Intrauterine devices (IUDs), also known as coils, are safe and effective contraceptive methods. According to representative surveys conducted by the Federal Centre for Health Education (BZgA) in Germany, 13% of adult women in Germany who use contraceptive methods also use IUDs. According to the BZgA, 5% of women aged 18-29 years use IUDs compared with 20% of women older than 40 years.

However, many women oppose this method because of concerns regarding pain. Two studies published in JAMA examined pain and pain relief associated with IUD use. A US study examined the number of women who chose to use pain medication. Swedish researchers investigated the effectiveness of intrauterine instillation of mepivacaine for relieving pain during IUD insertion.

“Many factors influence the decision to use a contraceptive method, including a woman’s life situation, family planning, and individual assessment of benefits and risks. Concern about pain during IUD insertion can also influence the decision to use or avoid an IUD,” said Cornelia Hösemann, MD, gynecologist in private practice in Großpösna and board member of the Professional Association of Gynecologists in Munich, Germany, in an interview with Medscape’s German edition.

“The potential for pain and the available options for pain relief should be discussed during the gynecological consultation before IUD insertion,” Hösemann said. However, that pain perception varies considerably among patients and cannot be reliably predicted in an individual case. The 2024 S2k Guideline on Non-Hormonal Contraception specifically addresses pain during IUD insertion and outlines pain relief options.

“The current German guideline also takes into account that women who have not previously given birth may experience more severe pain during insertion. It lists naproxen and local anesthesia among the options for pain relief. Ibuprofen has also been discussed; however, there is no evidence that its prophylactic use reduces pain during insertion. Pain relievers can, however, be used to alleviate symptoms during and after insertion,” Hösemann said.

The consensus statement in the S2k Guideline stated that pain relievers, such as naproxen and tramadol, as well as local application of an anesthetic in the form of a gel or cream at higher doses have an analgesic effect during IUD insertion. Studies have not shown that misoprostol administered before insertion generally facilitates the procedure. According to consensus-based recommendations, pain relievers may be used to alleviate pain during and after IUD insertion. Following a previous unsuccessful insertion, another attempt may be made after the administration of misoprostol.

Intravenous Sedation (IVS)

Armide Storey, MD, clinical fellow in complex family planning in the Department of Obstetrics and Gynecology at Brigham and Women’s Hospital in Boston, and colleagues examined how often patients offered IVS for IUD insertion chose to receive IVS. The researchers studied 1324 patients who underwent IUD insertion at outpatient family planning clinics in Massachusetts between April 1, 2024, and March 30, 2025.

Patients were routinely offered nonsteroidal anti-inflammatory drugs and a paracervical block with lidocaine for pain management. IVS with fentanyl and midazolam was also promoted online and offered to all patients when they scheduled their appointments. Overall, 269 of the 1324 patients (20.3%) received IVS.

Patients who received IVS were more likely to have never given birth (93.7% vs 84.9%; P < .001) and to have diagnoses of pelvic pain (5.9% vs 2.0%; P < .001) and depression or anxiety (64.7% vs 45.5%; P < .001). They were also more likely to identify as White (64.7% vs 53.1%) and as non-cisgender (10.0% vs 5.5%) and were more likely to not require an interpreter (98.9% vs 95.9%).

“In this sample, one fifth of patients received IUD placement with IVS when universally offered, indicating meaningful demand for this option in routine contraceptive care,” the authors concluded.

On the basis of the observed prevalence, the researchers suggested that the actual demand for IVS may be underestimated, particularly because of long appointment wait times, additional co-payments, restrictions on who can accompany patients, and limitations on activities after IVS. Comparable data are not available for Germany. “Due to a lack of data, we cannot quantify how often this is actually a deciding factor in Germany,” Hösemann said.

Mepivacaine Findings

Swedish researchers examined whether intrauterine instillation of mepivacaine could reduce pain during IUD insertion in nulliparous individuals. Mepivacaine is a local anesthetic of the aminoamide class that acts by blocking sodium channels in nerve cell membranes.

The multicenter, double-blind, randomized, placebo-controlled study included 370 nulliparous individuals aged 18-31 years and was conducted at 11 outpatient clinics in Sweden. Participants were randomly assigned in a 1:1 ratio to receive 10 mL of mepivacaine or saline (9 mg/mL) through a hydrosonography catheter 2 minutes before IUD insertion. The primary endpoint was the difference in pain scores.

The mean pain score during IUD insertion was 43.8 mm (SD, 24.7) in the mepivacaine group and 58.6 mm (SD, 21.5) in the placebo group, corresponding to a mean difference of 14.8 mm (P < .001).

The authors of the study concluded that intrauterine instillation of 10 mL of mepivacaine significantly reduced pain and improved tolerability during IUD insertion compared with the instillation of the placebo (saline).

In 2024, Karin Elgemark, MD, PhD, researcher in the Department of Clinical Sciences, Danderyd Hospital at Karolinska Institutet in Stockholm, Sweden, and colleagues had already reported evidence supporting the effectiveness of intrauterine mepivacaine during IUD insertion in a smaller study involving 151 patients.

Bettina Böttcher, MD, PD, senior physician in the Department of Gynecological Endocrinology and Reproductive Medicine at the Medical University of Innsbruck in Innsbruck, Austria, and coordinator of the S2k Guideline, said, in response to a query from Medscape’s German edition, that sufficient data on mepivacaine were not available when the guideline recommendations were developed. “The guideline is scheduled for revision in 2027, so all studies published in the meantime will be considered and, provided they meet the quality criteria, incorporated into the recommendations,” Böttcher said.

This story was translated from Medscape’s German edition.