprostol (Cytotec; Pfizer) due to evidence indicating it can significantly increase risk of AEs. Their recommendations limit use of misoprostol to patients with a recently failed insertion.⁵

“I think the data show that, especially for people who've never given birth, the addition of either a topical anesthetic to the cervix, which is the doorway into the uterus that we pass through in order to place an IUD in the uterus, whether that's topical or the paracervical block, that that significantly decreases the pain with insertion,” Aileen Gariepy, MD, MPH, MHS, family planning specialist at Weill Cornell Medicine, said in an interview with NPR.⁶

Local anesthetics, sedations, and other options are available for IUD placement, but are often not readily offered by clinicians. The updated CDC guidelines mark another step toward improved patient practices in gynecology and women’s health, placing the patient at the center of care.

REFERENCES

1. IUD. Planned Parenthood. Accessed August 14, 2024. https://www.plannedparenthood.org/learn/birth-control/iud
2. A history: the iud. Reproductive Health Access Project. March 20, 2024. Accessed August 14, 2024. https://www.reproductiveaccess.org/2024/03/a-history-the-iud/
3. Lopes-Garcia EA, Carmona EV, Monteiro I, et al. Assessment of pain and ease of intrauterine device placement according to type of device, parity, and mode of delivery. Eur J Contracept Reprod Health Care. March 24, 2023. doi:10.1080/13625187.2023.2189500
4. Tassi A, Parisi N, Londero AP. Misoprostol administration prior to intrauterine contraceptive device insertion: a systematic review and meta-analysis of randomised controlled trials. Eur J Contracept Reprod Health Care. 2020;25(1):76-86. doi:10.1080/13625187.2019.1706079
5. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. CDC. August 8, 2024. Accessed August 14, 2024. https://www.cdc.gov/mmwr/volumes/73/rr/rr7303a1.htm?c
6. New CDC guidance recommends doctors address IUD insertion pain for patients. NPR. August 8, 2024. Accessed August 14, 2024. https://www.npr.org/2024/08/08/nx-s1-5068298/new-cdc-guidance-recommends-doctors-address-iud-insertion-pain-for-patients